Ovarian lesions simulating appendicitis

OVARIAN

LESIONS SIMULATING EDWARD

F.

MCLAUGHLIN,

Surgeon, Nazareth

M.D.

HospitaI

PENNSYLVANIA

PHILADELPHIA,

T

APPENDICITIS*

ovarian Iesions which most often give symptoms suggestive of appendicitis are ruptured Graafian foIIicIes, foIIicIe and corpus Iuteum cysts and bIeedthat is ing corpora Iutea. The syndrome set up is of fairly frequent occurrence; the possibiIity of its occurrence is even more IikeIy, since a slight deviation from the normal physiologica changes of any menstrua1 cycIe may give rise to it. Excessive hemorrhage from a normaIIy rupturing follicle at the time of ovulation probabIy accounts for the mid-period type of pain-the mittel-schmerz. Bleeding from an insecureIy “pIugged” corpus Iuteum or the rupture of a cystic corpus Iuteum is the commonest type and occurs usuaIIy between the time of ovulation and of menstruation. Breaking of the more estabIished so-caIled simpIe cysts which may have arisen from atretic foIIicIes or persistent corpora Iutea aIs gives rise to symptoms of appendicitis and may occur at any time in the menstrua1 cycle. The peritoneum is irritated in any of these instances by the escaping bIood. Perhaps it is irritated at times by the cystic fluid. The reaction is miId-an active hyperemia-aIthough at times some true inflammatory changes have been noted. The number of reported cases of this “disease” is smaI1. ArticIes by Hoyt and Meigsl Manizade,2 Sexton,3 Harris and Groper,* WeiI,5 McLaughIin,6 Guy and Rotundi,’ and CastaIIos cover the fieId fairIy we11 as far as Iiterature on the subject goes. It is deemed worth-whiIe, therefore, to report some additiona cases, to discuss their reIation to appendicitis and to evaIuate the resuIts of operative treatment in preventing further attacks.

PRESENT

HE

* Read before the April Meeting,

STUDY

Forty nine patients* with ovarian Iesions were studied. appendicitis simuIating Eight were nonoperative cases (Case IT), Seventeen showed unruptured cysts at operation (Case II). (In this second group it is beIieved that cyst ruptures had occurred previousIy but operation happened to come at the end of an attack or in an “interva1 stage.“) In three more both appendicitis and cyst rupture existed simuItaneousIy (Case III). The remaining twenty-one cases showed freshIy ruptured cysts of the ovary (Case IV). AI1 patients were white. The white predominance, evident in other reports as we11 as this, is so constant that one may aImost say the condition is Iimited to white women. The patients’ ages varied from thirteen to forty-two, the average being 24.3; 69.3 per cent of the women were single. Symptoms and Signs. The symptoms and signs of cyst rupture foIIow in sequence the pathologic happenings in the abdomen and are in direct proportion to their severity. They arise from (I) the IocaI irritation caused by the escaping blood or cyst Auid; this gives rise to most symptoms; (2) the irritation of more distant areas of peritoneum as when the escaped fluid makes its way to the upper abdomen or under the diaphragm; (3) possibIy by visceral response to the irritation of its * The patients studied, other than the author’s, were under the care of severa different PhiIadeIphia surgeons; Doctors W. B. SwartIey, C. F. Mitchell, W. E. Lee, E. B. Hodge, S. D. Weeder, R. AIston and J. Toland, who have kindly permitted the use of their case histories. t Case histories ihustrating the four types of patients will be found at the end of the paper.

