If symptoms be due to the rupture of a cyst there will be the same sudden symptoms as if a twist had occurred, but the outline of a twisted cyst is well defined, feels firm, and the tumor is somewhat larger than previously, while in a ruptured cyst the outline of a tu mor becomes indistinct and feels flaccid, is smaller, or even disappears, while there is dullness in the flanks from gray itation of the extravasated contents to these regions. When the symptoms are due to a ruptured extra-uterine fcetation there will often be a history of missed, or at least irregular, periods. There may be suggestive signs about the breasts. Pain is more pronounced, while it is al most invariably accompanied by fainting and other symptoms of collapse. The antemie condition of the tissues, soft, rapid pulse, and sighing respiration sug gest bleeding, while an abdominal ex amination shows there is no definite tumor. These symptoms collectively can scarcely be mistaken for a twisted cyst. On the other hand, a limited haematocele into the broad ligament or into Douglas's pouch may closely resemble a twisted cyst. In such a case the tumor in Douglas's pouch and the fixing of the uterus should have suggested the nature of the ease. If a twisted cyst is not diagnosed early the symptoms may rap idly pass on into those of acute perito nitis, and, owing to the distension of the intestines disguising the cyst, the diagnosis is obscure. Directly the nature of the case is suspected the abdomen should be opened and the cyst removed. Harrison Cripps (Lancet, Feb. 15, '96).
Ovarian tumor, if acute torsion be present, shows an hmmorrhagic or pink surface, with a certain amount of sur face oedema. The symptoms usually come on suddenly, with a feeling of some thing displaced in the abdomen. The pain is at first localized over the af fected ovary, but rapidly becomes gen eral, extending into the loins and down the thigh on the affected side. Vomiting is an early symptom. At first it is mu cous, and later becomes green. Abdom inal respiration is suppressed. There is constipation, often almost complete. The face is usually somewhat drawn and pinched. The pulse is small and quick, and the temperature rises one or two degrees. Death may occur from various causes if speedy help be not given. Acute peritonitis may ensue, or
htemorrhage into the tumor, which may he followed by rupture. Ff the patient survives the acute stage, chronic peri tonitis, with the formation of numerous adhesions of the cyst-wall to the ab dominal viscera, often follows. Some times the cyst may suppurate. Chan delux (Soc. de Chir. de Lyon; La Gynec., June, '9S).
Two conditions are essential to the production of a torsion of the pediele of an ovarian tumor: a long, slender pedicle, and a small tumor, not larger than a fist, or at most a cocoa-nut. The size of the tumor when removed does not indicate its size when torsion occurred; for it grows with each twist. The tor sion may be either gradual or sudden, either partial or total. The pedicle may be twisted once on itself or many times, until it has become so thin as to appear on the point of breaking. Salient feat ures in diagnosis of a twisted ovarian pedicle are: moderate distension of the subumbilical region, with greater prominence either in the median line or on either side; rapid formation of swell ing, which perhaps was merely noticed before; more or less tenderness on press ure; tense but distinct fluctuation, with single or interrupted wave according as cyst is single or multilocular; out line of swelling generally distinct, but sometimes diffuse; dullness on percus sion over area of swelling; tumor touch able through anterior vaginal vault, and continuous with suprapubic swelling; uterus generally posterior to vagina! swelling; fluctuation-wave in vagina continuous with abdominal wave; tem perature somewhat elevated, perhaps to 102°; pulse rapid and small; general depression; anxious countenance. At tack has usually come on suddenly, and may have been preceded, at an interval of several weeks or months, by a similar less marked seizure attended by severe pain. P. F. Muncie (N. Y. Aled. Jour., Feb. 25, '99).
Series of 30 eases collected and 2 per sonal ones, in 26 of which torsion oc curred during pregnancy. The cause of the accident was discoverable in only 2, while in only 3 was the diagnosis cer tainly made before operation. It does not seem to occur with ovarian tumors. Petritschek (Inaug. Dis.; Centralh. f. Gynlik., No. 26, 1900).