A CASE OF PSEUDOMYXOMA OF THE PERITONEUM

1498 that requires further investigation. In pseudoof ovarian origin the jelly-like consistence is due to myxoma pseudomucin. Metastases such as occur in ovarian pseudomyxoma have not yet been observed in the cases of£

slightly turbid contents ;it was attached to the csecum by a pedicle formed of the proximal half inch of the normal vermiform appendix, and before operation had been diagnosed as a pedunculated myoma projecting from the right side of the uterus. In the course of my operative experience I have met with two cases throwing light on this condition ;in these the vermiform appendix was distended with clear soft gelatinous material, and in one of them the cyst thus formed ruptured during bimanual examination. As often happens with rare

a

cases,

then becomes distended with mucus and a cyst of similar origin to a hydrosalpinx is formed. The immediate cause of cyst formation is obscure. In hydrosalpinx there is in the early stage usually inflammation, mild in degree, of the mucous lining of the Fallopian tube, while later on further distension is due to exudation of noninflammatory nature along with atrophy of the mucous coat. In my two vermiform cysts there was no sign of inflammatory change in the mucous lining. The appendical cyst with aseptic contents must be sufficiently free from adhesions to allow of its rupture or perforation into the open peritoneal

these two were seen with a very short interval, both my wards at the same time.

being in

CASE 1.-Cyst of the vermiform appendix removed during hysterectomy for fibroids.-A woman, aged 52, married only four and a half years and never pregnant, was the subject of numerous uterine fibromyomata. For 12 months there had been ill-defined bearing-down pains, and two months before being seen for the first time there was an acute attack of pain with vomiting. Numerous adhesions were present in relation to the

fibroids.

none in connexion with the distended vermiform This last formed a pedunculated elongated cyst measuring 23/4 x xin. The wall was firm, fibrous, and opaque; the lumen, distended with clear mucinous fluid, did not connect with the lumen of the stump of appendix that formed a pedicle about half an inch in length. Under the microscope sections of the wall showed two layers of muscular tissue and a lining of mucous membrane with lymphoid tissue and mucous glands; a single layer of secreting epithelium similar to that lining the glands covered portions of the surface of the

appendix.

mucous

layer. (Fig. 3.) a good recovery

The patient made the operation.

and remains well two years after

The second case was sent in with a probable diagnosis of ovarian cyst. During gentle examination rupture took place and the gelatinous contents escaped into the peritoneal cavity. No reaction of any kind followed, neither pain, vomiting, nor rise of temperature or pulse. Indeed, there was so little disturbance that one hesitated to open the abdomen. Fortunately, the coexisting prolapse required operation, and the nature of the cyst was then discovered. CASE 2.-Cyst of vermiform appendix ruptesred during examination;; removal at the same time with radical cnre of ntc1’o-t’aginal prolapse.A woman, aged 68, was admitted to the Birmingham General Hospital on Oct. 10th, 1910, complaining of abdominal pain and swelling of three months’ duration, associated with nausea and vomiting. The patient In the lower abdomen a wellwas thin, and looked about her age. defined rounded lump, not tender, extended 1 inches above the pubes on

the

right

of the middle line.

On

vaginal

examination the upper

part of the vaginal wall and the cervix felt horny, the result of In the

a

large

olrl-standing prolapse. right lower abdomen a well-defined thinwalled cystic tumour as large as a fist was felt. While this was being examined bimanually without the use of force it was felt suddenly to burst between the examining hands and disappear. There was no pain or other reaction on the part of the patient. Twenty-four hours later there had been no rise of temperature or pulse, nor any other complaint. Operation for the prolapse was proceeded with, the patient being placed in the lithotomy position and a longitudinal incision made in the anterior vaginal wall. The bladder was pushed up from the front of the uterus and the utero-vesical pouch of peritoneum opened. On the uterus being drawn out of this incision thick gelatinous greyish material escaped from the peritoneal cavity to an amount estimated at from 6 to 8 oz. Both ovaries and tubes were atrophied and senile, but showed nothing abnormal, not even an adhesion. The pelvis was elevated, and with the aid of retractors its interior was inspected. Attachel to the right posterior brim of the pelvis was seen the opaque white corrugated wall of a collapsed cyst whose pedicle could not be reached through the vagina. The uterus was now sutured between the base of the bladder and the anterior vaginal wall ; and the anterior vaginal incision was closed by catgut sutures. An extensive colpo-perineorriiaphy was also done. The patient was then placed in the Trenielenburg position and the peritoneal cavity was opened by a suprapubic transverse fascial incision. The collapsed cyst above mentioned was in close connexion with the end of the caecum, from which two of the three longitudinal muscular bands could be traced on to the attached end of the cyst ; the internal and posterior band became lost under some fat. During the removal of the cyst the muscular wall of the csecum was bared over an areaxxin., but the lumen was not opened; two or three bleeding points were ligatured and the raw surface covered in by peritoneum. There were a few adhesions of the cyst to the end of the caecum and. to the peritoneum over the posterior part of the pelvic brim. The uterine appendages were again carefully examined from the abdominal side and showed nothing at all abnormal. The omentum was adherent to a part of the left anterior abdominal wall 3 inches above the pelvic brim and at some distance from the position of the cyst. The abdominal incision was closed without drainage and the patient made a good recovery.