1941, of the PhiIadeIphia 114

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covering peritoneum, and (4) again possibIy by absorption through the peritoneum of hormones from the escaped fluid or from an underIying etiologic hormona1 stimuIus itseIf. This hormona1 stimuIus, whatever be its source, accounts for the spotting which occurs in some of the cases (I 2 per cent). It may aIso make a woman more sensitive to pain stimuIi as is described in the reIated state of “premenstrua1 tension.” Among the signs and symptoms we find that pain, miId but definite, was common to a11 but one patient and was Iocated in the Iower right quadrant in 6g per cent of instances. It was never in the Iower Ieft quadrant aIone, but was “abdomina1” four times and epigastric five times. In but 18 per cent of the cases, did the onset resembIe the generaIized onset of acute appendicitis pain. Nausea was experienced by about haIf the patients (54 per cent) whiIe onIy Ig per cent vomited. Lower right quadrant tenderness accompanied the other symptoms g6 per cent of the time but rigidity couId be demonstrated in just 13 per cent of the examinations. The tenderness couId onIy be gotten on so-caIIed “deep” paIpation in 20 per cent of the cases. One finds that the onset of symptoms was sudden in twenty-two cases (45 per cent) and sIow in twenty-seven (55 per cent). They began on the average 16.9 days after the onset of the preceding period and 10.9 days before the next one started. There was a sembIance of reguIarity to the recurrence of attacks in but eIeven patients (22 per cent) while thirty-five (7 I .4 per cent) had had previous reguIar or irreguIar attacks; the cIassica1 reguIarity of the MittIe-schmerz was not very evident. AI1 but six of the patients (12 per cent) had reguIar menstrua1 periods (88 per cent). The record of temperature, puIse, Ieucocyte count and poIymorphonucIear percentage is best expressed in TabIe I. In a word, these values in a11 our ordinary cases were at the high IeveI of normaI. In the three cases in which acute appendicitis was associated with the ovarian Iesion, the

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average vaIues were temperature 100.2%. puIse 119, white bIood count 16,900, poIymorphonucIears 79.5 per cent-much higher than in the genera1 group.

FIG. I. Graafian foIIicIe buIging from ovarian surface; ovarian tissue over foIlicIe thinning out in preparation for rupture.

Examination of the peIvis by rectum or vagina was not done in two-thirds of the cases (65.3 per cent), a vaIuabIe maneuver having thus been omitted. When it was done (seventeen times) tenderness was reveaIed ten times and cystic ovaries were paIpated three times. Diagnosis. Appendicitis was considered as a diagnosis in a11 the cases. It was first choice in 56.6 per cent and secondary in 43.4 per cent. Ovarian Iesions were considered as an underIying cause 77 per cent of the time and were the primary diagnosis in 41 per cent of cases. In two of the three cases of appendicitis with associated cyst rupture both conditions were considered preoperativeIy. Operative Findings. In the forty-one patients operated upon, ruptured cyst’s were found twenty-one times (5 I per cent), unruptured cysts in seventeen (41 per cent) and ruptured cysts pIus acute appendicitis in three (7.5 per cent). The Ieft ovary was

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invoIved seven times (17 per cent), the right ovary thirty-one times (73 per cent), both ovaries once and in one instance the

DISCUSSION

DiJerentiaZ Diagnosis. Ovarian foIIicIes and simpIe cysts probabIy come and go

FIG. 3. EarIy corpus Iuteum showing hematoma-Iike center. This had bIown out its “plug” and was found bIeeding at operation.

FIG. 2. Section at site of a rupture. The surface covering has gotten down to an aImost one-layer thickness. Early Iuteinization of lining ceIIs has begun.

ovary invoIved was not designated. OId bIood, or bIoody fIuid was found in nineteen cases (46.3 per cent). In some of the others there seemed to be an amount of cIear Auid greater than normaI. Adhesions were noted in four cases (7.9 per cent); in one instance these adhesions bIocked the tubes. TABLE I AVERAGEVALUES DIFFERENT

FOR

THE

GROUPS

Temperature

ITEMS

OF

CASES

LISTED

IN

THE

STUDIED

-

-

Pulse

Leucocytes

!

Poly-

~vv;;

OF.

JULY, 1942

Lesions

without giving any appreciabIe symptoms 90 per cent of the time. When they do cause trouble, it often resembIes appendicitis so cIoseIy that any thought of deIaying operation wouId be foIIy. Yet on the other hand, in many instances there are recognizabIe differences and if these are carefuIIy weighed, the diagnosis of the ovarian Iesion can be made with a sufficient degree of accuracy and a nonoperative course oursued. In EeneraI the differencks can best ‘be expressed by tabIes. TabIe II shows the main differences from acute appendicitis and TabIe III those from recurrent appendicitis.

__-. TABLE

TotaI.. Ruptured cyst. Cystic ovaries. Nonoperative.

98.8 98.8 98.6

8g 89 86

98.5

85

10,500

9,700

71.7

ESSENTIAL

71.4

10,700 10,600

36 per cent had counts of 10,000 or over. 34 per cent had temperatures of 99°F. or more.

Operative Treatment. Appendectomy was done on a11 the operated patients., PartiaI oophorectomy with oversewing was done in thirty-seven (90 per cent). Oophorectomy was performed three times (7.5 per cent) and saIpingo-oophorectomy once (2.5 per cent). There was no mortaIity in the present group.

1. 2. 3. 4. 5. 6. 7.

