Brit. J. Dis. Chest (I962) 56, 96.

M E I G S ' S S Y N D R O M E

A REPORT ON AN UNUSUAL CASE

By C. STEPHANOPOULOS AND N. DoucAs

Greek Seaman's Chest Hospital, Pent¢li, Athens

S~VEN cases of fibroma of the ovary with ascites and hydrothorax were reported by Meigs and Cass in I937. In each, the extirpation of the fibroma resulted in the resorption of both the hydrothorax and the ascites. The combination of the three was described in Meigs and Cass as a " clinical entity." The syndrome had already been described by Spiegelberg (I886), Cullingworth (I879), Demons (I887) , Lawson (i95o) and Tait (i892), but the Meigs and Cass report reawakened interest in it.

Lemming (I96o) estimated that the number of cases described, after Meigs and Cass, was Ioo, most of them having been described by gynecologists in the United States. Thus in view of the frequency of ovarian-tumours the syndrome is rare.

Meigs and Cass found that ovarian fibroma were the commonest cause, but the syndrome was also seen in association with benign growths, such as myo- mata, teratomata, dermoid cysts, granulosa- or theca-cell tumours.

The criteria for the diagnosis of Meigs's syndrome are the simultaneous appearance of peritoneal and pleural effusions and their resorption following the extirpation of an ovarian tumour.

Johnson (I946) thought that the abundant blood supply of the superficial layers of the fibromata led to the development of ascites. Efskind (194o), after injection of methylene blue into the lower part of the peritoneal cavity, showed that the dye was rapidly passed to the diaphragmatic lymphatics and thence to the pleural cavity. This was most marked on the right side because of the proximity of the liver. The negative pressure in the thorax during inspiration facilitated the flow of the lymph.

Further investigations by Meigs, Armstrong and Hamilton (i943) and of Lawson (I95o) confirmed the findings of Efskind. Thus the hydrothorax in Meigs's syndrome may be due to the transfer of the ascitic fluid through the lymphatic system into the thoracic cavity.

Both pleural and peritoneal fluids are transudates, they have the same specific gravity and the same albumin content, and in some cases with hmmorragic ascitic fluid, the hydrothorax is also found to be bloodstained (Vogt, 194o; Long, 1948; Ridley, 1949; Dark and Dewhurst, 1956).

The predominance of right hydrothorax (in over two-thirds of the cases) can be explained by the fact that in the diaphragm the resorption is far more effective on the right side than on the left.

This interpretation of the pathogenesis of the syndrome raises certain questions: Why, despite the frequency of pelvic tumours with ascites, is Meigs's

(Received for publication January 3I, x962.)

PLATE V I I

FIG. I

FIG. 2

To face p. 96

MEIOSIS SYNDROME 97

syndrome so rare?--Why is there often abundant pleural fluid with little ascites ?

According to Lemming the conditions for resorption ofexudate in the pleural cavity are favourable when the pleura is normal and the drainage through intrathoracic lymphatics is intact. I f the lymphatics have been the site of chronic inflammation, the lymph flow is slowed down. Thus the normal evacuation of pleural fluid may be obstructed.

Normally, the drainage of the ascitic fluid through the lymphatic network of the diaphragm takes place easily, but when this path is blocked the fluid collects in the peritoneal cavity and ascites increases rapidly.

The present report tends to confirm the blockade hypothesis. The blockage occurred in the lymph flow between the thorax and the abdomen. This resulted in a rapid increase of the ascitic fluid and the resorption of the hydro- thorax.

Case History A woman aged 55 developed severe dyspncea with a feeling of heaviness in

the right chest and fever up to 380 C. A diagnosis of pleurisy on the right side was made. Her symptoms persisted and antibiotic treatment was started. Her chest was aspirated twice and the effusion was found to be sterile (Fig. i). During the next year she was in and out of hospital with recurrent effusions; her chemotherapy was continued and she had courses of prednisone.

