P E R I N E A L C I R S O I D 471

PERINEAL CIRSOID

BY LAMBERT ROGERS, V.R.D. FROM THE SURGICAL UNIT, THE WELSH NATIONAL SCHOOL OF MEDICINE,

THE ROYAL INFIRMARY, CARDIFF

‘‘ The swelling also is doughy and very compressible but when the pressure is removed, the blood enters it with a whiz and thrill, not with the distinct pulsating stroke that is found in aneurism.”-J. E. Erichsen on aneurism by anastomosis (1869).

CIRSOID aneurysms most commonly occur on the scalp and in relation to the cortex of the brain and are

Elkin (1946) suggested that the appearance of these scalp cirsoids may have given rise to the legend of

FIG. ~83.-Cirsoid aneurysm of scalp of a man aged 20, successfully treated by excision, January, 1936. This patient was seen well and without recurrence, March, 1955.

FIG. ~84.-Perineal cirsoid in a man aged 27.

comparatively rare elsewhere. A typical example the serpents on the head of Medusa. Examples of on the scalp is shown in Fig. 583. I extirpated subcutaneous cirsoids occurring in regions other than this eighteen years ago and it has not recurred. the scalp have been recorded ; in the neck (Cole and

472 T H E B R I T I S H J O U R N A L O F S U R G E R Y

Hunt, 1948), on the lip (Marshall, 1937 ; Cole and Hunt, 1948), in the pubic region (Bertola, Moreryra Bernan, and Parodi, 1946), and Sir John Bland-Sutton (1917) mentions that the largest which had come under his notice occupied the perineum of a lad, aged 19.

With his wide knowledge of comparative anatomy Sir John Bland-Sutton saw the resemblance between cirsoid aneurysms and the vascular arrangements of the rete mirabile in the forelimbs of sloths, the tails

I am indebted to my colleage, Mr. J. F. E. Gillam, F.R.C.S., for kindly giving me the opportunity to deal with the following example of a perineal cirsoid in which there was fibrous and fatty tissue along with a multitude of ramifying vessels some being quite large channels, many of which were thick- walled arteries.

Case.-A married man, aged 27, a clerk in a Govern- ment office, complained of an irritant, hot, and pulsating

FIG. gSS.-Angiograms of perineal cirsoid. Same patient as Fig. 584.

of spider monkeys, and the subpleural plexuses of the cetaceans.

Known by a variety of names, such as plexiform or racemose angioma of arterial, venous, or mixed varieties, aneurysmal varix, varicose nzvus, aneurysm by anastomosis, aneurysmal or pulsating angioma, and varicose, plexiform, or cirsoid aneurysm, the subcutaneous lesions fall into the same two groups into which Cushing and Bailey (1928) classified the blood-vessel tumours of the brain, namely the angiomatous malformations and the hzmangio- blastomata. Elsewhere (Rogers, 1936) I have recorded examples of both varieties occurring in the scalp. Searby (1932) has clearly shown that all these vascular lesions contain abnormal connecting channels between their arterial and venous com- ponents and are thus all examples of arteriovenous aneurysms.

swelling in the perineum which had been present through- out his life. Profuse perspiration in the area resulted in irritation which was worse when walking and limited his activities, such as playing football. Twice the skin over the mass had broken and there had been profuse bleeding, on one occasion in the form of a jet which necessitated his admission to hospital for its arrest.

Examination showed a healthy well-built young man, normal in all respects except for a large perineal swelling extending backwards from the scrotum almost as far as, but not involving the anus (Fig. 584). Approximate measurements of the swelling were 7 in. long by 2 in. wide and 3 in. in depth. On palpation it was soft and hot and could be felt to contain large pulsating vessels. The covering skin was pigmented and beset with tortuous veins. When a stethoscope was placed over the mass, a to-and-fro bruit could be heard. There was no evidence of any effect of the lesion on the general circulation. Angiograms obtained from injecting the

P E R I N E A L C I R S O I D 473

femoral arteries, for which I am indebted to Dr. Arthur Jones, of the Cardiff Royal Infirmary, are shown in Fig. 585.

AT OPERATION.-The tumour along with some perineal skin covering it was excised under general anaesthesia, the patient being placed in the lithotomy position and receiving a blood transfusion meanwhile. Large vessels were ligated as exposed, but even so there was a good deal of bleeding because of cutaneous vascular connexions

vascular anomalies composed of interlacing masses of vascular channels which are either predominantly arterial, or predominantly venous, or consist of a mixture Of both types Of Or they may 'On- tain fibrous and fatty tissue in addition to the vascular

and be better regarded as haemangio- T h e only satisfactory treatment of either blastomas.

variety is excision.

FIG. 586.-Perineal cirsoid after excision. In right hand figure the tumour has been partly opened to show the wide mouths of some of the constituent vessels.

FIG. 587. Other views of perineal cirsoid tumour to show the tortuous vessels of which it is composed. Many of these are thick-walled arteries.

which had to be divided. After the vascular mass had been excised the superficial perineal muscles were exposed in the wound. To prevent the passage backwards of the testes into the perineum, a new central perineal point was constructed by stitching the skin to the super- ficial perineal muscles with thread sutures which were also used to bring the skin edges together. Healing and convalescence were satisfactory. The specimen is shown in Figs. 586, 587.

SUMMARY Cirsoid aneurysms most commonly occur on

the scalp, but are occasionally found elsewhere. An example in the perineum is here reported. These aneurysmal angiomas may be purely developmental,

REFERENCES BERTOLA, V. J., MORERYRA BERNAN, P., and PARODI, H.

(1946), Bol. SOC. Cirug. Cordoba, 7, 348. BLAND-SUTTON, J. (I917), Tumours, Innocent and Malig-

nant, 6th ed. London : Cassell. COLE, P. P., and HUNT, A. H. (1948), Brit. J . Surg.,

CUSHING, H., and BAILEY, P. (1928), Tumours arising from the Blood-vessels of the Brain. Springfield, Ill. : C. C. Thomas.

ELKIN, D. C. (1946), Ann. Surg., 123, 591. MARSHALL, F. W. (1937), 3. R. Army med. Cps, 69,

ROGERS, LAMBERT (1936), Aust. N.Z. J . Surg., 6, 99. SEARBY, H. (1932), Bid., I, 209.

36, 346.

16.