DIFFERENCES

II

BETWEEN

CYSTS

AND

ACUTE

APPENDICITIS Acute Appendicitis Ruptured Cyst later Pain IocaI and remains so Pain _..generaI, localizing Nausea Iess frequentIy; Nausea and vomiting vomiting unusua1 Spotting 0ccasionaIIy No discharge definite Tenderness slight; Iower Tenderness, McBurney’s Absence of rigidity Rigidity and puIse Temperature and puIse Temperature norma eIevated blood ceIIs and White blood ceIIs and White poIymorphonucIears polymorphonuclears about high norma

Acute Appendicitis. From acute appendicitis the points of difference are essen-

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NEW SERIESVOL. LVII. No. r

tially as fohows: The onset in acute appendicitis is usuahy graduaI and generaI, Iater IocaIizing in the Iower right quadrant. The onset in the kind of cyst cases comparabIe to acute appendicitis is often sudden. But sudden or sIow it aImost invariabIy begins as a Iocalized pain and remains so or becomes more generaIized Iater. Tenderness is much more acute in appendicitis and one does not need to do a “deep” palpation to get it. It centers roughIy around McBurney’s point. Tenderness in cyst rupture is absent or of a miId degree. It is not definiteIy centered but is found Iower down than in appendicitis. One does not often get rigidity after cyst breaking; nausea occurs occasionaIIy and vomiting aImost never. In contrast, the usua1 history of acute appendicitis contains a record of both nausea and vomiting fohowing the onset of pain. Fever, puIse rise, Ieucocytosis and increase in percentage of poIymorphonucIear ceIIs characterize appendicitis. In the other cases one often finds a normal temperature and puIse rate or perhaps a sIight rise above normal and the white ceIIs and the differentia1 count are usuaIIy at high norma Iimits. TABLE III DIFFERENTIAL POINTS IN CYST RUPTURE AND RECURRENT APPENDICITIS

Recurrent Appendicitis r. Irregularity of occurrence 2. Unrelated to menstrual cycle 3. Right side 4. No discharge 5. 0 c c a s i o n a I attacks 6. N 0 masses

acute

Ruptured Cyst Sometimes regular Mid-period or latter half of cycIe Occasiona left sided attack Spotting or discharge with attack No typical appendica1 attack “Phantom” tumor

Pelvic Appendicitis. A very dangerous condition in any case, peIvic appendicitis may be said to mask itseIf by simuIating ovarian disease rather than the reverse. For too Iong a time the initia1 signs and symptoms, miId enough to suggest very strongIy a cyst rupture, wil1 persist in their miIdness because of the peIvic Iocation of the appendix and the distinguishing points

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of rigidity, fever, tachycardia, Ieucocytosis, etc., may appear onIy after appendicea1 rupture has taken pIace. The peIvic findings of tenderness and possibIy a smaI1 mass are aImost useIess. It may be said that the patient with appendicitis is distinctIy the sicker one, but this wiI1 not make the differential diagnosis. The obvious answer is that one should operate if there be any reasonabIe suspicion of appendicitis existing in the peIvis. Chronic or Recurrent Appendicitis. In this type of appendicitis and in those cases of cystic disease resembling it, symptoms are miId and immediate decision as to operation is not imperative so that one may take more time to arrive at an accurate differential diagnosis. In this group of cases accurate differentiation is possibIe if one has the patience to study them over a sufhcient period of time, that is, through severa menstrua1 cycIes. First, an accurate history is important. The woman patient is rare who wiI1 voIunteer any information as to when her attacks of pain have come in reIation to the menstrua1 cycIe. She does not think of them in that Iight and neither do many physicians. If it can be elicited that they come with a fair degree of reguIarity at mid-period time (haIfway between menses), a very vaIuabIe cIue has been gotten as to their source. Most cases of cystic rupture do not have this characteristic of reguIarity, however. But most patients wiI1 give the history that their attacks occasionaIIy shift to the Ieft side (if one keeps the patient under observation Iong enough to find this out). WhiIe it is true that rupture of cysts in the Ieft ovary frequently give rise to rightsided symptoms, yet there wiI1 certainIy be some attacks entireIy centering in the Iower Ieft quadrant. The occurrence of mid-period spotting accompanying Iower abdomina1 pain is about the most pathognomonic sign of foIIicIe cyst rupture. It is a very heIpfu1 symptom when it occurs but it is recorded rather infrequentIy (I z per cent of present cases). In some patients there occurs a

