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Control of the spastic anal sphincter
CONTROL OF THE SPASTIC ANAL SPHINCTER WALTER
F. PREUSSER, M.D. ALBANY,
T
HE anorecta1 region because of its generous sensory nerve supply is peculiarly subject to numerous painfuI diseases. Very often the amount of pain experienced is out of a11 proportion to the size of the Iesion presenting itseIf. SurgicaI corrective measures are notoriousIy known to be foIIowed by proIonged periods of intense discomfort. The hesitancy which the genera1 pubIic dispIays in appIying for remedia1 measures is thus partIy accounted for. With the possibIe exception of pain due to periana1 or perirect21 suppuration, most of the distress is occasioned by a reflex spasticity of the ana sphincter muscuIature. AIthough the action of each muscle is controIIed by a separate innervation, they are reffexIy interdependent. It has been proved experimentaIIy that remova of the tonus of the externa1 sphincter resuIts in a considerabIe Ioss of tonicity of the interna sphincter. The Iatter after such a procedure becomes diIatabIe with a minimum of effort. It has been the custon among surgeons to perform divuIsion of the ana sphincters routineIy in a great many operations of the anorecta1 zone. The sphincters are forcibIy stretched in an effort to produce a paresis of these structures with the idea of preventing postoperative spasm. The method is open to a number of serious objections. The empIoyment of force with its attendant rupture of muscIe fibrils, the production of edema and ecchymosis with consequent fibrosis vioIates the fundamental principIes of sound surgica1 practice. A divuIsion which accomphshes this may we11 be rewarded by a Ioss of sphincter tone and in a good many instances by an incontinence which Iasts an embarrassing
N. Y.
Iength of time. The Iiterature is repIete with accounts of this unexpected compIication. HiIIer found a great dea1 of variabiIity in the structura1 anatomy of the sphincter muscIes. The direction of the fibers is not constant, the anococcygea1 raphe may be poorIy deveIoped, and the interna sphincter at times does not form a compIete circle. On the other hand, simpIe diIatation is usuaIIy foIIowed by a rapid return of spasticity when surgica1 measures have been instituted. It has been demonstrated that the externa1 sphincter wiI1 regain its tonus even though its motor nerves are sectioned. This argues for the presence of a myotonic center in the muscIe. Divulsion or effective diIatation necessitates the administration of genera1 or spina anesthesia which impIies a certain risk. Transsacral bIock may be empIoyed. In this event hospitalization is caIIed for and the method requires for its performance a considerable degree of skiI1. Division of the sphincter by incision resuIts in a springing apart of the muscIe fibriIs. It is weII-known that incontinence foIIows this operation. Gant estimates that. it occurs in about I per cent of cases. Its empIoyment is to be condemned except in chronic indurated fissure where partia1 division usuaIIy suffices. In fi.stuIa it is resorted to only when collateral tracts having previousIy been incised and trimmed, have granuIated and contracted so as to offer a supporting framework in the fina stage of sphincter section and eIimination of the interna opening. It was with the idea of obviating these objections that those interested in rectal surgery sought to devise aIternative methods. A simpIe method has been devised to provide adequate sphincter relaxation. 327
328
American Journal of Surgery
Preusser-Spastic
It has become we11 established that soIutions in oiI are much Iess readiIy absorbed than aqueous ones. In the treatment of Iues, aqueous soIutions of mercury and bismuth are used for their ready absorbabihty, whereas the oiIy suspensions guarantee a more sustained effect. This knowIedge has been empIoyed in proctoIogy by incorporating anesthetic agents in sweet aImond oiI for injection purposes. Sweet aImond oiI with its Iower viscosity is preferabIe to some of the other vegetabIe oiIs. GabrieI of London empIoys nupercaine in a 0.5 per cent soIution. Butesin or benzocaine may be empIoyed in concentrations up to 5 per cent. AI1 these anesthetic agents are comparativeIy insoIubIe in oiI, necessitating the use of benzy1 aIcoho1 as a soIvent in the mixture. This soIvent in about 2-3 per cent concentration is sufficient. Yeomans, Gorsch and Mattesheimer empIoyed such a preparation in the treatment of pruritus ani and Hayes used it as a IocaI anesthetic agent. * The technique of administration offers no tech&a1 diffIcuIties. SeIect a point about x inch from the anaI verge posteriorIy and in the midIine. This may be anesthetized using a fine needIe and producing a whea1 with a few drops of I per cent novocaine soIution. A 20 gauge needle about 3 inches in Iength is introduced at this point. The course of the needIe is directed IateraIIy and subcutaneousIy. The IateraI course of the needIe must be estimated to foIIow the course of the fibers of the externa1 sphincter mu&e. InfiItration of the posterior haIf of the muscIe with 2 C.C. of the oiIy soIution foIIows. A simiIar procedure is performed on the posterior segment of the opposite side. It shouId be accomphshed without removing the needIe from its point of origina insertion. The needIe is now directed forward and paraIIe1 to the ana cana for a distance of I inch. This is the point at which the fibers of the externa1 sphincter converge posteriorIy. One cubic centimeter of the soIution is used to infihrate this zone. It is necessary to
Sphincter
AUGIJST, rgjq.
