CHAPTER IT. (Part 13)

names of warts and papillomata, may be defined histologically as an hypertrophy of the papillary layer of the skin and of the papillary layer only. They are composed of the connective tissue, the epithelial covering, and the blood- vessels which, in their natural quantities, form the papillae of the derma. The gross appearances of these warty growths are represented in Pig. 46. Under the influence of any of the exciting causes which will soon be mentioned, little tumors resembling ordinary warts appear, and grow rapidly till they reach two or three millimetres in size. The extremity of the tumor shows a decided tendency to branching and bifurcation, and when there are many of them their branching extremities may fuse to- gether and form a large flat tumor, which will be attached to the skin, however, by numerous little pedicles, so that, if shaved off, the skin will not be wounded except in numerous small points where the pedicles have had each its independent attachment. When the wart is isolated it is dry, but when several are united they become macerated in the secretion of the part which decomposes between them and gives rise to inflammatory phenomena. The tumor then be- comes moist and foetid, and all the adjacent parts become irritated. According to the size of the growths, the condition of the patient, the abundance of the secretions, and the irritation to which they are origin- ally due, these vegetations take on various shapes, and have been described as cockscombs, cauliflower excrescences, etc., etc., but the elementary structure of them all is the same — an hypertrophy and branching of the papillae of the derma. On placing a longitudinal section of one of these warts under the microscope, the following structures will be seen. In the centre, a frame-work of connective tissue composed of a prolongation of the papil- lary bodies of the derma, in the centre of this a vascular loop; the whole covered by one or more layers of epithelium, the form and size of which are variable, and depend apparently on several conditions, such as the moisture and dryness of the parts, and the amount of pressure to which the growths are subject. When the connective tissue is abundant and the epithelial layer relatively thin, the vegetations are dry and hard. When the conditions are reversed, they are moist. When the vascular network is greatly developed, the tumors are red and turgescent, and bleed easily. The growth occurs from the cells of the proliferating zone between the summit of the papilla and the epithelial covering. The intercellular 144 DISEASES OF. THE BECTUM A^D ANUS. substance of the connective tissue becomes less abundant^ while the cel- lular elements increase, and mingle above with the epithelial layer and below with the connective tissue. Similar proliferating zones may be seen on the lateral surfaces of the ramifying warts and, through their medium, the ramifications develop at the extremity of the wart, while on the level with the proliferating zones, the capillary loops grow and develop by which the afferent and efferent vessels communicate (Rind- fleisch, MoUi^re). These vegetations were formerly considered as proof positive of the existence of syphilis, and even of sodomy, and were treated as such. Molliere * relates how, at the time of Dionysius, there was a special hos- pital at Rome for the treatment of these growths; and Dionysius himself tells how the surgeons spared neither the iron nor the fire, and were not moved to pity by the cries of the patients, inasmuch as this disease was the result of unnatural intercourse between man and man. The same false idea has lasted until the present time, and is even now far from unpopular; and yet the independence of these growths upon syphilis would seem to be beyond question, except to the extent that any syphilitic sore in this neighborhood may, by the irritation of its dis- charge, cause their production. They owe their growth, in the first place, as pointed out by Diday,' to a special predisposition to the forma- tion of warty growths on various parts of the body in the individual, and this predisposition is assisted by the presence of any irritation of the part. Thus the discharge from a gonorrhoea or a leucorrhoea, or any disease of the rectum or genitals, may cause them to grow, and they may appear in persons apparently perfectly healthy and cleanly. Pregnancy has an undoubted influence upon their production, and they sometimes disappear spontaneously after delivery. From what has been said, it is evident that these growths are neither contagious nor inoculable, and that anti-syphilitic treatment can be of no avail. Symptoms. — These vegetations may occur at any age from infancy to adult life, though they generally belong to the latter period. They may vary in size and quantity from a single enlarged papilla at the verge of the anus to a mass such as is represented in the plate, and which weighs as much as a pound. The symptoms, in any case, will vary with their size, number, location, and the amount of the secretion. When they grow from one side of the intergluteal fold, and are large enough to press with their moistened surface upon the corresponding point of the opposite side, a second patch may be developed at the point of contact. The irritation from any other source would have the same effect. The development of the growths may be slow or rapid, and when the tumors 1 Op. cit., p. 506. •Exposition critique et pratique des nouvelles doctrines sur la syphilis. Paris, 1868. NOK-MAUaKANT OBOWTH8 OF THE BECTUM ANB ANUS. 145 • are of large size, the patient is constantly troubled by the feeling of a foreign body, by a sanious and foul-smelling discharge, and by fresh erosions and superficial ulcers in the adjacent parts. Great pain in de- fecation may be produced by a small wart situated just at the verge of the anus, and