- Email: [email protected]
Torsion of the normal ovary
Torsion
of the Normal
ROBERT L. BERCER, M.D., Mattapan, Brookline,
Massachusetts, Massachusetts
From the Departments of Surgery, Tbe Boston City. HosIJitul, Boston, :Ma.ssacbusetts, and Brookline Hospitul, Brookline, Massachusetts. o
much emphasis has been placed on the hazards of a diseased ovary becoming twisted and infarcted that it is virtually unknown that the same may occur in a normal ovary. It is such an unusual occurrence that textbooks do not even mention it and rarely, if ever, is it discussed in the diagnosis of problematic surgical abdomens. The rare instance of torsion of the normal ovary precipitates the urgent picture of an acute condition within the abdomen. On the right side, it is usually mistaken for acute appendicitis. On the left, the problem is more disconcerting and is handled with considerable hesitanc.y. This paper records one case of torsion of the normal ovary in a child and presents a brief rcvic\v of the literature. s
CASE REPORT A ten year old white female child was admitted to the hospital complaining of pain in the left lower quadrant of about eight hours’ duration. The pain was scvcrc, nonradiating and constant, but \vith intermittent sharp exacerbations. It seemed worse when lying and was partially relieved by sitting up. She felt nauseated but did not vomit and had two normal bowel movements during the day. There was no diarrhea, chills or urinary symptoms. The mcnarche had not yet occurred. The patient had had measles, mumps, chickcnpox, tonsillitis, pneumonia at the age of eight weeks, asthma since the age of six years and numerous allergies. Physical examination reveafcd an ill, well developed, obese child with flushed facies. Temperature was IOO’P., pulse 120 per minute and respirations 20. Blood pressure was 100/60 mm. Hg. General physical findings were noncontributory, but local examination of the abdomen revealed marked tenderness and spasm in the left lower quadrant, and while the remainder of the abdomen was
,
AND
Ovarv . GEORGE KOBBINS,
M.D.,
somewhat resistant, palpation rcfcrrcd pain to the left lower quadrant from all other parts of the abdomen. The liver, spleen and kidneys were not palpable. Bimanual rectal examination set up increased muscular rcsistancc, so that the examination was not entirely satisfactory. There was marked tenderness in the cul-de-sac with a suggestion of a mass on the left side. Hemoglobin was I 2.8 gm. per 100 ml.; white blood count, I 1,000 per cu. mm.; and urinalysis, negative. Plain films of the abdomen and a chest plate showed no demonstrable abnormalities. An enema of saline solution was returned rclativcly clear. The child was rc-examined under general anesthesia and the prcsencc of a small mass in the left fowcr quadrant confirmed. Laparatomy rcvcaled a left ovary twice the size of the right. The left ovary was twisted on its pediclc with infarction of the ovary and scvcrc congestion of the tube. Although thcrc was slight recovery of the ovary after the twist was rclcascd, the organ appeared to be so scvcrcly damaged that a left salpingooophorcctomy and incidental appendectomy were performed. The child made an uncvcntful recovery and left the hospital on the eighth postoperative day. Pathologically the specimen was described as follows: The specimen consisted of a totally rcsccted ovary together with the attached tube. The ovary had been sagittally split and measured 4 by 2.5 by 1.5 cm. The scrosal covering retained a grey pearly quality, but was thin and permitted visualization of the underlying intcnscfy red-blue hemorrhagic engorged ovarian stroma. The cut surface had almost the appearance of a coagulated blood clot. Dispcrscd throughout this stroma were small red focal areas of increased consistency which appear to have been small cysts now filled with hemorrhagic coagulated fluid. These cysts averaged 3 to 4 mm. in diameter. There was no single large cyst or tumor and the ovary appcarcd to be either in a state of early hemorrhagic infarction or extremely intense vascular congestion. The tube was somewhat engorged but less hemorrhagic than the ovary and it measured 6 by .5 cm. The serosal surface was slightly granular due to
‘;1 .,,
-.T-.w
Manes [19] Hinshaw et al. ~ZO] Sarason et al. 1211
Sieber [IX]
Cohen [6] Rost [7] Downer (81 Northcutt rt al. [D] Baron [I”] Hicken et al. [II] Necl ct nl. [rz] l:owlic [r3] Gould [ICI Conf. [I51 Taylor [r6] Robins [17]
Hartman 111 Norris [zl Cassidy 131 Barrington [4] Monroe [5]
Author
; ?# IO a3 34 5 13
I1 26 20 3 4-:
-^-._
YCS
YCS
Yes
NO NO YL,,
YCS
NO
YCb
NO
Yes
YCS NO
Yes
Yea
Ye!3
_
YCS
YL?S
No
YCS
Yes
NO 2
3
NO
NO
3
4
2
2
4
9 4
Yes
Yes
Yes
Yes
Y‘S
NO
Yes
NO
Y‘S
Yes
N,
Y‘S
Y9 o 99.2 101.0 99.4 98 0 98 8 100.” IOO.” 98.6 Y9.” 101 .O I”I.0 99 6 99 8 UP
,“I .8
NO
Yes
NO
. 98.0 100.2
Yes
Temperature (OF.1
T
I WITH
P&C
TABLE PATIENTS
Yes
1v’omiting
pation
Duration of Symptoms (days)
ON
NO
and/or
NLlUSCl ,Consti-
-
INFORMATION
NO
1RCXlrPZWX of IIlness
T
PERTINENT
-
21.0 2”. I I, 0 r1.5 13 2 20.0 8.0 15.8 18.5 II 0 12.4 Normnl 12 Y 18.0 II.1 15.0 UP 166
1-J.” 25 ”
17.8
.