point

appendical origin. Pseudomyxoma of the peritoneum originating in the vermiform appendix is rare, because the necessary antecedent conditions are rare. The cavity of the appendix must be cut off from the lumen of the caecum, usually by a cicatricial septum remaining from some old inflammatory condition ; the cavity

cavity. The irritation caused by the presence of the gelatinous fluid is slight, so that it usually becomes encapsuled by recently formed delicate connective tissue. According to Trotter, the peritoneal endothelium in contact with the gelatinous effusion may persist and is apt then to become cubical or columnar, or it may grow over and cover in the foreign substance. Most observers have found scattered through the jelly chains of cubical or columnar cells ; these have been supposed by some observers to be derived from the epithelial lining of the appendix, by others from the transformation of the peritoneal endothelium. Another origin is likely for many of them, which may be plasma cells engaged in the attempt to absorb the effused substance. The peritoneal changes are due either to attempts at absorption or to plastic inflammation of mild degree set up by the presence ofthe foreign material.

Bibliog),aphy.-IVatkins and others: Zeiitrall)latt fiir Gynakologie, 1910, p. 197; Transactions of the Gynecological Society of Chicago, Nov. 20th, 1909. Merkel: Transactions of the Gynecological Society of Chicago, 1911, p. 245. Cramer: Ibi,1., 1911, p. 373. Trotter : Brit. Med. Jour., vol. i., 1910, p. 687.

Moore : Ibid., p. 1109. Neumann : Berliner No. 1. Weinhold: Monatsschrift fiir Geburtshiilfe und Gynakologie, April, 1909. Wilson: Transactions of of the Royal Society Medicine, Obstetrical and Gynaecological Section, Klinische

Wochenschrift, 1909,

1912.

_________________

A CASE

OF

PSEUDOMYXOMA OF THE PERITONEUM

ARISING FROM PERFORATION OF A GELATINOUS OVARIAN CYST AND ASSOCIATED WITH SIMILAR CYSTIC DISEASE OF THE VERMIFORM APPENDIX. BY THOMAS WATTS

EDEN, M.D. EDIN., F.R.C.S. EDIN.,

SURGEON TO THE CHELSEA HOSPITAL FOR WOMEN; GYNÆCOLOGIST TO THE CHARING CROSS HOSPITAL.

so-called gelatino?ts, colloid, the ovary form a subject about which information is scanty and pathological opinion ill defined. The tendency of these cysts to undergo spontaneous perforation and then to attack the peritoneum has been recognised for many years. The peritoneal affection consists of epithelial implantation, followed by wide dissemination over all parts of the abdomen. To this condition the name of"pseudomyxoma peritonei" has been applied. During the last 11 years a small number of cases have been recorded in which the vermiform appendix and not the ovary has been the seat of the primary disease which arises in The cyst was unilocular with a broad base of attachment the epithelium of the appendicular mucosa. The appendix to the csecum ; at its distal end was a nipple-like projection becomes first distended with colloid or gelatinous material, which formed the thickest portion of the cyst wall. A small and later perforation occurs, leading to general peritoneal mesentery,t X ! in., was seen near the base of the dissemination, as in the case of the ovary. In the instance tumour; there were no adhesions. The nipple-like projec- here recorded, while the ovary was the organ primarily tion was examined microscopically, and shows in the cyst affected, the vermiform appendix was the seat of an exactly wall discrete collections of lymphoid tissue and a few groups similar, although apparently independent, change. of glands of appendicular type. The interior is for the most Instances of a rare disease which present any unusual features should always be placed on record for the informapart bare of epithelium. (Fig. 4.) Unfortunately the gelatinous material in these cases was tion of subsequent workers, who may be able to put to not tested chemically. Trotter states definitely that the practical uses clinical facts which at the time of their jelly gives the microchemical reactions of mucin, but this is occurrence appeared incapable of explanation. THE nature and

or

origin of the pseudomyxomcztozcs cysts of

1499 The

patient, August, 1908.