inject the soIution so that it is evenIy distributed aIong the course of the muscIe fibriIs, thus preventing poohng. Pooling in the deep structures may Iead to a rather painfu1 induration; SubcutaneousIy, it often resuIts in the production of sIough. Another precaution to be observed is to prevent puncturing the ana mucosa, which A finger shouId be invites infection. introduced in the ana cana to guide the course of the needIe. Under no circumstances must the needIe be directed into a coIIection of puruIent materia1 or inflamed tissue. The risk of dissemination is ever present under such conditions. ReIaxation of the sphincter occurs aImost immediateIy foIIowing injection. Proctoscopes may now be introduced with great faciIity. Reflex spasticity due to painfu1 ana Iesions disappears, offering an opportunity to examine more carefuIIy for pathoIogica1 conditions. The anesthesia and reIaxation so produced may be expected to continue unti1 absorption of the oiI anesthetic is compIete. The average duration is from four to seven days. This procedure is very definiteIy indicated in cases where a spastic condition of the externa1 sphincter of the anus is undesirabIe. Where for any reason gradua1 diIatation is advisabIe, matters wiI1 be expedited. In acute fissure there is aImost immediate reIief. Drainage of infected crypts is faciIitated. It may be used to avoid the postoperative discomfort incidenta1 to hemorrhoidectomy and excision of an externa1 thrombotic hemorrhoid. It is efficacious in promoting the reduction of proIapsed and thrombosed interna hemorrhoids. It facihtates the repIacement of a proIapsed and stranguIated rectum. ‘The method is therefore recommended as a safe, simpIe means of controIIing sphincter tone without the production of incontinence. SUMMARY
Pain foIIowing surgica1 measures for the reIief of anorecta1 disease is for the most
lh\;ta
SEHIL-s Vol..
XXV,
No.
2
Preusser-Spastic
part occasioned by reflex spasticity of the anaI sphincter muscuIature. DivuIsion of the anaI sphincters may resuIt in Ioss of sphincter tone and inSimpIe diIatation is usuaIIy continence. foIIowed b> a prompt return of spasticity. Incontinence aIso foIIows division of the sphincter by incision. To obviate these objections a simpIe
A,,icric:~n J<,urn:il
Sphincter
01 ‘it,rcc,y
329
method of effecting reIaxation of the sphincters has been devised. This comprises the injection of an anesthetic agent incorporated in sweet aImond oi1, the technique of which is described. Relaxation of the sphincter occurs aimost immediateIy and continues until the oil is compIeteIy absorbed, usually from four to seven days.
REFERENCES of anal fissure and listuIa. Surp. Gvnec. Obst.. 35:
GANT. S. Diseases of the Rectum, Colon and Anus. PhiIa., 1923. GABRIEL, W. B. The treatment of pruritus ani and anai fissure. &it. M. J., 2: 311-312 (Aug. 30)
5659 (May) 1931. PREUSSER, W. F. Fissure in ano. Med. J. ~9~Record,
1930. HAYES, H. T. Benacol in rectal conditions. South. ,M. J., 24: 309-311 (Apr.) 1931. HII.I.ER, R. I. The anal sphincter and the pathogenesis
YEOMANS, F. C., GORSCH, R. V., and MATTESHEIMEH, J. L. Benacol in the treatment of puritus ani Trans. Am. Proct. Sot., 28: 24-32, 1927.
138: 8gg1
(Aug. 2) 1933.