9.4
White Cell Count (1.0”“)
‘I 3lood
TORSION
1
.
Bloody Bloody Bloody Bloody Bloody Bloody
BlwKl.y
Bloody Bloody Bloody Bloody NOIll? Bloody Bloody Bloody %K”US Blor,rl,v None
Bloody CIear
NOW?
-
THE
I‘eritoneal FIuid
OF
Right Right Left Right Right Right Right Right Left Right Left Left Ixft Left Right ? Right Left Left Right Right Right Left Left Left Left Left Left Right
Side of rorsion
NO
Yes
NO
Yes
YL.S
NO
YCS
YCS
Yes
NO
NO
NO
NC,
Yes
YCS
ii
Yes
Yes
Yes
Yes
Yes
-
Tube Ovary Tube Ovary Tube Ovary ovary ovary Ovary Ovary Tube Tube Tube Tube Ovary Tube Tube Tube Tube Tube Tube Ovary Ovary Ovary Tubr Ovary Ovary Tube Ovary
Organ
OVARY
Pnlpable Mass
NORMAL
Clinical
Diagnosis
Appendicitis Appendicitis, ?torsion N0n.Z and “vary None and ovary None Appendicitis Appendicitis Appendicitis N0nL? Appendicitis iind “vary Torsion of “vary and “vuy ?Appendicitis, ?torsion and “vuy Appendicitis and “vary Appendicitis Appendicitis and “VB~Y ?Appendicitis nnd “vary None and “vary Torsion of Ovary and ovary None and ovary Appendicitis and ovnry Non‘2 N011e NO”‘2 Appendicitis and ovxry None NO”? NolIe and ov:*ry Appendicitis None
and Ovary
Involved
-3
cq
G 5
z w
Z
B 0
$ w.
Berger al the engorgement. There was no evidence of involvement of the fimbriae and no fusion. Microscopic examination reveaIed the ovarian substance to be extensively hemorrhagic. This hemorrhage was of very recent origin and consisted of large Iakes and masses of coaguIated bIood in some areas, while in other regions, there was diffuse permeation of underlying ovarian stroma by the recent hemorrhage. There was no evidence of Iuteinization or of previous ovulatory reaction and no suggestion of other abnormality or tumor within the ovary.