Eighteen months after the start of her symptoms, pelvic and other examina- tions being negative, it was decided to do a right thoracotomy. The middle lobe was found to be shrunken and it looked cystic. Otherwise no abnormality was found. Lobectomy was done. Shortly after this operation she developed abdominal swelling due to ascites, and a laparotomy was done. The right ovary was found to have undergone cystic degeneration and it contained a cauliflower-like tumour 13 by 8 by 6 cm. It was resected. Histologically the tumour was a benign mucinous cystadenoma.

Five months after her second operation the patient was symptom free with no signs of effusion in the pleura or in the abdomen (Fig. 2).

Discussion This case had all the characteristics of Meigs's syndrome: a benign ovarian

tumour, ascites and a hydrothorax. For more than a year the diagnosis was not suspected. It was only finally confirmed at laparotomy.

After the thoracotomy, when the shrunken middle lobe was removed, recurrence of the pleural effusion ceased, but ascites developed almost imme- diately, and only then was the true cause of the condition revealed when laparotomy was done.

It is suggested that the thoracotomy caused a blockage of the normal diaphragmatic and intrathoracic lymph flow and that the flow of ascitic fluid into the pleural cavity was thus prevented. Moreover, the formation of adhe- sions in the pleural cavity after the thoracotomy made it impossible for fluid to collect there and it remained in the peritoneal cavity instead, resulting in the rapid development of ascites.

98 STEPHANOPOULOS AND DOUCAS

Our case showed that , when the lymph flow into the pleurM cavity is blocked, the collection of fluid in the peritoneal cavity increased markedly, while the pleural collection is minimal or non-existent.

This gives clinical confirmation of Lemming 's blockade theory. He invoked the blockage of the intrathoracic lymph vessels, which resorb and drain the fluid towards the thoracic duct, to interpret the collection which is more marked in the thorax than in the abdomen.

Summary A case of Meigs's syndrome is reported. Before the diagnosis an exploratory

thoracotomy was made, followed by the resorption of the hydro thorax and the speedy increase of the ascites, which was limited before the thoracotomy. The l apa ro tomy revealed the presence of a cys tadenoma of the ovary: the extirpation of this resulted in the resorption of the ascites.

The disappearance of the hydro thorax and the increase of the ascitic fluid, after thoracotomy, was due to the blockage of normal lymph vessels. This stopped the flow of the ascitic fluid into the thorax and led to its accumulat ion in the peritoneal cavity.

REFERENCES CULLINCWO~TH, C.J. (i879) • Obstet. Soc. Lond., 2x, 276. DARKE, C. S., and DEWHURST, C.J. (i956) : Thorax. H, 4 I. DEMONS, A. (I887) : Bull. Soc. Chir. Paris, z39 77 I. EFSKIND, L. (I94o) : Exp. Untersuch fiber die Biologic des peritoneuns. Oslo, I-II. JOHNSON, S. R. (I946) : Svenska Liik.-Tidn., 43, 719 • LAWSON, J. G. (x95o): J. Obstet. Gyruec. Brit. Emp. 57, 595. LONG, A. E. (I948): Calif. Me&, 68, 383 . L•MMXNO, R. (x96o) : Acta med. Scand. x68, x97. MEres, J. V. (I934) • " Tumors of the Female Pelvic Organs." New York, Macmillan. MEIGS, J. V., and CASS, J. W. (I937) : Amer. 07. Obstet. Gynec., 33, 249. MEres, J. V., ARMSTRONC, S. A. and HAMmTON, H. H. (I943) : Amer. 07. Obstet. Gynec., 46, 19. RIDL~Y, J. H. ( I949) : Sth. med. 07., Bgham, Ala., 42, 757. SPmGELBERC, O. (I886): Mschr. Geburtsh. Kunde, 28, 415 . T~T, L. (I892): Med.-chir. Trans., 75, xo9. VOGT, C. J. 094 o) : Amer. 07. Obstet. Gynec., 4 o, ~85.