ABSTRACT OF A Clinical Lecture ON A CASE OF SYPHILITIC PAPILLOMA COVERING THE WHOLE PERINEUM AND SPREADING TO THE PUBES.

AUGUST 27, 1881. situated behind the scrotum and surrounding the anus. This posterior portion is ovoid in form, with the following measurements : Longest diameter from the edge of the scrotum backwards, 6 in.; width at the posterior end of the sore, 2 in.; width just behind the anus, 3 in.; width ON A CASE OF just in front of the anus, 3 in. ; width in front at the edge of the scrotum, 2 in. Anterior portion : Distance between the COVERING THE PAPILLOMA SYPHILITIC ends of the curve above the pubes, 63 in.; width of the WHOLE PERINEUM AND SPREADING ulcerated curve, §in.; width of the bands of ulceration between the scrotum and thighs rather less. The ulcerated TO THE PUBES. surface is exactly symmetrical in its lateral extent. The granulations or papillary growths are pale and irregular, Delivered at Westminster Hospital, May 26th, 1881, much more prominent in patches, attended with very little BY GEORGE COWELL, F.R.C.S., discharge. The edges are undermined, but both ulceration and growth are very slow, presenting little or no change SENIOR SURGEON TO THE HOSPITAL. from day to day. The diagnosis of the case was not free from difficulty. GENTLEMEN,-I propose to speak to you to-day about a The position of the sore, and the papillary and almost vege,case recently discharged from St. Matthew ward. Many tative character of its surface-growth, would point to its of you watched the progress of the case, and heard the re- being of a syphilitic nature. In the absence of a distinctly marks that I made from time to time at the bedside ; but, syphilitic history, it might be a simple papilloma ; or it at the risk of repeating what I have before said, I think might be a lupus, although this is very rare in the anal or, lastly, it might be of a malignant nature, either that it will be instructive to look back at this case now that region; scirrhus or epithelioma - a supposition which would be it is complete, and now that all doubts as to its nature have favoured by the cachectic aspect of the patient and by the been removed by the patient’s recovery. I am indebted for absence from the sore of any tendency to heal. Let us adopt the method of exclusion in forming an the complete notes of this case to Mr. Doyle, one of my opinion on this case. First, we may say that this disease is - dressers. not simple papilloma, from the manner in which it has Charles H-, aged twenty-nine, at present a labourer, spread, and from the fact that the papillary growth cannot but formerly a soldier, was admitted into St. Matthew ward be scraped from its base with a spatula or sharp spoon. on Nov. 10th last, with a peculiar extent of papillary growth Secondly, the disease is not lupus, so rare in this position, The because we should have had scars in connexion with the or ulcerated surface on and surrounding his perineum. surface from the healing process going on in one family history obtained from the patient was as follows. ulcerated whilst extension of the sore was occurring in another. part His father, who was a sailor, of healthy constitution, died We have then to decide between the syphilitic or cancerous at the age of forty-nine, but the patient does not know the nature of the disease. In favour of the latter, we have the cause of his death. His mother, a healthy woman, died in cachectic appearance of the patient already mentioned, the childbirth at the age of twenty-five. One sister died from grey, warty, and irregular granulations and spreading cha" "breaking a bloodvessel." There is no history of cancer. racter of the sore, the persistent absence of the healing pro Previous to his present illness the patient was strong and cess, and the absence of any history of syphilitic infection. healthy. At the age of eighteen he enlisted, and passed, Against the disease being cancerous are the facts that there he says, three separate medical boards, and it is thus fair to is no family history of the disease and no glandular impliinfer that at this time the patient presented no evidence of cation whatever; and perhaps I may also point to the age disease. In December of the same year (1869) he went to of the patient, and to the fact that his residence in a hot India. As early as the following May he had the first signs