Robbins It is not surprising that the most frequent preoperative diagnosis with right-sided torsion was uncompIicated appendicitis, and perforated appendicitis with peritonitis when the process affected the left ovary. SubtIe differences in the cIinica1 pictures of torsion of the adnexa1 structures and acute appendicitis merit emphasis. In torsion, repeated short bouts of abdomina1 pain, nausea and vomiting with spontaneous remission may occur. This presumabIy corresponds with torsion and reIease of torsion of the affected ovary. Unlike appendicitis, the pain is sharp and becomes IocaIized immediately, without preIiminary migration, in either Iower quadrant. In addition, the duration of symptoms in infarction of the ovary is sIightIy Ionger (average 3.7 days with
COMMENTS
The first case of torsion and infarction of the norma ovary was reported by Hartman in 1898 [r]. A thorough search of British and American pubIications uncovered an additiona twenty-eight cases. The fiIes of the Boston City HospitaI’s MaIIory Institute of PathoIogy do not contain even a singIe case. Reports of twisted faIIopian tubes without ovarian invoIvement are sIightIy more numerous. We elected to review only cases with ovarian pathoIogy and a summary of the pertinent features are presented in TabIe I. Torsion of adnexa1 structures may invoIve the tube, the ovary (in this situation the dista1 tube is aIso damaged), and both the tube and the ovary. The mechanism of torsion has been attributed by various authors to a Iong mesosaIpinx or mesovarium, the persistence of a spira1 uterine artery, variations in intraabdomina1 pressure due to cough, hiccough and straining, and finaIIy to changes in body position. In the majority of instances, torsion of the norma ovary occurred during the first two decades of Iife. Four patients had been in the gravid state. AbdominaI pain, vomiting and constipation were the more constant and most prominent symptoms. The pain appeared suddenly, became IocaIized in either Iower quadrant of the abdomen and usuaIIy was described as sharp. About a half the patients spoke of simiIar iIlnesses with spontaneous recoveries in the past. A low grade fever associated with tachycardia and Ieukocytosis was a common finding. The right and left ovaries were invoIved with approximately the same frequency. In every patient, the site of abdomina1 pain, tenderness and muscIe spasm corresponded with the side on which the twisted ovary was found. A paIpabIe mass, on recta1 examination, was described in thirteen cases.
a range of one to eleven days) than in acute appendicitis. The presence of a peIvic mass, especialIy on the Ieft side, may tip the scaIe against the diagnosis of appendicitis. Even with incompIete data, two-thirds of the patients are reported to have bIoody fIuid in the peritoneal cavity. Therefore, an abdomina1 tap, essentiaIIy an innocuous procedure, may on occasions be instrumenta in making the correct diagnosis. SUMMARY I. One case of torsion of a norma ovary in a ten year oId chiId is reported and a review of the Iiterature presented. 2. The outstanding diagnostic features of torsion of the norma adnexa1 structures are discussed.
Acknowledgment: We wouId Iike to thank Dr. Stanley L. Robbins for the pathoIogic description. REFERENCES
wnec. et obst., I: 167; 1898. Abstracted in: A;.” J. Obst. ti ‘Gynec.,. 2: 507, 1921. 2. CASSIDY, M. A. Torsion of the Ieft broad Iigament and fallopian tube in a child. Lance-t, I : 98, 191 I. of the normal uterine 3. NORRIS, C. C. Torsion appendages and the report of a case. Am. J. Obst., 63: 850, 191I. F. J. F. A case of torsion of a norma 4. BARRINGTON, ovary. J. Obst. v Gynaec. Brit. Emp., 27: 141, I. HAKTMAN. F. Ann.
1916.
f*
MONROE,R. Acute torsion of ovary in young girls:
report of two cases. .I. M. A. Georgia, 7: I@, 1917. Torsion of uterine adnexa before puberty. J. A. M. A., 80: 382, 1923. W. L. Twisted ovarian pedicIe causing 7. Row,
6. COHEN, M.
7’8
Torsion
X.
r).
I o.
I I.
I 2.
r3. 14.
of Norma1 Ovar)
gangrene of normal ovary and simulating acute appendicitis. Arch. Pediat., 40: 787, 1923. DOWXEK, I. G. and BRINES, 0. A. Torsion ofundiseased uterine adnesa in virgins. Am. J. 06.~. P Gynec., 2 I : 665, ~93 I. NOK.I.IIC~~T,J. D. and BAKO~, C. Torsion 01 normal ovary and tube with rupture of the ovary and review of aI1 litcx~turc to date. heentuck).M. J.. q: 590, ,931. B -\Ko’L, (1. Torsion of the normal ovary. J. A. M. 4., 102: 1675. ‘934. HICKE.Y, N. F. and RASMUSSEN, L. P. Intraperitoneal hemorrhage caused by stranguIation and rupture of a normal ovary in an eight year old girl. J. Pediat., 18: 652, 1941. NEEL, f I. B., LEA, A. and VIRNING, 11. P. Torsion of the uterine adnesa in childhood. Am. J. 06~. ti+ Gp-WC., 45: 326, 1943. FOWLIE, J. A. Twisted ovarian cyst in children. Am. J. Surg., 64: 285, 1944. Gor-rn, A. IH. Torsion of ovarian pedicle in a two
I j.