a married woman, first consulted me in She was then 46 years of age and had ceased

to menstruate in 1897, at the early age of 35. She had had children. In 1891 she had an illness which was said to be "typhlitis,but in other respects her past history was good and presented no points of importance. She had never been very robust. Her present complaint was of abdominal enlargement, which had come on gradually and had increased at a slow rate so that she was unable to remember the time at which it had been first noticed ; " several months " was as near as she could recollect. There had been no pain, but she had of late felt fatigued and unfit for exertion. There was no vaginal discharge of any kind, and there had been no return of the periods. She was a little ansemio, but did not look ill. On examination of the abdomen an oval, soft, rather ill-defined tumour was found occupying the whole of the right side of the abdomen from the costal margin to Poupart’s ligament. It was dull on percussion, and its mobility was The epigastric region was resonant and a very limited. colon note could be made out in the right nank outside the limits of the tumour; but the left flank was dull. There was, however, no definite evidence of free fluid, for the dulness did not shift with change of posture, and there was no fluid thrill. On vaginal examination a normal-sized anteverted uterus was found, and the lower pole of the tumour could be felt on the right side, but only with considerable difficulty ; it appeared to lie above the level of the pelvic brim. The diagnosis made was simply " ovarian no

adhesions were found. The walls of the cascum and adjacent coils of ileum were rough and deeply injected, but otherwise The appendix was removed and the stump unaltered. invaginated, and finally the peritoneal cavity was flushed with warm saline, but a great deal of adherent colloid remained when this had been done. The patient made a good recovery from the operation. On opening the appendix it was found to be distended with clear pale yellow jelly, closely resembling that of the

Fw.1.

cvst—risht side." Five days later the abdomen was opened and the tumour removed. It was a cyst of the right ovary which had ruptured, and there was a large amount of clear yellow jelly in the peritoneal cavity. The walls of the cyst were very friable and it was further torn in extracting it, so that the abdomen was flooded with the jelly; that contained in A portion of the wall of the ovarian cyst suspended by its the cyst was identical in appearance with that in the Fallopian tube. The colloid material is aggregated in peritoneal cavity. A good pedicle was obtained as the rounded masses, which owe their shape to being formed by On tissues of the broad ligament were not friable. clistension of small compartments in the cyst. attempting to remove the masses of jelly from the peritoneum great difficulty was found owing to its firm adhesion; ovarian cyst, but somewhat paler in colour. It was lightly the peritoneal membrane was much injected in all adherent to the mucosa, and the greater part of it was parts. After swabbing out as much of it as possible the extruded through the opening by retraction of the muscular abdomen was flushed with normal saline solution, but wall. (Figs. 1 and 2 ) Microscopic examination of the wall of the ovarian cyst nothing like a complete cleansing of the peritoneum was possible. The uterus and the left tube and ovary were showed high palisade epithelium in great abundance, and for normal, except for adherent jelly. No note was made of the most part in an advanced stage of degeneration. Here and the condition of the vermiform appendix, and I cannot FIG. 2. recollect whether it was looked at or not. The patient made that she a good recovery, and three months later I heard was quite well. I did not hear of her again until December, 1910, two years and four months after the operation. She then wrote to say that she had been feeling unwell for some time, that there was a good deal of enlargement of the abdomen, and much abdominal discomfort. I saw her a few days later, and this time found a soft, elastic, ill-defined tumour in the left side of the abdomen, of approximately the same size and much the same general characters as the first one. The parts of the abdomen not occupied by the tumour were resonant to percussion. It was clear that another tumour had grown in the left ovary, and I greatly regretted that I had not removed it at the first operation. The second operation was performed on Dec. 9th, 1910, when a perforated cyst of the left ovary was found, along with abundant and widely disseminated colloid material covering the peritoneum in all visible parts. The jelly was for the most part clear yellow material, of the colour of pale orange pulp, and was precisely uniform in characters wherever it was found. The cyst wall was so friable that the tumour broke up completely in The vermiform appendix. A longitudinal incision has been handling, and it was ladled out of the abdominal cavity in made through which a mass of colloid material has been handfuls, the pedicle being the only part where resistant extruded. The peritoneal surface of the appendix is tissues remained. The peritoneum was thick and red, and seen to be roughened. The uterus was the colloid was closely adherent to it. small, and the right broad ligament was unaltered except there well-preserved goblet cells distended with secretion for adherent jelly. The vermiform appendix was sought for were seen ; generally, however, the cell bodies were converted and examined, and was found to be cylindrically dilated into a coarsely granular debris, the nuclei at their bases from its tip to a point half an inch from the wall of the being well preserved. On examining the wall of the bowel. It was about the size and length of the operator’s appendix the greater part of the mucosa was found to have little finger, and the undilated part formed its pedicle. Its been destroyed. Patches remained, however, which showed surface was rough and of a dull red colour ; there was not aggregations of coarsely granular amorphous material much colloid adhering to it, but several long slender adherent to theirfree surface-representing the colloid.