such a little tumor may give rise to all the characteristic symptoms of a painful fisstire, including a slight discharge, and an oc- casional drop or two of blood. They are not very infrequent on the line of junction of the mucous and cutaneous surfaces, just within the verge of the anus. They may, also, spring entirely from the mucous membrane, above the sphincter, though they are generally confined to the first inch of the canal, and, iii such cases, give rise to a much more aggravated train of symptoms, and to much difficulty of diagnosis. There they are gen- erally smaller and harder than when on the cutaneous surface, and cause a serous discharge, which may be so profuse as to escape from the anus between the acts of defecation, and cause much suffering from pruritus and rectal tenesmus. On examination in such a case, the mucous membrane will be found dry and glistening, as a rule, though sometimes there may be a more or less extensive proctitis ; and the little hard, tender, warty excrescence, which is the cause of all the grave train of symptoms and of so much suffering, may easily escape detection. The only treatment for such a condition is to seize the little tumor with the toothed forceps, and excise the mucous membrane to which it is attached. It may, however, return many times. ' Diagnosis. — The dignosis of these growths is not generally difficult, though care is necessary when they are small and located within the grasp of the sphincters. The mistake most commonly made is to con- sider them as syphilitic condylomata; and, indeed, they may not always be easily distinguishable from the raised mucous patch or flat condy- loma which is a manifestation of true syphilis. A careful examination of a raised mucous patch can scarcely fail, however, to show the differ- ence between its general character and that of a cauliflower growth which has sprung up from the surface like a shrub, and is attached to it by numerous little pedicles. The two may exist simultaneously, the wart being caused by the irritation of the discharge from the other. There is little danger of mistaking these vegetations for malignant growths, though they have been known to assume a semi-malignant epi- thelial character, and to return frequently after removal. Treatment. — The surest, most rapid, and in every way most satisfac- tory way of curing these vegetations, is by simple excision, with the knife or scissors. The ligature is often inapplicable, and cauterization is not always easy to limit in its action. The growths may, however, 'Des Yerrues de Pintestin rectum. Bognetta, Gaz. mM. de Paris, June, 1885. 10 146 DISEASES OF THE BEOTUM AND ANUS. often be indnced to dry and shrink np by applications of powdered alum or tannin, and by washing with astringent lotions, snch as Labaraque's solution. Condylomata. — The term condyloma has been applied to many differ- ent growths around the anus, as well as to the raised mucous patch al- ready spoken of, and to the remains of external haemorrhoids. It will be used here to refer to the non-syphilitic growths of skin frequently seen around the anus, which are attached by a broad base, are pinkish in color, soft, fleshy, glistening, moist, and irregular in shape, flattened where two are pressed together, or where one is subjected to the pressure of the buttocks, and generally giving out a slight secretion. They generally have one of the radiating folds of the anus as their point of departure, and they differ from the class of vegetations last described, in that they consist of an hypertophy of the whole thickness of the skin, and not alone of the papillae. The epithelial element in them is not as marked as in the warts, and the blood-vessels are also less developed. They are merely the result of a localized chronic inflamma- tion and thickening of the skin, and often follow an external hsemor- rhoid or any local irritation such as has been spoken of in connection with vegetations. They are generally isolated and few in number; but it may happen that after the irritation to which they owe their origin .has ceased, the growth may continue, becoming harder and more movable, and resembling a true fibroma. Such a hard tumor may, under sufficient irritation, take on an ulcerative and suppurative action, its size all the while increasing, until a foul, painful, indurated mass results which strongly resembles malignant disease. Paget * once said that without considering these growths as absolutely and always syphi- litic, they are so rare without it, that, as yet, he had not seen a case. They are a very common accompaniment of any ulcerative process within the rectum, and hence of stricture, and many a stricture has been untruly stamped as syphilitic because the discharge from the anus had caused a development of these fleshy tags. They are indeed common in syphilis of this part, but they are not syphilitic. These condylomatous tumors occasionally reach a large size, as in a case recently reported by Dr. Barnes.' The tumor in his case was the size of an ordinary orange, and had been protruded from the anus during labor. It proved to be a dense growth attached to the margin of the anus, the rest of the anal circumference being surrounded by piles more or less indurated. At one point, the tumor was greenish, as if about to sphacelate. It was removed by galvano-cautery. It had a broad base, and Dr. Barnes looked upon it as an outgrowth from a haemor- rhoidal tumor. Dr. Goodhart reported it as, for the most part, composed » Med. T. and Gaz., vol. i., 1865, p. 279. «Br. Med. Jour., April 12th, 1879. tfON-MALlOKANT QBOWTHS OF THB SECTCU AlID ANUS. 147 of loose fibro-cellalar tissue, coTered by a tough and altered mncoos membrane; the deep partB were, howerer, caTemoos in stntctnre. He was of opimoa that it originated in some chronic orergrowth of con- nectiTe tisBiie round a pile. The diagnosis of these growths is generally easy. They can scarcely be mistaken for aught except a eyphilitic gummy deposit or malignant disease, and they are not apt to be confounded with either. I have seen malignant deposit, however, mistaken for simple condyloma, and treated by mercurials, ablation, and the hot iron, it is needless to say without benefit. The necessity for distinguishing between the syphilitic and non- syphilitic condylomata around the anus has already been referred to. Fio. 4T.