16. 17.
18.
19.
(linical (lmfercncc. C:tsc 3. Torsion of the f:dIopi:~n tube and ovary with inf:trction of the, ,lv:~r\. .I. l’ediat., 36: 52r, I950. 'I‘AYLOH, S. Torsion of ov;,r> it1 ~hiltlh~~c~tl. .4r_rb. Dis. Chid., 27: 368, ,952. KORINS, A. I. Torsion of tube and ov;gr?- complicatlng pregnancy: report 01 two c:~ses. ,I\~n. .J. Obst. c’++w., 68: 932, 1954. SIEBEK, \\‘. E;. Torsion of normal utcrint, adncxa in infancy and childhood. I’ediatrics, 14: 663, ,954. PIANOS, T. N. Torsion of uterine adneua: report of :L case in n gir1 three years oId. Obio .$,I. J., 50:
559, 1934. 20. HINSHAU-, D. B. and KUC.EI., A. I. Torsioll and infarction of the normal ovary. tl~. J. 0i.s. Chilii., 92: 57, 1956 21. SARASON, E. L. and PRIOK, .J. T. Acute ;tbdomin;~l pain due to torsion and infarction of :t nornxtl r)var\-. Surg. GAxec. 6:s Ohst., 107: --I. ro;X.
7’9
of the Normal
ROBERT L. BERCER, M.D., Mattapan, Brookline,
Massachusetts, Massachusetts
From the Departments of Surgery, Tbe Boston City. HosIJitul, Boston, :Ma.ssacbusetts, and Brookline Hospitul, Brookline, Massachusetts. o
much emphasis has been placed on the hazards of a diseased ovary becoming twisted and infarcted that it is virtually unknown that the same may occur in a normal ovary. It is such an unusual occurrence that textbooks do not even mention it and rarely, if ever, is it discussed in the diagnosis of problematic surgical abdomens. The rare instance of torsion of the normal ovary precipitates the urgent picture of an acute condition within the abdomen. On the right side, it is usually mistaken for acute appendicitis. On the left, the problem is more disconcerting and is handled with considerable hesitanc.y. This paper records one case of torsion of the normal ovary in a child and presents a brief rcvic\v of the literature. s
CASE REPORT A ten year old white female child was admitted to the hospital complaining of pain in the left lower quadrant of about eight hours’ duration. The pain was scvcrc, nonradiating and constant, but \vith intermittent sharp exacerbations. It seemed worse when lying and was partially relieved by sitting up. She felt nauseated but did not vomit and had two normal bowel movements during the day. There was no diarrhea, chills or urinary symptoms. The mcnarche had not yet occurred. The patient had had measles, mumps, chickcnpox, tonsillitis, pneumonia at the age of eight weeks, asthma since the age of six years and numerous allergies. Physical examination reveafcd an ill, well developed, obese child with flushed facies. Temperature was IOO’P., pulse 120 per minute and respirations 20. Blood pressure was 100/60 mm. Hg. General physical findings were noncontributory, but local examination of the abdomen revealed marked tenderness and spasm in the left lower quadrant, and while the remainder of the abdomen was
,
AND
Ovarv . GEORGE KOBBINS,
M.D.,
somewhat resistant, palpation rcfcrrcd pain to the left lower quadrant from all other parts of the abdomen. The liver, spleen and kidneys were not palpable. Bimanual rectal examination set up increased muscular rcsistancc, so that the examination was not entirely satisfactory. There was marked tenderness in the cul-de-sac with a suggestion of a mass on the left side. Hemoglobin was I 2.8 gm. per 100 ml.; white blood count, I 1,000 per cu. mm.; and urinalysis, negative. Plain films of the abdomen and a chest plate showed no demonstrable abnormalities. An enema of saline solution was returned rclativcly clear. The child was rc-examined under general anesthesia and the prcsencc