TORSION OF THE PEDICLE is a quite frequent complication. It is only when the alteration is sufficient to influence the circulation that it produces disturb ance. The right-sided tumor turns to the left and the left-sided to the right. The cause of the torsion is unknown. Kfistner ascribes it to peristalsis and the varying distension of the rectum; Car rio to sudden belly pressure; Mickwitz to contraction of the transversalis mus cle. It is very frequent when associated with pregnancy; may occur also from in jury. The twist may involve one or two turns of the pedicle, though as many as six twists have been observed. The tend ency to torsion of the pedicle is favored by the existence of a long, membranous pedicle, spherical form of the tumor; still further by pregnancy, labor, and child birth, through the changing relations of the organ in the abdominal cavity. Tor sion is the cause of obstruction of the vessels, in which the thin-walled veins suffer before the more resisting arteries. The pumping of blood into the tumor by the artery and its inability to escape by the vein gives rise to rapid increase in the size of the tumor. Fatal result can occur from haemorrhage into the abdom inal cavity. Memorrhage may be ar rested, but the nutrition of the tumor suffers, its covering epithelium is lost, extensive adhesions follow between its surface and the omentum, intestines, and parietal peritoneum. Adhesions at first are very loose, subsequently become organized. The growth thereby obtains a new source of nutrition. Where the twisting of the pedicle is sufficient to ob struct the arteries, the entire circulation is cut off and necrosis of the growth re sults. Necrosis is followed by shrinking of the tumor and absorption of its fatty contents; peritonitis may follow, and ex tensive ascites exist. Peritonitis arising independently of micro-organisms is due to irritation from the presence of a for eign body or the chemical products of the tumor. Sometimes suppuration of the tumor and pytEmia ensue.
An ovarian tumor may, in consequence of torsion of the pedicle, have its cir culation cut off to such an extent that its vitality is destroyed, and gangrene, suppuration, and death may ensue unless adhesions are so extensive as to furnish a sufficient supply of blood to the parts.
Other suppurating tumors result from the passage of pathogenic germs from the bowel through the walls of the tu mor. These germs are the pyogenic cocci, such as the streptococcus and more frequently the bacillus coli communis. W. II. Wathen (Med. News, Oct. 15, 'PS).
Dermoid growths are occasionally found free in the abdominal cavity or in pedicle-hike adhesion with other struct ures. Deus has resulted from adhesions of the intestines to the tumor or to the pedicle. Torsion infrequently may pro duce no symptoms. These are usually slight, and can be suspected when the patient suffers a severe pain associated with meteorism, sensibility to pressure, acceleration of the pulse, sometimes singultus, vomiting, and fever.
Thirteen cases of strangulated ovarian cysts met with out of a little over one hundred. It is important to recognize the condition early. If the twist occur suddenly symptoms are very character istic. The woman, being previously in comfort, is suddenly seized with severe abdominal pain, sometimes sufficient to make her feel faint, and generally fol lowed by some vomiting. There is a diffuse tenderness over the whole abdo men. The patient, if she knows that she has previously had a tumor, will note that coincident with the attack the tu mor seemed to swell up and become hardened. On abdominal examination the tumor may be felt of a globular out line, but generally of not a very large size. It is tender on pressure and has a somewhat firmer feel than the major ity of ovarian cysts. It can be moved from side to side. Occasionally some creaking can be heard and felt. Per raginain the uterus is probably movable, and the tumor, if felt at all, is lying higher up, only resting on the brim of the pelvis. The general condition is one of distress. Pulse is rapid and the tem perature more often raised than not. If the temperature is raised the prognosis is far more favorable than when the same symptoms are present with a normal or subnormal temperature. Symptoms re sembling those of a twisted cyst may be due to a simple inflamed cyst, a ruptured cyst, an extra-uterine fcetation, or an himatocele.