Pruritus of the Genitals. 
By Hunter Robb, M. I). 
Professor of Gynaecology, 
Western Reserve University, 
Cleveland, O. PRURITUS OF THE GENITALS.* 
HUNTER ROBB, M. D. 
Professor of Gynaecology, Western Reserve University, Cleveland, O. 
You may remember that Plato in the Phaedo speaks of 
“pure” pleasures and “mixed” pleasures. The former 
were such as were not associated with pain at all, while the 
latter presupposed some inconvenience. In the category of 
“mixed pleasures,” besides eating and drinking, which are 
preceded respectively by hunger and thirst, and many others, 
he puts scratching. Scratching presupposes the pain of 
itching, although scratching in itself may be delightful. I 
am not here to lecture on Plato or to improve upon him, but 
I want to say only that the scratching belonging to Pruritus 
Vulvce is not a mixed pleasure at all, but an unmixed evil. 
Pruritus of the genitals is such an annoying condition 
and therefore of such importance both to physician and 
patient that a careful study of it cannot be counted as a 
waste of time. 
Pruritus of the vulvas is not a disease -per se, but a 
symptom which may accompany several quite different 
affections. It may come from diseases of the vulva and 
vagina, the uterus, the uterine appendages, the urethra, the 
bladder, the kidneys, the rectum, or from certain systemic 
diseases. In many cases the itching is due to local ana- 
tomical changes. An erythema of the vestibule, together 
with an intense itching may be caused by acrid discharges 
coming from the uterus or vagina, or by the irritation from 
diabetic urine ; or again, in patients whose skin is naturally 
irritable it may occur as a result of incontinence, though 
the urine may be normal. 
It is to be insisted, however, that pruritus may occur in 
♦Read before The Cleveland Society of Medical Sciences, May, 1895. 2 
Robb : Pruritus of the Genitals 
cases of inflammation of the uterus or vagina without the 
presence of any irritating discharge. 
Not infrequently pruritus is the first sign of an incipient 
carcinoma of the vulva. In other cases again, it may be due 
to obstructed and enlarged sebaceous follicles on the inner 
surface of the 'vestibule ; at other times again at the place 
where the itching is most intense, scars will be found either 
in or near the vestibule. Pruritus som'etimes occurs in 
pregnancy. 
Parasites, more especially the pediculus pubis if 
neglected, may give rise to this annoying symptom, and 
sometimes especially in children, the presence of worms in 
the vagina, which have come from the rectum will account 
for the patient’s distress. 
Masturbation may either precede as a cause, or follow 
as an effect of pruritus. In man}'- cases, a vicious circle is 
formed, and the masturbation which has been caused by the 
pruritus in turn increases the latter, besides leading to other 
severe nervous symptoms. 
The systemic diseases by which pruritus is sometimes 
a symptom, are diabetes, lithmmfa, and various neuroses. 
Pruritus sometimes occurs at the menstrual period, but 
much more frequently just about the time of the menopause, 
and in the latter case may be due to atrophic changes which 
have taken place in the vulva, and to the increased nervous 
irritability of the patient. 
Symptoms.—The cases vary much in intensity. Some- 
times a mild burning is complained of; sometimes a tickling, 
while at other times, in the more severe cases the patient 
complains of a burning and itching which is worse than that 
encountered in the severe eczematous affections elsewhere 
in the body. 
In these cases, transient relief is found only by 
scratching, and the patient often secludes herself in order 
that she may obtain this comfort, unsatisfactory as it is. 
At times, the condition amounts to one of real agony, and Robb: Pruritus of the Genitals. 
3 
so much does it affect the nervous system that not in- 
frequently the woman falls into a condition of profound 
melancholia. 
Treatment.—In treating a case of pruritus, the main 
thing is to discover the cause. But even when this has 
been found, we are sometimes powerless to relieve the con- 
dition. Suppose that we find an endometritis with purulent 
leucorrhoea, this should be at once attended to, since with 
its removal, the pruritus may also disappear. If we have to 
deal with a neoplasm, with an acne, or more especially with 
cicatrices in the vulva, some cutting operation is more likely 
to bring relief than any other procedure. 
Unfortunately the patient hardly ever comes to us at 
the verv beginning, and it is often impossible to be certain 
how much of the excoriation is due to the underlying cause, 
and how much is due to a dermatitis caused by the frantic 
efforts of the patient who has sought some, although only 
temporary, relief by scratching. 
The removal of acne pustules covering the mucous 
membrane of the vestibule was followed in several cases, 
reported by Kustner, by the disappearance of the most 
obstinate pruritus. 
Frederick and Wilshire hold that the disease generally 
has a parasitic origin and would treat it with the various 
parasiticides. 
When a woman comes to us complaining of pruritus, it 
may at first be allowable to give some one of the many 
washes so highly recommended for this condition, but as a 
rule the affection will not be cured in this way, and if the 
symptoms are not at once alleviated, an examination should 
always be insisted upon. 
