“Unless it be that their presence is unattended by local symptoms, and hence they have failed to attract the attention of either patient or the physician. But in view of the fact that they occur in so many chronic conditions, and the additional fact that marked benefit almost invariably follows their removal, I insist upon it that no obstinate case of chronic disease has been properly examined until their presence or absence has been ascertained. The most happy and the most marvelous results that I have ever seen in the practice of medicine and surgery have followed the removal of pockets and papillæ, and in thus bringing them to your notice, I do so in the confident belief that a proper appreciation of their importance on your part will add materially to your resources in battling with disease, and in helping those who apply to you for relief.” (Pratt.) PRURITIS ANI. Excluding all discoverable local causes whereby the presence of this obstinate affection may be explained, such as piles, ulcer, fistula, oxyuris vermicularis, eczema marginatum, etc., and take the disease unalloyed, or as it may exist in a state pure and simple, and assure a patient thus afflicted that he can be quickly and permanently cured, would not only be presuming too much, but would be stepping beyond the legitimate bounds of all past recorded experiences. To furnish something of an idea to those who are not already familiar with this seemingly trivial yet rebellious complaint, I here quote the language of Dr. Hoyt, who uses words somewhat extravagantly in the beginning but palliates his feelings down later on with _lotio niger_. “With what anguish its unhappy victims battle through innumerable sleepless nights fighting this demon of so-called local epilepsy, with its long array of itching, burning, exuding, corroding, exhausting, and blaspheming characteristics, as though they had been brewed by the chemistry of hell. The whole organization becomes a chaotic discord, the disposition is cruelly warped, the countenance shows a sad picture of living woe, the carriage is nearly lost to all laws of equilibrium, and the complete being merges into a throbbing phantom of despair, trembling upon the very threshold of idolized suicide. “Of course I speak of the most aggravated cases, instances that seldom occur within the experiences of general practitioners. Wherefore then these phenomena? What is the mighty influence that yields so much distress, as all these objective symptoms are but an appearance outflowered by some subtle and specific force. The meager literature upon this subject hobbles upon the crutches of hypothetical inferences, telling you _perhaps_ it is capillary congestion or chronic proctitis, or neurotic hyperæsthesia or eczema, or malaria, suggesting a panoramic array of remedial agencies all unsatisfactory, thereby confessing to a sad condition of helpless empiricism.