climate and the prolonged discharge from the perineal surof his present illness. Whilst in India he states that he had face may together be more than sufficient to explain his pale much travelling in the sun, and had often to sit on the hot and cachectic appearance. ground. He distinctly denies any syphilitic infection, and Although it has not been possible to obtain any syphilitic there is no sign of it, unless his disease be considered such. history from this patient, we can only allow ourselves to He states that he first noticed a boil to the right side of the admit that the candour of his replies to the questions that anus, which gradually enlarged and broke two or three have been repeatedly put to him render it possible to give months afterwards. The ulcer which remained did not heal, him credit for being really ignorant of his having contracted and it was "cut out" by the surgeon under whose care he that disease. Whether we give him this credit or not, it On resuming duty the growth returned and must not be forgotten that as an old soldier he would be very was placed. began to spread, and has been extending gradually ever likely to have been exposed to contagion. There is no since. The patient has had the part "burnt" with nitric cicatrix of a chancre to be found, but the wandering chaacid, potassa fusa, and caustic several times. He states racter of the disease, and the position which it occupies further that about a year after the commencement of hisI would, in spite of the patient’s statements, lead us to give illness he was in hospital with scarlet fever. Twice also he him the benefit of the doubt, and to treat him for syphilis. was under treatment for "piles," at which times he used to I pointed out to you that the improved appearance of the pass blood with his motions. He was under treatment at sore from the application of iodoform during the previous Netley in the spring of 1874, and also two years ago at the fourteen days had been such as to encourage me in Norwich Hospital, where he was admitted on account of the opinion that the administration of a drachm of iodide considerable contraction of the anal aperture preventing the of potassium daily, and the application once a day of passage of any solid faeces. The condition was remedied by calomel to the sore, would very probably clear up our -a crucial incision and the passage of bougies. The diseased doubt by curing the disease. Those of my colleagues and surface, however, did not improve on treatment, and he was Dr. Colcott Fox, who saw the patient, expressed the same discharged. opinion. The result was eminently satisfactory. This treatThe patient is a fairly nourished, but pale, cachectic- ment was commenced on Dec. 2nd, and continued uninterlooking man, with an anxious, dejected expression of ruptedly until the end of January. It was omitted for a countenance. A large elevated ulcerated surface lies upon fortnight, and then recommenced. The improvement at the an indurated base and surrounds the anus, involving the edges of the wound was decided within a fortnight of comwhole perineal area and a portion of the nates on either mencing this treatment, there was more action in the granuside; it extends backwards beyond the tip of the coccyx, lations, and cicatrisation actively progressed. The tendency and in front to the edge of the scrotum. A narrow raised to anal contraction was counteracted by the occasional pasband of ulceration of the same character extends forwards sage of a bougie. The patient was discharged in the middle on each side between the scrotum and the thighs, meeting of March with the whole surface of the sore healed, with the above the pubes, where there is a curved line of similar exception of a small depression near the anus, and another ulceration, with the concavity looking upwards towards the about the pubes still smaller. He had throughout the treat. umbilicus, the horns of the semicircle following a course ment, and at the time of his discharge, no proper control above and parallel to Poupart’s ligament. The line of dis- over the anus, as the sphincter had probably been destroyed ease thus completely surrounds the scrotum and root of the by the disease. The inconvenience of the condition was, penis, the greater portion of the diseased surface being however, somewhat diminished by the gradual contraction