— Oondyloma Ma, or vegatactag condytomA IBumslead and Tarlor). There is a variety of mocons patch situated upon the skin near the anus which is often spoken of as condyloma lata or vegetating condyloma. The syphilitic condyloma Srst manifests itself as a red spot and by a Blight effusion beneath the epidermis, which is soon rnbbed off by fi-iction, exposing a raw surface, generally covered by a grayish pellicle. This sur- face is subsequently elevated by an upward growth, and by bmnching of the papillffi, with formation of connective tissue, and dilatation of the blood- vessels. Where this development of the papillte has reached a consider, able extent, the cauliflower appearance is thj result, and what was at first a simple mucous patch may become; a large pedunculated wart Burroonded by other vegetations which have sprung up around the original lesion, and which are due to the irritation of its presence (BumBtead and Taylor, EeyeB, Baumler). 148 DISEASBB OF THB BEOTUH AND ANUS. It may be impossible to distinguish this form of syphilis from the simple yegetation already described, except by the history, the fact of its infectiousness, and the results of treatment. Under the microscope, both are composed of an hypertrophy of the papillae of the derma. It ought not, however, to be difficult to distinguish between this syphilitic mucous patch and the simple hypertrophy of the skin, such as is seen at the site of an old external pile, to which we here limit the name of condyloma. This loose and iindeflned use by the word condyloma is much to be regretted, but is so common as to make any change out of the question. It is used here to denote only one form of growth, the simple non- syphilitic hypertrophy of the whole skin. What is usually called the syphilitic condyloma is here referred to as the raised or vegetating mucous patch. The only treatment necessary in cases of condylomata is their simple excision, after which there will generally be no return. Benignfungua. — ^Underthis title MoUi^re* describes a granular condi- tion of the mucous membrane of the lower end of the rectum occasionally seen in children as a result of prolapse. It is composed of soft, friable, Tascular tissue identical with the granulations of a cicatrizing wound. The surface of the mass is red and uneven, the base is marked by dilated veins. After defecation the tumor may remain prolapsed, but it is easily Teducible, and when prolapsed is not painful, which is a distinguishing mark between it and polypus. The haemorrhage attending this form of growth is always abundant and may cause much wasting. On account of this haemorrhage the growth is best treated by cauterization and astringents. Oummata. — These also may affect either anus or rectum, though their rarity in the latter may best be judged by the statement of Fournier* that he has never seen one, and only admits their existence on the testimony of Vemeuil who has seen one. However, their presence, a fortiori ^xoh- able, has been demonstrated by other observers than Verneuil. Esmarch* admits it; ZeissP reports a case in a male, and Zappula* another; Mollidre' has seen one starting at the anus and extending into the ischio- rectal fossa; and Foumier^ himself met one in a young woman starting in the left buttock and secondarily involving the anus and then the rec- tum. ^ Op. cit., p. 524. ^ Lesions tertiaires de T Anus et du Rectum, Paris, 1875, p. 8. 'Op. cit. < Vrtljschr. f. Dermatol, u. Syph., 1876, H. ii. * Ann. Univ. de Med., Milan, ccxiii., 1870. * Op. cit., p. 645. ' Op. cit. NON-MALIGNAKT GROWTHS OP THE RECTUM AND ANUS. 149 Ano-rectal syphiloma. — This affection is defined by Fournier* as " an infiltration of the rectal walls by a neoplasm, whose initial structure is still undetermined, but susceptible of degenerating into retractile fibrous tissue and of constituting in this way more or less extensive intes- tinal strictures." He speaks of its also as ^^hyperplastic rectitis l)ecoming later a fibro-sclerous rectitis," and as identical or at least analogous to other lesions of the same order developed in different viscera, as the liver or testicle. He particularly emphasizes the fact that this process begins in the submucous layers, and that the mu- cous membrane is only secondarily destroyed, being at first entirely free from ulceration or cicatrices. Its point of predilection is the rectal pouch, but it may be found below. He has never seen it above. Some- times only two or three centimetres of the wall are involved, but when it begins at the anus it may reach seven or eight centimetres up. It forms a cylinder around the whole circumference of the bowel. In the initial stage the rectum is only stiffened and thickened but not contracted. When the infiltration is limited to the vicinity of the anus, it is not uni- formly diffused around its circumference, but forms irregular masses which are at first covered by healthy tissue. These are painless unless inflamed, but are liable to erosion and ulceration. The disease is more common in females than in males— eight to one. Unfortunately the specific character of this ulceration cannot be proved under the microscope, there being nothing distinctive in its struc- ture. The theory advanced by Pournier has held its own, however, and has gained adherents. Duplay' adopts it, and Van Buren has distinctly recognized this form of disease, and has also '^ seen it