of a small mass in the left fowcr quadrant confirmed. Laparatomy rcvcaled a left ovary twice the size of the right. The left ovary was twisted on its pediclc with infarction of the ovary and scvcrc congestion of the tube. Although thcrc was slight recovery of the ovary after the twist was rclcascd, the organ appeared to be so scvcrcly damaged that a left salpingooophorcctomy and incidental appendectomy were performed. The child made an uncvcntful recovery and left the hospital on the eighth postoperative day. Pathologically the specimen was described as follows: The specimen consisted of a totally rcsccted ovary together with the attached tube. The ovary had been sagittally split and measured 4 by 2.5 by 1.5 cm. The scrosal covering retained a grey pearly quality, but was thin and permitted visualization of the underlying intcnscfy red-blue hemorrhagic engorged ovarian stroma. The cut surface had almost the appearance of a coagulated blood clot. Dispcrscd throughout this stroma were small red focal areas of increased consistency which appear to have been small cysts now filled with hemorrhagic coagulated fluid. These cysts averaged 3 to 4 mm. in diameter. There was no single large cyst or tumor and the ovary appcarcd to be either in a state of early hemorrhagic infarction or extremely intense vascular congestion. The tube was somewhat engorged but less hemorrhagic than the ovary and it measured 6 by .5 cm. The serosal surface was slightly granular due to
‘;1 .,,
-.T-.w
Manes [19] Hinshaw et al. ~ZO] Sarason et al. 1211
Sieber [IX]
Cohen [6] Rost [7] Downer (81 Northcutt rt al. [D] Baron [I”] Hicken et al. [II] Necl ct nl. [rz] l:owlic [r3] Gould [ICI Conf. [I51 Taylor [r6] Robins [17]
Hartman 111 Norris [zl Cassidy 131 Barrington [4] Monroe [5]
Author
; ?# IO a3 34 5 13
I1 26 20 3 4-:
-^-._
YCS
YCS
Yes
NO NO YL,,
YCS
NO
YCb
NO
Yes
YCS NO
Yes
Yea
Ye!3
_
YCS
YL?S
No
YCS
Yes
NO 2
3
NO
NO
3
4
2
2
4
9 4
Yes
Yes
Yes
Yes
Y‘S
NO
Yes
NO
Y‘S
Yes
N,
Y‘S
Y9 o 99.2 101.0 99.4 98 0 98 8 100.” IOO.” 98.6 Y9.” 101 .O I”I.0 99 6 99 8 UP
,“I .8
NO
Yes
NO
. 98.0 100.2
Yes
Temperature (OF.1
T
I WITH
P&C
TABLE PATIENTS
Yes
1v’omiting
pation
Duration of Symptoms (days)
ON
NO
and/or
NLlUSCl ,Consti-
-
INFORMATION
NO
1RCXlrPZWX of IIlness
T
PERTINENT
-
21.0 2”. I I, 0 r1.5 13 2 20.0 8.0 15.8 18.5 II 0 12.4 Normnl 12 Y 18.0 II.1 15.0 UP 166
1-J.” 25 ”
17.8
.
9.4
White Cell Count (1.0”“)
‘I 3lood
TORSION
1
.
Bloody Bloody Bloody Bloody Bloody Bloody
BlwKl.y
Bloody Bloody Bloody Bloody NOIll? Bloody Bloody Bloody %K”US Blor,rl,v None
Bloody CIear
NOW?
-
THE
I‘eritoneal FIuid
OF
Right Right Left Right Right Right Right Right Left Right Left Left Ixft Left Right ? Right Left Left Right Right Right Left Left Left Left Left Left Right
Side of rorsion
NO
Yes
NO
Yes
YL.S
NO
YCS
YCS
Yes
NO
NO
NO
NC,
Yes
YCS
ii
Yes
Yes
Yes
Yes
Yes
-
Tube Ovary Tube Ovary Tube Ovary ovary ovary Ovary Ovary Tube Tube Tube Tube Ovary Tube Tube Tube Tube Tube Tube Ovary Ovary Ovary Tubr Ovary Ovary Tube Ovary
Organ
OVARY
Pnlpable Mass
NORMAL
Clinical
Diagnosis
Appendicitis Appendicitis, ?torsion N0n.Z and “vary None and ovary None Appendicitis Appendicitis Appendicitis N0nL? Appendicitis iind “vary Torsion of “vary and “vuy ?Appendicitis, ?torsion and “vuy Appendicitis and “vary Appendicitis Appendicitis and “VB~Y ?Appendicitis nnd “vary None and “vary Torsion of Ovary and ovary None and ovary Appendicitis and ovnry Non‘2 N011e NO”‘2 Appendicitis and ovxry None NO”? NolIe and ov:*ry Appendicitis None
and Ovary
Involved
-3
cq
G 5
z w
Z
B 0
$ w.
