I desire to report a case which was primarily papilliferous adenoma of the appendix, but which later showed myxomatous degeneration and cyst formation. The same condition occurring in the ovary is described in Eden and Lockyer’s “Gynæcology,” second edition as pseudo-myxomatous tumours whether of appendix or ovary rupture and pour out their secretion of pure pseudo-mucin into the general peritoneal cavity, giving rise to that rare disease pseudo-myxoma peritonei where the tenacious secretion increasing with semi-malignant characters may involve the whole abdomen.

This case was operated on before rupture of the pseudo-myxomatous cyst when it was about the size of a hen’s egg.

Mrs. J., aged 44. She came in August, 1921, complaining of pain in the lower abdomen very severe the last week, but troublesome on and off for several years in less degree. There was also a history of pain in the back since the last child was born and a dragging pain in the vagina. She had a thorough nervous breakdown eight months ago which she attributes to these sufferings.

Previous history.—She has two children, the youngest sixteen. In May, 1921, I removed a suspicious ulcer from the forehead which the pathologist reported as rodent ulcer. The scar is now quite healthy.

On examination the abdomen appeared normal. Vaginally there was partial perineal laceration and small cystocele. The uterine body was partially retro-verted, and on straining prolapsed slightly. The pre-operative diagnosis of prolapsus uteri was made and operation advised as this would also give opportunity to explore the abdomen.

Operation 7th August, 1921.—Assisted by Dr. H. M. Monro I performed perineorrhaphy and opening the abdomen fixed the uterus by Kocher’s method. Before closing the wound the abdomen was explored and the cæcal region exposed. Here at the caput a tumour was found about the size of an egg, but soft and cystic, irregular in shape, adherent everywhere to the peritonem of the ileo-cæcal angle. It was recognised only on looking for the appendix that this was a diseased appendix, for the anterior linea of the colon ran into a broad appendix stump which widened into this tumour. At this stage it was taken for an old inflamed appendix probably full of pus. It was freed by swab dissection with difficulty from its surroundings down to its base which was cut through and the stump invaginated in the ordinary way. There was now a wide raw area to cover over. The separation was not affected without the contents partly escaping from a small tear in the organ. The contents were most striking in appearance, resembling nothing so much as lemon jelly. It was sticky and dry. The abdomen was closed.

Progress.—The wound healed by first intention, and the patient made a quick recovery. It is now six months since operation, and there is no sign of recurrence. The condition of pseudo-myxoma peritonei is incurable by removal of the jelly masses together with their origin in ovary or appendix, because of the destroyed vitality of the peritoneum which results in gland cells being implanted and proliferating with continued production of pseudo-mucin. Yet it seems that if the diseased ovary or appendix is removed before rupture and implantation, as in this patient, there would be little fear of recurrence.

The fully developed disease pseudo-myxoma peritonei is very rare. It usually starts from the ovary. According to Eden and Lockyer only about twelve cases are recorded which started in the ovary and appendix. Of these only three were females, and in them, both ovary and appendix were diseased. The present case differs from those analysed by Eden and Lockyer in being that of a female, with the appendix alone involved, the ovaries being normal. Seelig* brings the knowledge of the disease up to date. When the pseudo-mucinous cyst of the ovary or appendix bursts there are four possible terminations:—

1. Absorption of exudate may occur.

2. The exudate may be limited and encapsulated in the right iliac fossa forming a tumour there.

3. Generalised spread of exudate which becomes incapsulated in small masses like polypi.

4. Generalised spread of exudate which does not become incapsulated, but implants itself and goes on secreting, producing ascites, cachexia and death, with all the semblance of widespread abdominal carcinoma.

Professor A. M. Drennan, Pathologist of the Otago Medical School, kindly provided a complete report of serial sections of the specimen set to him. I append his conclusions:—

“The specimen consists of a thin-walled sac with some mucus and white calcareous material adhering to the wall.

“At one side is a rounded stump which on longitudinal section appears to be the appendix, and it merges with the lumen of the sac. At the opposite side of the sac is another smaller rounded stump suggesting the tip of the appendix.”

Of the most comprehensive section he reports:—

“This is the most interesting section. In one part is appendix with usual mucosa, but much diminished lymphoid tissue.  Adjacent to and apparently continuous with this is a very hyperplastic mucosa lined with tall columnar cells and forming long compound papillary ingrowths amongst which is much mucus. The muscle coats of appendix are present for a certain distance and then are replaced by a fibrous wall (the wall of the sac); also immediately adjacent to the hyperplastic epithelium is a deposit of calcareous debris, and mucus, bounded by a definite fibrous wall.

“The condition is, I think, primarily a papilliferous adenomatous formation of the appendix epithelium which has resulted in rupture through the wall, with inflammatory reaction around forming the sac: the calcareous part is due to degenerated masses of epithelium. In parts the fibrous tissue has also become myxomatous.”

*Seelig—“Surgery, Gynæcology and Obstetrics,” January 20th 1920.