1500 CASE 3.-A married woman, aged 40, was admitted to the London The epithelial cells themselves were either distended to Hospital under the care of Dr. Francis Warner. Her history was that bursting point with secretion or the bodies were destroyed, she had been confined nve weeks previously and had been quite well leaving the nuclei either alone or along with a certain until the tenth day after her confinement, when she got up, but had a amount of granular amorphous material. It was quite clear shivering fit and returned to bed. She had been in bed since and had had several attacks. On admission the looked

from these appearances that the colloid material contained in the appendix was the product of its own mucous membrane, and was therefore in its origin independent of the ovarian cysts. The simultaneous and independent occurrence of this colloid disease in the ovary and the vermiform appendix has not, I believe, been previously recorded. The disease is epithelial in origin, and the fact that it may simultaneously arise in two types of epithelium of such divergent characters as that of the ovary and the appendix is curious and

shivering patient extremely ill, and was found to be suffering from a high intermittent with occasional There was no abnormal temperature rigors. vaginal discharge and the pelvic organs were healthy. A culture of theblood was made during a rigor. 5 c.c. of blood were obtained and divided among four broth tubes. All tubes yielded a profuse growth of a colon bacillus. A catheter specimen of urine con-

tained pus and gave a pure culture of a colon bacillus in all cultural characters identical with that obtained from the blood. This. patient is still in the hospital, and after three weeks remains in much the same condition except that the rigors have ceased. She presents. no further physical signs of disease.

The blood cultures in all these cases were made by bordering on malignancy, puncture of a vein in the arm through the skin with a many ovarian cases are on record where complete recovery sterile needle after painting the skin with the usual iodine has followed an operation, which must be called partial solution. The obvious criticism which might be brought ’owing to the difficulty of removing the colloid adhering to against our findings are that the colon bacilli were conthe peritoneum. In the present case the patient has remained taminations derived from the skin and were not actually well up to the time of writing, one year and eleven months in the circulating blood. We cannot deny thepresent after the operation. bare possibility of this contention, but maintain that it is Queen Anne-street, W. extremely improbable. Blood cultures performed in this way by us are almost invariably free from external contamination, and in a very large number of such cultures we havenever found the colon bacillus present as a contamination. A NOTE ON THE OCCURRENCE OF THE Further, all these three cases were suffering from an aeute infection by the colon bacillus. COLON BACILLUS IN THE BLOOD. We regard these cases as of great interest in that they BY P. N. PANTON, M.B., B.C. CANTAB., M.R.C.S. ENG., afford direct evidence that the bacilli are spread by the blood stream and may be there demonstrated. Also our L.R.C.P. LOND. ; findings suggest a direct relationship between the occurAND rence of a rigor and the entry of organisms into the blood

interesting. Although regarded

as

H. L. TIDY, M.D. OXON., M.R.C.P. LOND., M.R.C.S. ENG.

(From the

Clinical Laboratory, the London

Hospital.)