%I3 REFERENCES
OF
FLEISCHER. Bericht ueber einen eigenartigen ZufaIIsbefund: Pseudomyxom der Appendix. Monatscbr. J. Geburts. u. Gynaek, 63: 155, 1923. HALLOPEAU. Pseudo tumeur d’origine inffammatoire developpee autour de I’appendice. Bull. et men. Sot. anat. de Paris, 87: 437, 1912. HALLOPEAU. Tumeur infiammatoire autour d’un appendice g&ant. Bull. et mem. Sot. anat. de Paris. No. 14. 786, 1919. IIAMMEKFAHR. Fin FalI von Pseudomyxom der Appendix. Berl. klin. W&s&r., I: 1034, 19x3. HARTMAXN and KINDLEY. A case of ‘pseudomyxomatous cyst of the appendix. J. A. M. A., 62: 1795, 1914. HOFMEISTER. Beitr. f. Cbir., 6: 344. I IOKWITZ, 0. SyphiIis and appendicitis. Ann. Surg., I 7: 74, 1898. HL.ETTL. Beitr. z. Cbir., 84. LEOKAT. Les fibromyomes de I’appendice. Marseille Med., p. 869, 1924. LEORAT. Les tumeurs de I’appendice. Gaz. des Hop. de Paris (March 28) 1925. LOCKHART MUMMERY. Diseases of the Rectum and CoIon and their Surgical Treatment. London, BaiIIiere, 1923. LYNCH and FELSEN. Tumors of the CoIon and Rectum, their Pathology, Diagnosis and Treatment. N. Y., Hoeber, 1925. I\IASSON. Les nevromes sympathiques de I’appendice obIiterant. Lyon cbir., 17: 281-299, 1921. RIMSON. VoIumineux nkvromes appendicuiaires ayant provoque I’ecIatement des musculeuses. Bull. et !\/lkm.Sot. anat. de Paris, 93: 305, 1923. bIASSON. Tumeur argentaffme de I’appendice. Sot. anat. de Paris, 89: 405, 1919. ~IINERVINI. Pseudomixom peritoneaIe incistato di origine appendicoIare in uomo aduIto. Arch. ital. di cbir., 13: 150, 1925. * Continued
DR.
ST.
JOHN*
MORLOT ET MATHIEL-. MucoceIe g&ant de I’appendice coeca1. Bull. et mCm. Sot. anat. Paris, 93: 333, I 923. NOESSKE. Die StrahIenpiIzkrankheit. In Kirschner and Nordman’s Die Chirurgie. OGILVIE. Pseudomyxomatous cyst of the appendix with calcification of waIIs. Report of cast. J. A. ,Zf. A., 64: 637, 1915. OMBREDANNE. Myxome de I’appendice. Bull. et me%. Sot. chr. de Parts, 43: I 179, 1917. PLISSOI~ET CARRIVE. Tumeur inffammatoire dc Ia fosse iIiaque droite dheloppk aux d&pens d’un appcndice et diverticules muqueux. Bull. et mkm. Sot. chir. de Paris, 1084;rogz, 1921. RANZI. Ueber Mukokelen der Appendix. !&‘iener med. Wcbnscbr., 76: 643, 1926. R~BLI. Ueber ein Fibromyxom des Darmes. Thesis. Wuerzburg, 1891. &IOTA. Ztscbr. f. Chir., IOI : SCHIPPERS. Myxoma intestinalis. Niederl. TiJdscbr. v. Geneesk., Amsterdam, p. 1855, 1917. TACLIAVACCHO SACCO. Fibromixoma de1 apendice en una hernia inguina1 derecha con deshzamiento de1 ciego apendicectomia y cura radica1. Rev. asoc. med. argentina, 24: 569, 1916. THEVEIGARD. Pseudo tumeur coIIoide appendicuIocoecale. Sot. Chir. Paris (May 5) 1922. THEVET~ARD ET DURANTE. Tumeurs inff ammatoires ileo-coeco-appendicuIaires simuIant Ia tuberculose hyperplasique. Bull. et mkm. Sot. anat. de Paris, 92: 281, 1922. TROTTE.R. PeritoneaI pseudo myxoma originating from the vermiform appendix. Brit. M. J., p. 687, rgro. WATERWORTH. Pseudo-myxoma of the appendix. New Zealand M. J., 21: 221, 1922-23. \vILLEMS. Dermoidcyste zwischen den BIaettern der Mcsoappendix in ihrer Differential-diagnosenstehung der appendicitischen Tumorbildungen Be&. z. klin. Cbir., 86: 223, 1913. from p. 248.