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whitish, or yelIowish, or even watery discharge with their pain but this is usuaIIy overIooked and only of sIight vaIue in differentiation if present. Recurrent appendicitis is in reaIity a succession of miId attacks of acute appendicitis so we shouId expect the exhibition of fairIy cIassica1 symptoms during some one attack. CertainIy the chance that temperature, puIse and Ieucocyte count wiI1 be higher is much greater than in the ovarian conditions. Nausea and vomiting are, of course, more IikeIy to occur when the appendix is invoIved. Curtis has described what he caIIs the a simpIe cyst of the “phantom tumor,” ovary which ruptures between examinations, so that in successive examinations no sign of the previousIy described pelvic mass can be feIt. This point can be made use of in a patient suspected of having recurrent pain from cyst rupture, by having her report for a peIvic examination every few days through a menstrua1 cycIe. The examinations may revea1 that one ovary enlarges before her attack of pain occurs and is decreased in size afterward. Diagnosis at Operation. Since the existence of a ruptured cyst is so often either not considered or onIy secondariIy thought of, one must say a word about the identification of such a condition when the abdomen is opened. First, it is probabIy true that in many instances ruptured retention cysts are overIooked through faiIure to examine the peIvis or by making a very cursory peIvic examination, not visuaIizing the ovaries. Through a McBurney incision it is diffIcuIt accurateIy to fee1 both ovaries and it is aImost impossibIe to expose the Ieft one. Through a smaI1 or high right rectus incision it is again difflcuIt truIy to appraise the peIvic viscera. At times an appendix, whose outer coat is hyperemic due to the irritating fluid in the peritonea1 cavity, is taken to be the sole source of trouble, is removed and the abdomen cIosed. Ignorance is bIiss in such a case until the patient returns a few months Iater wanting to know why attacks

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of pain simiIar to those suffered preoperativeIy are coming back just as often and just as severeIy. Upon opening the peritonea1 cavity one may find nothing abnorma1. Even the ovaries may seem within norma Iimits. CIoser inspection may revea1 a smaI1 cyst that has a dark spot on its surface as the onIy remains of an opening through which fluid escaped. These are the cases in which the patients symptoms have been present for some days- and by the time of actua1 operation the “evidence” may be gone. At the other extreme, one may open the abdomen and find definite hemorrhage and an increased voIume of intra-abdomina1 fluid. The viscera1 surfaces may appear injected but I have never seen the process advanced to a degree where pIastic exudate was found. The ovary may show a cyst waI1 with a rent in it. There may be a persistant trickle of bIood from this or the opening may be seaIed over with a cIot. Some cysts wiI1 be fiIIed with bIood and have a pIug of coaguIated materia1 in a smaI1 round hoIe on the surface. At times bIood has been seen coming past the edges where such a pIug was not tight. At a Iater stage one may find the cyst cIosed and shrunken with only a few smaI1 cIots of bIood in the peIvis to indicate what has taken pIace. Postoperative Diagnosis. Even with a ruptured cyst oversewn, the appendix, incidentaIIy removed, and the abdomen cIosed one is not yet abIe to rest on his diagnosis. For the obIiging pathoIogist often reports “10~ grade appendicitis,” “fibrous appendicitis,” etc., with “fragments of ovarian tissue resembIing corpus Iuteum.” The more convenient diagnosis of “appendicitis ” is used in the record room and another case of cyst rupture which was taken for appendicitis and which Ied to a Iaparotomy not absoIuteIy necessary, is effectiveIy buried. Treatment. It is beIieved from the data presented that there are those cases which can be safeIy and with a sufficient degree of accuracy distinguished from appendicitis.

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If a diagnosis of the ruptured cyst syndrome can be made, no operative treatment is indicated unless the symptoms prove too distressing or if there is evidence of too much bIood 10s~. It is well to remember, however, that once a patient is put down as suffering from the ovarian cyst rupture syndrome every attack of abdominal pain, especiaIIy that IocaIizing in the Iower right quadrant, is not assuredIy from this same cause. Such a patient shouId be examined in each attack to eIiminate if possibIe the question of appendicitis. One such patient appeared in our series in which after repeated attacks of intermenstrua1 pain, orie attack differed from the others. Operation was done and an acute appendicitis was found associated with a Ieaking corpus Iuteum cyst. Where there is a reasonabIe doubt as to whether or not a given patient suffers from appendicitis of cyst rupture, Iet it be cIearIy understood that operation is mandatory. FOLLOW-UP