We shall examine then (1) the external genitals for 
skin eruptions. In doing this, it will be well to obtain 
scrapings and examine them with the microscope for para- 
sites. (2) We next examine the cervix for signs of 
leucorrhoea and inform ourselves of the general condition ol 4 
Robb: Pruritus of the Genitals. 
the uterus and appendages. (3) An examination should be 
made per rectum ; and (4) the chemical and microscopical 
examination of the urine should never be omitted. 
The presence of enlarged sebaceous glands or any signs 
of malignant disease should be carefully looked for. The 
urine as we have said should be examined more particularly 
for albumen and sugar, and also microscopically. Hemor- 
rhoids or fissures of the anus should be treated and the 
vulva should be kept free from all irritating discharges. 
The general health of the patient should never be forgotten. 
When the vulva is dry too frequent bathing should be 
avoided and the surface should be kept moist, being treated 
not with evaporating lotions, but with ointments. Supposi- 
tories containing codeia or opium and hyoscyamus at night 
will often give the patient relief, since all the symptoms are 
aggravated when the patient gets warm in bed. 
The name of the various external applications for 
pruritus is legion. You will find (and this is not an original 
remark) that whenever you have a long list of infallible 
remedies for any one morbid condition, that some of them 
or perhaps all of them, will disappoint you nine times out of 
ten if not ninety-nine times out of a hundred. 
Zweifel used to say in his lectures that nothing was 
good except a two per cent, solution of nitrate of silver ; this 
has sometimes disappointed me. Ointments containing from 
two to ten per cent, of salicylic acid are sometimes effective. 
An application of a mixture of a drachm of chloroform to an 
ounce of olive oil will occasionally do some good, and some- 
times none at all. A two per cent, solution of carbolic acid, 
the ordinary lead and opium lotion, a solution of the acetate 
of morphia (two grains to the ounce) often give relief for a 
time. But when the exciting cause cannot be removed, the 
treatment is of necessity empirical and too often un- 
satisfactory. 
The most popular internal remedies are bromide of 
potassium, especially at night, and some form of belladonna, Robb: Prur tins of the Genitals. 
5 
both of these drugs tending to decrease irritation of the 
peripheral nerves. 
Some time ago, Kustner and Schroder began to try- 
excision of the affected area, and in obstinate cases this has 
in their hands often proved successful. 
I do not think that when we have tried everything else 
we should shrink from a cutting operation, because the bad 
effects of the disease upon the patient and the agony which 
she goes through, justifies the employment of heroic 
measures. 
In his book published in 1893, Kustner gives only three 
instances all of which, however, were ultimately successful. 
In the first case, the patient had an endometritis which 
was cured without however, any alleviation of the pruritus. 
Kustner then removed a portion of the mucous membrane, 
which was crowded with small retention cysts, and for 
three years afterwards, at any rate, the patient was free from 
pruritus, although she still suffered to a certain extent from 
endometritis. Another similar operation which he quotes 
was quite as successful. 
In a third case in which the patient complained of 
pruritus, the vaginal portion of the cervix was found much 
enlarged. Kustner amputated it and found that the en- 
largement was due to retention cysts there being no signs 
of carcinoma. 
After the operation, the pruritus continued to be as 
severe as before. A further examination brought to light 
an old defect of the perineum due to a previous labor. A 
perineorrhaphy was undertaken, the whitish part of the 
mucous membrane which had been the seat of the irritation, 
was removed and the patient was cured. 
The following case, from Dr. Kelly’s clinic at the 
Johns Hopkins Hospital, is interesting in this connection. 
Mrs. A. E., married, aged 57, was admitted to the 
Gynaecological Ward, Oct. 12, 1894, complaining of pain 
and itching in the vagina. She had born no children but 6 
Robb : Pruritus of the Genitals. 
had had one miscarriage at the age of thirty-two. Meno- 
pause between fifty-five and fifty-six. The family and 
personal history contained nothing of importance. The 
present illness began twenty years ago. At periods suffered 
from itching and a burning which lasted one or two days, 
beginning the day before the appearance of the flow. For 
about three years, the suffering has been constant; little 
blebs and blisters would form in the vagina and on the 
vulva ; when these would break the resulting raw surface 
hardly ever healed and would exude a quantity of pus ; the 
eruption does not extend to the thighs or loins. The general 
condition of the patient on admission was good. The urine 
was negative. To relieve the pruritus, the excision of the 
diseased area including the mucous surface of the labia 
majora, the clitoris and labia minora was decided upon. The 
area having been outlined with a knife, the whole thickness of 
the mucosa was removed ; the removal was from above 
downwards, the flap being turned down and gentle traction 
being made upon it as it was dissected off. The dissection 
reached to within one centimetre of the urethra and 
encircled the upper two-thirds of the outlet. The part 
removed consisted of thick, irregular white patches ; on the 
upper part were a few superficial ulcers, and below the 
surface was thin, glazed and reddish. The patient made a 
satisfactory recovery, and the symptoms of which she 
complained have disappeared.