F. PREUSSER, M.D. ALBANY,
T
HE anorecta1 region because of its generous sensory nerve supply is peculiarly subject to numerous painfuI diseases. Very often the amount of pain experienced is out of a11 proportion to the size of the Iesion presenting itseIf. SurgicaI corrective measures are notoriousIy known to be foIIowed by proIonged periods of intense discomfort. The hesitancy which the genera1 pubIic dispIays in appIying for remedia1 measures is thus partIy accounted for. With the possibIe exception of pain due to periana1 or perirect21 suppuration, most of the distress is occasioned by a reflex spasticity of the ana sphincter muscuIature. AIthough the action of each muscle is controIIed by a separate innervation, they are reffexIy interdependent. It has been proved experimentaIIy that remova of the tonus of the externa1 sphincter resuIts in a considerabIe Ioss of tonicity of the interna sphincter. The Iatter after such a procedure becomes diIatabIe with a minimum of effort. It has been the custon among surgeons to perform divuIsion of the ana sphincters routineIy in a great many operations of the anorecta1 zone. The sphincters are forcibIy stretched in an effort to produce a paresis of these structures with the idea of preventing postoperative spasm. The method is open to a number of serious objections. The empIoyment of force with its attendant rupture of muscIe fibrils, the production of edema and ecchymosis with consequent fibrosis vioIates the fundamental principIes of sound surgica1 practice. A divuIsion which accomphshes this may we11 be rewarded by a Ioss of sphincter tone and in a good many instances by an incontinence which Iasts an embarrassing
N. Y.
Iength of time. The Iiterature is repIete with accounts of this unexpected compIication. HiIIer found a great dea1 of variabiIity in the structura1 anatomy of the sphincter muscIes. The direction of the fibers is not constant, the anococcygea1 raphe may be poorIy deveIoped, and the interna sphincter at times does not form a compIete circle. On the other hand, simpIe diIatation is usuaIIy foIIowed by a rapid return of spasticity when surgica1 measures have been instituted. It has been demonstrated that the externa1 sphincter wiI1 regain its tonus even though its motor nerves are sectioned. This argues for the presence of a myotonic center in the muscIe. Divulsion or effective diIatation necessitates the administration of genera1 or spina anesthesia which impIies a certain risk. Transsacral bIock may be empIoyed. In this event hospitalization is caIIed for and the method requires for its performance a considerable degree of skiI1. Division of the sphincter by incision resuIts in a springing apart of the muscIe fibriIs. It is weII-known that incontinence foIIows this operation. Gant estimates that. it occurs in about I per cent of cases. Its empIoyment is to be condemned except in chronic indurated fissure where partia1 division usuaIIy suffices. In fi.stuIa it is resorted to only when collateral tracts having previousIy been incised and trimmed, have granuIated and contracted so as to offer a supporting framework in the fina stage of sphincter section and eIimination of the interna opening. It was with the idea of obviating these objections that those interested in rectal surgery sought to devise aIternative methods. A simpIe method has been devised to provide adequate sphincter relaxation. 327
328
American Journal of Surgery
Preusser-Spastic
It has become we11 established that soIutions in oiI are much Iess readiIy absorbed than aqueous ones. In the treatment of Iues, aqueous soIutions of mercury and bismuth are used for their ready absorbabihty, whereas the oiIy suspensions guarantee a more sustained effect. This knowIedge has been empIoyed in proctoIogy by incorporating anesthetic agents in sweet aImond oiI for injection purposes. Sweet aImond oiI with its Iower viscosity is preferabIe to some of the other vegetabIe oiIs. GabrieI of London empIoys nupercaine in a 0.5 per cent soIution. Butesin or benzocaine may be empIoyed in concentrations up to 5 per cent. AI1 these anesthetic agents are comparativeIy insoIubIe in oiI, necessitating the use of benzy1 aIcoho1 as a soIvent in the mixture. This soIvent in about 2-3 per cent concentration is sufficient. Yeomans, Gorsch and Mattesheimer empIoyed such a preparation in the treatment of pruritus ani and Hayes used it as a IocaI anesthetic agent. * The technique of administration offers no tech&a1 diffIcuIties. SeIect a point about x inch from the anaI verge posteriorIy and in the midIine. This may be anesthetized using a fine needIe and producing a whea1 with a few drops of I per cent novocaine soIution. A 20 gauge needle about 3 inches in Iength is introduced at this point. The course of the needIe is directed IateraIIy and subcutaneousIy. The IateraI course of the needIe must be estimated to foIIow the course of the fibers of the externa1 sphincter mu&e. InfiItration of the posterior haIf of the muscIe with 2 C.C. of the oiIy soIution foIIows. A simiIar procedure is performed on the posterior segment of the opposite side. It shouId be accomphshed without removing the needIe from its point of origina insertion. The needIe is now directed forward and paraIIe1 to the ana cana for a distance of I inch. This is the point at which the fibers of the externa1 sphincter converge posteriorIy. One cubic centimeter of the soIution is used to infihrate this zone. It is necessary to
Sphincter
AUGIJST, rgjq.