The immediate probIem is soIved by operative remova of the Ieaking cysts. But the underIying urge remains. There is no assurance that the Iesion wiI1 not again arise in the same or the opposite ovary. However, the main question is: “How often do clinica symptoms recur?” In searching for an answer twenty-eight of the thirty-one eIigibIe operative patients in this series were folIowed and 78.8 per cent had no recurrence. The Iiterature furnishes IittIe heIp on this point and so Ietters were addressed to men interested in the subject. Meigsg recaIIs no patient, to whom the situation was properIy expIained, coming back with the same compIaint unremedied. GuylO recaIIs but three or four patients who had symptoms persist after operation. WeiI l1 had nine cases recur out of fifteen foIIowed. CastaIIo12 teIIs qf four persona1 cases with no recurrences. HarrisI had recurrences in but two of fifty cases and beIieves that “the operative resection of organized corpus Iuteum or foIIicIe cyst from the ovary is practicaIIy a cure” and

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thinks there is a higher incidence of recurrence in nonoperated patients. Totaling a11 the avaiIabIe figures (TabIe I\I), we may say that 82 per cent of ninety-seven cases showed no return of cIinica1 symptoms which couId be attributed to a repetition of the cyst rupture syndrome. This is comforting to the conscientious surgeon who finds no acute appendicitis upon opening an abdomen but a ruptured cyst and who often wonders whether he is doing the patient any good by resecting the cyst which is the immediate offender. it wouId seem from the figures coIIected that the patient was being distinctIy benefitted by the cyst removal. CASE REPORTS CASE I. M. McH., No. 49, came home from work with a persistent pain in the Iower right side, fearing she had appendicitis. She had had previous attacks during the few months preceding, each time shortly before a menstrua1 period. The present attack began tweIve days before the expected period and was accompanied by some spotting of bIood. Her temperature was g8.6”F., and puIse 72. Tenderness in Iower right quadrant was practicaIIy ni1. She was observed for twenty-four hours, by which time symptoms had subsided. CASE II. D. W., No. 37, a woman of twentyfive had about six attacks of Iower right quadrant pain which gave symptoms for a day or so. These usuaIIy came near mid-period or in the earIy part of the Iatter haIf of the cycle. UsuaIIy no fever accompanied the pain. The patient desired to have “something done” and operation was performed away from the time of an attack. Unruptured retention cysts of both ovaries were found and excised; the appendix was normaI. CASE III. M. B., No. 20, nineteen years of age, had sudden pain in the right Iower quadrant whiIe stepping into a car. Her period was due in ten days. Within three hours she was hospitaIized and there was tenderness but no rigidity in the Iower right quadrant. She was nauseated and vomited. Her temperature was IOOOF., puIse 120, white bIood ceIIs 19,400, poIymorphonucIears 78. Cyst rupture was suspected and she was aIIowed to go tiI1 morning when operation was thought advisabIe with

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tenderness stiI1 persisting. A ruptured cyst and an acute peIvic appendix were found. CASE IV. I. G., No. 8, a nurse of twenty, at mid-period time had a sudden pain in the Iower right quadrant. It remained IocaIized to that area. There was no nausea or vomiting. Her temperature was g8.z°F., pulse 92, white bIood ceIIs 8,400, poIymorphonucIears 84. Tenderness and some rigidity were noted in paIpating the Iower right quadrant of the abdomen. Operation was advised to be on the safe side and upon opening the abdomen blood-tinged fluid was seen and a small oozing cyst of the right ovary exposed. The cyst was resected, the exposed ovarian tissue oversewn and the appendix removed. SUMMARY

AND

CONCLUSIONS

I. The ovarian Iesions which most often simuIate appendicitis are ruptured foIIicIes, foIIicIe and corpus Iuteum cysts and bIeeding corpora Iutea. Forty-nine such cases are reported. 2. A certain number of these may be cIinicaIIy differentiated from appendicitis and a nonoperative course pursued. TABLE IV RESULTS

OF

FOLLOW-UP

STUDIES

ON

CYST

RUPTURE

CASES I

Cases

Harris.. WeiI.. . . . Castalto.. Present series. Total.

I

I

Syw-

Cure, Per Cent

9

48 6

:

4 22

96 40 100 78.6

I7

80

82

Recurrences

2

50 15 4 28 ___~~

.

97

tom Free

NON-OPERATIVE

Patient I

C. S.. M. McL..

I

Hospital

I

-

Private Patient Private Patient

E.M...... .._...._,.... I.S........ . M.F . . . . . . . . . .._... C. Y . . .._. 12104 F. B.. M.McH...