WHILE infections of the

body tissues by the bacillus coli and while there is every reason to extremely common, that believe spread of infection in no inconsiderable number of cases takes place by way of the blood stream, it is remarkable how rarely direct proof of blood infection can be obtained during life. We are not acquainted with any publication of English literature in which the bacillus is claimed to have been obtained from the blood stream. Blood cultures made from persons suffering from undoubted coli infections are almost invariably sterile, but it has happened to us on three distinct occasions during the last nine months to obtain from the blood a pure growth of the colon bacillus. In two out of the three cases the blood was withdrawn at the commencement of a true rigor, and while the patients In the third case the blood was were actually shivering. obtained three and a half hours after a rigor. In other and subsequent cases of similar infections blood taken a few hours after a rigor has been sterile. The following is a brief account of the three cases referred to :— are

CASE 1.—A man, aged 28, was admitted to the London Hossptta under His history was that tour weeks the care of Dr. Lewis A. Smith. previously he had been suddenly seized with acute abdominal pain and The had been pain present at intervals since the onset. On vomiting. admission the general condition and aspect of the patient suggested a There were no local man in the third or fourth week of typhoid fever. physical signs of disease other than indefinite signs of fluid at the base of the right lung. The Gtrunbaum-Widal reaction was completely negative and the blood count was that of acute inflammation. A blood culture was sterile. The temperature was high and intermittent with five rigors later in the disease. A second blood culture was made a fortnight later during the early part of a rigor. 10 c.c. of blood were Three tubes remained taken and divided among four broth tubes. sterile. The fourth tube yielded a growth of the bacillus coli. The cultural reactions of this bacillus were fully investigated and were in every way typical. The patient died 12 days later, and post mortem were found a purulent appendix, peritonitis, a subphrenic abscess, pylephlebitis, and a considerable abscess in the liver. CASE 2.-A man, aged 55, was admitted to the London Hospital, under the care of Mr. Frank S. Kidd, with a history of difficult micturition for 18 months. On admission he was suffering from acute retention of urine and an enlarged prostate. The bladder was washed out and a rigor occurred during the process. Subsequently a suprapubic cystotomy bad to be performed for secondary hemorrhage, and blood and pus were present in the urine throughout. About seven weeks later 6 c.c. of blood were withdrawn from a vein three and a half hours after a rigor and divided among four broth tubes. Three tubes yielded a growth of the bacillus coli, typical in all its cultural characters. The patient died three weeks later from sepsis and a secondary haemorrhage, which post mortem was found to have been due to ulceration into the

deep epigastric artery.

in considerable numbers. We hope to be able to produce further evidence upon the question of the spread of the bacillus by the blood in cases of coli infection as well as upon the relationship of blood infection to the rigors, which are so common in these conditions. With these points in view we are continuing our investigations with the assistance of Mr. Kidd.

OBSTRUCTIVE JAUNDICE RELIEVED BY OPERATION. BY KENNETH H.

JONES, M.B.,

CH.B.

VICT.,

STAFF SURGEON, ROYAL NAVY.

THE patient, a man, aged 36 years, was first placed on the sick list on board his ship on Jan. 20th, 1908, but he stated that he had felt unwell for about a month previously. He complained of loss of appetite and of diarrhoea, and was somewhat jaundiced. A physical examination of the liver revealed no increase of dulness on percussion, nor did there appear to be any tenderness on palpation or on deep pressure. The patient, who gave a history of having contracted syphilis some 12 years before, was put on low diet, and iodide of potassium was given in 10-grain doses. He was admitted to Hong-Kong Hospital on Jan. 29th. He was an old-looking man for his years, rather stout, of a melancholy cast of countenance, and deeply jaundiced. A physical examination revealed nothing abnormal in the abdomen or thorax, but he was found to have an unusually slow pulse. The urine was stained with bile, but it contained no albumin. The temperature was 990 F. The patient was evidently much depressed. From Feb. lst to 10th the jaundice continued to increase, and the chief complaints were mental depression and an intense itching of the skin. On the 15th unusual resistance on deep pressure was first made out in the right hypochondriac region. On the 18th the patient had an attack of nausea and vomiting. The resistance over the situation of the gall-bladder showed an inclination to increase, and in a few days tenderness was found to be present also. Opinions were divided as to the nature of the condition present, whether due to carcinoma or gall-stones, but the age of the patient and the absence of emaciation were against the former, and the lack of any definite history of biliary colic contra-indicated the latter. It was obvious bv