inject the soIution so that it is evenIy distributed aIong the course of the muscIe fibriIs, thus preventing poohng. Pooling in the deep structures may Iead to a rather painfu1 induration; SubcutaneousIy, it often resuIts in the production of sIough. Another precaution to be observed is to prevent puncturing the ana mucosa, which A finger shouId be invites infection. introduced in the ana cana to guide the course of the needIe. Under no circumstances must the needIe be directed into a coIIection of puruIent materia1 or inflamed tissue. The risk of dissemination is ever present under such conditions. ReIaxation of the sphincter occurs aImost immediateIy foIIowing injection. Proctoscopes may now be introduced with great faciIity. Reflex spasticity due to painfu1 ana Iesions disappears, offering an opportunity to examine more carefuIIy for pathoIogica1 conditions. The anesthesia and reIaxation so produced may be expected to continue unti1 absorption of the oiI anesthetic is compIete. The average duration is from four to seven days. This procedure is very definiteIy indicated in cases where a spastic condition of the externa1 sphincter of the anus is undesirabIe. Where for any reason gradua1 diIatation is advisabIe, matters wiI1 be expedited. In acute fissure there is aImost immediate reIief. Drainage of infected crypts is faciIitated. It may be used to avoid the postoperative discomfort incidenta1 to hemorrhoidectomy and excision of an externa1 thrombotic hemorrhoid. It is efficacious in promoting the reduction of proIapsed and thrombosed interna hemorrhoids. It facihtates the repIacement of a proIapsed and stranguIated rectum. ‘The method is therefore recommended as a safe, simpIe means of controIIing sphincter tone without the production of incontinence. SUMMARY
Pain foIIowing surgica1 measures for the reIief of anorecta1 disease is for the most
lh\;ta
SEHIL-s Vol..
XXV,
No.
2
Preusser-Spastic
part occasioned by reflex spasticity of the anaI sphincter muscuIature. DivuIsion of the anaI sphincters may resuIt in Ioss of sphincter tone and inSimpIe diIatation is usuaIIy continence. foIIowed b> a prompt return of spasticity. Incontinence aIso foIIows division of the sphincter by incision. To obviate these objections a simpIe
A,,icric:~n J<,urn:il
Sphincter
01 ‘it,rcc,y
329
method of effecting reIaxation of the sphincters has been devised. This comprises the injection of an anesthetic agent incorporated in sweet aImond oi1, the technique of which is described. Relaxation of the sphincter occurs aimost immediateIy and continues until the oil is compIeteIy absorbed, usually from four to seven days.
REFERENCES of anal fissure and listuIa. Surp. Gvnec. Obst.. 35:
GANT. S. Diseases of the Rectum, Colon and Anus. PhiIa., 1923. GABRIEL, W. B. The treatment of pruritus ani and anai fissure. &it. M. J., 2: 311-312 (Aug. 30)
5659 (May) 1931. PREUSSER, W. F. Fissure in ano. Med. J. ~9~Record,
1930. HAYES, H. T. Benacol in rectal conditions. South. ,M. J., 24: 309-311 (Apr.) 1931. HII.I.ER, R. I. The anal sphincter and the pathogenesis
YEOMANS, F. C., GORSCH, R. V., and MATTESHEIMEH, J. L. Benacol in the treatment of puritus ani Trans. Am. Proct. Sot., 28: 24-32, 1927.
138: 8gg1
(Aug. 2) 1933.