Date

Number

. . Private Patient Private Patient

MunicipaI 4-4-4 1 4-14-41 Municipal 4-8-4 I Municipal I 0-28-40 Germantown

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JULY,1942

TABLE

Patient

Iv-(Continued)

CYSTIC

OVARIES

-

Number

Date

35928 25830 33785 40154 35245 35615 32952 36295 35980 36567 25541 1803 I756 323 421 256 214

IO-X-39 2-8-39

HospitaI

-D. S .. V. K M. D. . . t M. P. G. S ........... E. McE ........ C. H R. B D. R. . . M. F A.M.......... D.S . . . . . . . . .._ D. W R.S . . . . . . . . . G. M . . . . H. B . G. K.

-

E.

3-22-39 IO-8-40 7-29-39 9-4-39 I-2-39 1I-4-39 Io-6-39 I I-30-39 4-26-40 2-26-4 I 2-19-41

I

5-31-40 6-20-40 5-15-40 5-f-40

-

_L RUPTURED

CYSTS

Patient

Number

Date

H ............

IO349 IO350 32582 5540 11631

10-12-39

L. N ............ C. McK. ........ N. B ............ M. G. .......... F. E. E ......... W. O’D ......... I. G ............ M. R. .......... T. N ............ A. G. ........... C. McG. V. F ............ J. S............. A. G. ........... M. B ........... M. C ........... R. L ............ K. McC. ........ M. B ........... G. G. ........... s. c. ........... R. D ............ E. B ............

35835 34469 28942 35296 23682 21062 36135 35656 35793 5161 33360 36283 32936 28623 10076 1662 I703 I947 I877

Germantown Germantown Germantown Germantown Germantown Germantown Germantown Germantown Germantown Germantown Germantown Nazareth Nazareth Nazareth Nazareth Nazareth Nazareth

3-23-39 I 1-22-38 12-31-38 9-19-40 10-3-39 5-25-39 3-22-39 8-3-39 9-16-36 IO-I I-39 10-21-39 9-7-39 9-19-39 4-12-40 2-I-40 I I-2-39 I-l-39 I-3-4 I 9-7-39 2-I-41 2-15-41 3-20-4 I 3-13-41

T

HospitaI

Chestnut Hi11 Chestnut Hi11 Germantown Chestnut Hi11 Chestnut Hi11 Germantown Germantown Germantown Germantown Germantown Germantown Germantown Germantown Germantown Germantown Germantown Germantown Germantown Germantown Chestnut Hill Nazareth Nazareth Nazareth Nazareth

3. If the ovarian Iesions be found when the abdomen is opened, resection of the cystic’ portion wiI1 give freedom from further clinica symptoms in 82 per cent of cases. 4. The fina word should be an admonition not to hesitate to open the abdomen

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in those cases in which any doubt to the possibility of appendicitis.

exists as

REFERENCES I. HOYT,W. F. and MEIGS,J. V. Surg., Gynec. @ Ok., 62: 114, 1936. 2. MANIZADE,D. M. VON. Wien. klin. Wcbnscbr., 49: 1392, 1936. 3. SEXTON, D. L. J. Missouri Med. Ass., 35: 388, 1938. 4. HARRIS, F. I. and GROPER,M. J. Surg., Gynec. @ Ok., 68: 824, 1939. 5. WEIL, A. M. Am. J. Obst. CYGynec., 38: 288, 1939.

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E. F. Am. J. Oh. CYGynec., 39: 684, 6. MCLAUGHLIN, 1940. 7. GUY, C. C. and ROTONDI,A. J. Surg., Gynec. CC Obsi., 70: 1100, 1940. 8. CASTALLO, M. Persona1 communication. 9. MEIGS, J. V. Persona1 communication, ApriI 24, 1941. GUY, C. C. Personal communication, April 22, 1941. IO. A. M. Persona1 communication, April 21, I I. WEIL, 194’. 12. CASTALLO,M. A. Persona1 communication, April 22, 1941. 13. HARRIS, F. I. Persona1 communication,

1341.

TUMOR of the ovary may be soIid or cystic, benign or mahgnant, smal1 or huge. Primary ovarian tumor can occur at any time: before puberty, during menstrua1 Iife, or after menopause. Metastatic tumor of an ovary is not uncommon, especiaIIy from the gastro-intestina1 tract, breast, cervix, or uterus.

April

21,