Progress in Public Hygiene

SAMUEL W. ABBOTT
1904 Boston Medical and Surgical Journal  
moved normally, no distention, no fever. Although at work, she did not feel well. On Jan. 11, in the morning, she had another sudden attack of pain, similar to the other two. Flowing was still present, although usually it lasted only three days. Temperature 97.8, pulse GO, vomiting about every fifteen minutes, with continuous pain. At four in the afternoon, after another attempt at palpation of the abdomen, the pain suddenly disappeared. When seen with Dr. Baldwin on the afternoon of Jan. 11,
more » ... rnoon of Jan. 11, about five o'clock, she had no fever, pulse was 72, and she was apparently free from pain. There was no distention. The abdomen was soft, with considerable fat between the umbilicus aud pubis. No tenderness in the epigastrium. She did not appear sick. On careful examination, a globular tumor could be felt in the hypogastrium, which slipped readily from side to side. The tumor was about the size of a large grape fruit, irregular in contour, clastic, not tender to pressure. It could be pushed to the left for several inches, when further pressure caused a sensation of tension and pain in the right, iliac fossa. It could also be pushed upward, so that it occupied the right hypochondriac region. Attempts to push it further were again resisted by an apparent attachment in the right iliac fossa, and caused pain and tenderness in that region. When tho tumor was pushed into the right iliac fossa, no pain was caused. On making deep pressure on the inner side of the right pelvic brim, there was slight tenderness. On coughing, there was no evidence of a hernia in either the. femoral or inguinal canals. The right kidney was not palpable, and the tumor could not be pushed below the ribs. No blood count was made, nor was a vaginal examination proposed, owing to the flowing. In view of the vomiting, apparently of a reflex nature, the absence of constipation or distention, and the presence of a tumor, movable to a certain degree, as if attached on the right iliac fossa; also in view of the absence of fever, tenderness or spasm suggesting appendicitis, the diagnosis of an ovarian cyst, the pedicle of which had become twisted, causing these three attacks of pain, seemed assured. That; in one instance, the abdominal manipulation had righted the twist, did not seem improbable, in a tumor of such marked motility. The other two reductions were apparently more spontaneous. The tenderness at the point of origin of the pedicle, which was moat probably the right broad ligament, appeared to indicate where the twist had occurred, and that here thrombosed vessels might be found. In view of the ease with which reduction had occurred, with relief of all symptoms, except slight tenderness and vomiting, it seemed as if the cyst could not have twisted more than once or twice. Immediate operation was advised, on the grounds that the tumor might be infarcted, or further twisted at any time, with consequent gangrene, that nothing could be gained by delay, and that if thrombosis occurred, it might become progapated to the vena cava, or to the internal iliac vein. Operation was done on tho morning of Jan. 12, 1904. The previous night had been fairly comfortable. She vomited once, but in the morning felt well enough to walk upstairs, and was free from pain, though the abdomen was somewhat tender. For the first time, . she had a temperature of 100 F°. On opening the abdomen, just inside of the right rectus, the intestines were found collapsed, and an infarctcd ovarian cyst at once presented, in a moderate amount of fluid, containing a few fibrin flakes. The tumor was dark purplish, tense and shiny. It was seen to spring from the right broad ligament, the tube being continued over it. The twist had occurred immediately after the tube and ovary left the uterus. The round ligament was slightly involved in the rotation. The tube had also been twisted, and was of a deep violet color. It was found that the tumor was rotated one and three-quarters times on its axis, the rotation being towards the median line. The ovarian vein was ligated, and the tube and ovary removed, cutting the narrow pedicle close to the uterus. The ovarian veins, and those in the broad ligament were found thrombosed, at the site of the twist. On examining further, a similar tumor, about as large as a medium-sized orange, was found to involve the left ovary. This tumor was the color of an ovarian dermoid, and was not infarcted. The tube was not enlarged. It was decided, owing to the age of the woman to leave a small amount of ovarian tissue, which was dissected off from the base of the ovary. No ligatures were used, but the few bleeding points were controlled by a continuous chromic catgut suture. The uterus was small, and in normal position. Recovery from the operation was entirely satisfactory, and the patient made an uninterrupted convalescence. Had a vaginal examination been possible, the left ovarian tumor, which lay beneath the one with the twisted pedicle, could easily have been discovered. Of especial interest in this case are the repeated reductions of the torsion, which, together with the physical examination, gave a perfectly definite clinical picture, on which to base the diagnosis. Pathological Report of Specimens sent to Dr. W. F. Whitney, consisting of a cystic tumor of each ovary : First, a tumor the size of an orange, with a thin wall; the sac containing sebaceous material and hair, and the inner surface lined with a cutaneous membrane. Second, a cystic tumor, the size of a grape fruit, of a dark blue color, with evident infiltration of the walls with blood. On section, it was found to be chiefly composed of a single cyst, with papillary projections from one side. Diagnosis: Simple dermoid cyst of one ovary, and papillary cysto-adenoma-, with infarction of the other. Me d i c a l P r o g r e s s PROGRESS IN PUBLIC HYGIENE
doi:10.1056/nejm190404071501405 fatcat:hdg6jrjt7ff3bkxi3jtj6on2hm