%I3 REFERENCES
OF
FLEISCHER. Bericht ueber einen eigenartigen ZufaIIsbefund: Pseudomyxom der Appendix. Monatscbr. J. Geburts. u. Gynaek, 63: 155, 1923. HALLOPEAU. Pseudo tumeur d’origine inffammatoire developpee autour de I’appendice. Bull. et men. Sot. anat. de Paris, 87: 437, 1912. HALLOPEAU. Tumeur infiammatoire autour d’un appendice g&ant. Bull. et mem. Sot. anat. de Paris. No. 14. 786, 1919. IIAMMEKFAHR. Fin FalI von Pseudomyxom der Appendix. Berl. klin. W&s&r., I: 1034, 19x3. HARTMAXN and KINDLEY. A case of ‘pseudomyxomatous cyst of the appendix. J. A. M. A., 62: 1795, 1914. HOFMEISTER. Beitr. f. Cbir., 6: 344. I IOKWITZ, 0. SyphiIis and appendicitis. Ann. Surg., I 7: 74, 1898. HL.ETTL. Beitr. z. Cbir., 84. LEOKAT. Les fibromyomes de I’appendice. Marseille Med., p. 869, 1924. LEORAT. Les tumeurs de I’appendice. Gaz. des Hop. de Paris (March 28) 1925. LOCKHART MUMMERY. Diseases of the Rectum and CoIon and their Surgical Treatment. London, BaiIIiere, 1923. LYNCH and FELSEN. Tumors of the CoIon and Rectum, their Pathology, Diagnosis and Treatment. N. Y., Hoeber, 1925. I\IASSON. Les nevromes sympathiques de I’appendice obIiterant. Lyon cbir., 17: 281-299, 1921. RIMSON. VoIumineux nkvromes appendicuiaires ayant provoque I’ecIatement des musculeuses. Bull. et !\/lkm.Sot. anat. de Paris, 93: 305, 1923. bIASSON. Tumeur argentaffme de I’appendice. Sot. anat. de Paris, 89: 405, 1919. ~IINERVINI. Pseudomixom peritoneaIe incistato di origine appendicoIare in uomo aduIto. Arch. ital. di cbir., 13: 150, 1925. * Continued
DR.
ST.
JOHN*
MORLOT ET MATHIEL-. MucoceIe g&ant de I’appendice coeca1. Bull. et mCm. Sot. anat. Paris, 93: 333, I 923. NOESSKE. Die StrahIenpiIzkrankheit. In Kirschner and Nordman’s Die Chirurgie. OGILVIE. Pseudomyxomatous cyst of the appendix with calcification of waIIs. Report of cast. J. A. ,Zf. A., 64: 637, 1915. OMBREDANNE. Myxome de I’appendice. Bull. et me%. Sot. chr. de Parts, 43: I 179, 1917. PLISSOI~ET CARRIVE. Tumeur inffammatoire dc Ia fosse iIiaque droite dheloppk aux d&pens d’un appcndice et diverticules muqueux. Bull. et mkm. Sot. chir. de Paris, 1084;rogz, 1921. RANZI. Ueber Mukokelen der Appendix. !&‘iener med. Wcbnscbr., 76: 643, 1926. R~BLI. Ueber ein Fibromyxom des Darmes. Thesis. Wuerzburg, 1891. &IOTA. Ztscbr. f. Chir., IOI : SCHIPPERS. Myxoma intestinalis. Niederl. TiJdscbr. v. Geneesk., Amsterdam, p. 1855, 1917. TACLIAVACCHO SACCO. Fibromixoma de1 apendice en una hernia inguina1 derecha con deshzamiento de1 ciego apendicectomia y cura radica1. Rev. asoc. med. argentina, 24: 569, 1916. THEVEIGARD. Pseudo tumeur coIIoide appendicuIocoecale. Sot. Chir. Paris (May 5) 1922. THEVET~ARD ET DURANTE. Tumeurs inff ammatoires ileo-coeco-appendicuIaires simuIant Ia tuberculose hyperplasique. Bull. et mkm. Sot. anat. de Paris, 92: 281, 1922. TROTTE.R. PeritoneaI pseudo myxoma originating from the vermiform appendix. Brit. M. J., p. 687, rgro. WATERWORTH. Pseudo-myxoma of the appendix. New Zealand M. J., 21: 221, 1922-23. \vILLEMS. Dermoidcyste zwischen den BIaettern der Mcsoappendix in ihrer Differential-diagnosenstehung der appendicitischen Tumorbildungen Be&. z. klin. Cbir., 86: 223, 1913. from p. 248.