ABSTRACT

OF

A

Clinical Lecture

n

No.

3026.

366 of the cicatrix. The patient gained in weight under the treatment. The last report from the patient, under the date of April 16th, states that the two small points remain unhealed, but that his improvement has been fully maintained. A continuation of the iodide would probably result in the completion of the cure. The neglect of themselves usual among this class of patients will, however, very

probably bring the case before us again.

HÆMORRHOIDS OR "PILES." BY JOHN GAY, F.R.C.S. (Continued from I

p.

than the efferent, and together apgreater relative capacity. Some of the larger of them were formed of "knots" of closely-compacted or convoluted small veins (Fig. 2, b c), also in a state of abrupt dilatation and thrombose (Fig. 1, B); whilst the larger anal dilatations or bulbs (c c c) consisted each of loose corrugated and thickened skin which enclosed encysted and condensed areolar tissue, and were probably piles " burnt out." The anal series was largely fringed by corrugated folds of hypertrophied skin. Through the kindness of a friend I have had an opportunity of examining another specimen of rectal hsemorrhoids (Fig. 3, Col. Mus., pn. 1278 B). The verge of the

were more numerous

peared to

be of

"

170.)

FIG. 3.

now describe appearances displayed by some made to inject and dissect the parts in which piles attempts bearing the foregoing characteristics were met with. I have not been able to obtain many such opportunities. Some years ago I had an opportunity of dissecting some bulbous piles which surrounded the verge of the anus. Each pile was pendant (like the bulb of a thermometer on its stem) to a small vein which ran up the bowel, like that in Fig. 2, b b, c c, (Col. Mus., 1278 c), and which I could only trace by its blood-clot. In this, as in other specimens, the little pile projections had here and there ulcerated, and thus exposed their cavities with enclosed clot.

WILL

FIG. 2.

ro

portion of haemonhoida.1 rectum, in which the veins, A A, were injected backwards. The cut edge is seen running

Lower

across

the bowel.

mucous

membrane stripped off, and exhibiting circular muscular coat behind. The veins were filled with clot, and injection ran only into a few of them. A, Anal piles. B, Rectal piles. D, Edge of cut intestine. a a a, Vein branches on which are b b b, Pile tumours, some ulcerated. b c, Erectile (a better term than trabecular) pile tumours. e e, Old pile tumours obliterated.

mucous

In a case recently dissected by myself (Col. Mus., 1278 B) the heamorrhoids were in two tiers (Fig. 2, A B). The lowest, A, as usual, occupied the extremity of the rectum, whilst the second, B, took a like circular course, and was situated about level with the superior edge of the sphincter. There were a few (D) scattered piles in the rectum above. I endeavoured to inject them from a lower hsemorrhoidal branch, but without success, for, with the exception of one, all the other veins and their locular swellings were filled with old and tough clot. The varices of the 1lpper circle consisted of small abrupt dilatations or pouches, on small branches of the lower haemorrhoidals—continuations of bianches which took their rise at the verge of the anus, and on which the bulbous dilatations of the lower series were situated. They were all imbedded in the submucous areolar tissue of the intestine, and had no other connexion with its muscular coats. The afferent venules or veins of these pouches or varices

The bowel has been

stripped off.

opened

and the

in this case thickened into the form of a superserrated ridge, surmounted by a considerable dermoid fold or fringe. Ulcers had laid open the cavities in several of these piles and disclosed blood-clots-firm in some, loose in others. The parts sent me included the bladder, prostate, and vesiculae seminales. With Mr. Pearson’s good help I first injected the prostatic branch of the internal iliac vein with blue wax. (See pn. 1278B.) The injection ran back freely into the veins of the prostatic plexus, and escaped from some very few orifices, where the parts had been severed from their connexions. Some small veins of this plexus abutted upon the rectum and intertwined with a very few of its outermost longitudinal muscular fibres. Its loop veins filled rapidly but did not "bleed," neither did the injection pass into any of the branches of the hsemorrhoidal veins. Red injection was then forced into the mouth of the inferior haemorrhoidal vein. It ran back into all its tributaries (Fig. 3, A A) to the minutest venules of the mucous and submucous tissues, even into the vense venarum; and as it ran so it expressed a quantity of ordinary slightly tinged mucus, but it did not pass into any, even the most approximate, of those of the prostatic plexus. There was no apparent anastomosis between the veins of the two series. It ran, too, through the efferent veins into the empty bulbs. But the injection did not finish its course here, for escaping the thrombose piles, it found its way into a plexus or congeries of minute venules (Fig. 3), which connected the initial portions of the afferent veins (a a a) on the one hand with the skin on the other, and fed the piles that were not thrombose. This, which I will venture toname the anal plexus, lay in a bed of fine areolar tissue which surrounded the extreme verge of the anus, and which, with it, became gradually lost as it was traced upwards on the primary bsemorrhoidal branches at about a line even with the upper edge of the sphincter. This plexus is important, I think, in connexion with hsemorrhoidal disorders, and in this instance, its vessels showed to advantage, as they appeared to have undergone permanent dilatation. Thus each of these anal piles was a distinct bulbous dilatation of a branch of the lower haemorrhoidal vein as it formed out of the anal plexus, and seemed to emerge out of the section anus was

ficially

Lower portion of hasmorrhoidal rectum slit up, laid open, with

membrane