Berger al the engorgement. There was no evidence of involvement of the fimbriae and no fusion. Microscopic examination reveaIed the ovarian substance to be extensively hemorrhagic. This hemorrhage was of very recent origin and consisted of large Iakes and masses of coaguIated bIood in some areas, while in other regions, there was diffuse permeation of underlying ovarian stroma by the recent hemorrhage. There was no evidence of Iuteinization or of previous ovulatory reaction and no suggestion of other abnormality or tumor within the ovary.
Robbins It is not surprising that the most frequent preoperative diagnosis with right-sided torsion was uncompIicated appendicitis, and perforated appendicitis with peritonitis when the process affected the left ovary. SubtIe differences in the cIinica1 pictures of torsion of the adnexa1 structures and acute appendicitis merit emphasis. In torsion, repeated short bouts of abdomina1 pain, nausea and vomiting with spontaneous remission may occur. This presumabIy corresponds with torsion and reIease of torsion of the affected ovary. Unlike appendicitis, the pain is sharp and becomes IocaIized immediately, without preIiminary migration, in either Iower quadrant. In addition, the duration of symptoms in infarction of the ovary is sIightIy Ionger (average 3.7 days with
COMMENTS
The first case of torsion and infarction of the norma ovary was reported by Hartman in 1898 [r]. A thorough search of British and American pubIications uncovered an additiona twenty-eight cases. The fiIes of the Boston City HospitaI’s MaIIory Institute of PathoIogy do not contain even a singIe case. Reports of twisted faIIopian tubes without ovarian invoIvement are sIightIy more numerous. We elected to review only cases with ovarian pathoIogy and a summary of the pertinent features are presented in TabIe I. Torsion of adnexa1 structures may invoIve the tube, the ovary (in this situation the dista1 tube is aIso damaged), and both the tube and the ovary. The mechanism of torsion has been attributed by various authors to a Iong mesosaIpinx or mesovarium, the persistence of a spira1 uterine artery, variations in intraabdomina1 pressure due to cough, hiccough and straining, and finaIIy to changes in body position. In the majority of instances, torsion of the norma ovary occurred during the first two decades of Iife. Four patients had been in the gravid state. AbdominaI pain, vomiting and constipation were the more constant and most prominent symptoms. The pain appeared suddenly, became IocaIized in either Iower quadrant of the abdomen and usuaIIy was described as sharp. About a half the patients spoke of simiIar iIlnesses with spontaneous recoveries in the past. A low grade fever associated with tachycardia and Ieukocytosis was a common finding. The right and left ovaries were invoIved with approximately the same frequency. In every patient, the site of abdomina1 pain, tenderness and muscIe spasm corresponded with the side on which the twisted ovary was found. A paIpabIe mass, on recta1 examination, was described in thirteen cases.
a range of one to eleven days) than in acute appendicitis. The presence of a peIvic mass, especialIy on the Ieft side, may tip the scaIe against the diagnosis of appendicitis. Even with incompIete data, two-thirds of the patients are reported to have bIoody fIuid in the peritoneal cavity. Therefore, an abdomina1 tap, essentiaIIy an innocuous procedure, may on occasions be instrumenta in making the correct diagnosis. SUMMARY I. One case of torsion of a norma ovary in a ten year oId chiId is reported and a review of the Iiterature presented. 2. The outstanding diagnostic features of torsion of the norma adnexa1 structures are discussed.
Acknowledgment: We wouId Iike to thank Dr. Stanley L. Robbins for the pathoIogic description. REFERENCES
wnec. et obst., I: 167; 1898. Abstracted in: A;.” J. Obst. ti ‘Gynec.,. 2: 507, 1921. 2. CASSIDY, M. A. Torsion of the Ieft broad Iigament and fallopian tube in a child. Lance-t, I : 98, 191 I. of the normal uterine 3. NORRIS, C. C. Torsion appendages and the report of a case. Am. J. Obst., 63: 850, 191I. F. J. F. A case of torsion of a norma 4. BARRINGTON, ovary. J. Obst. v Gynaec. Brit. Emp., 27: 141, I. HAKTMAN. F. Ann.
1916.
f*
MONROE,R. Acute torsion of ovary in young girls:
report of two cases. .I. M. A. Georgia, 7: I@, 1917. Torsion of uterine adnexa before puberty. J. A. M. A., 80: 382, 1923. W. L. Twisted ovarian pedicIe causing 7. Row,
6. COHEN, M.
7’8
Torsion
X.
r).
I o.
I I.
I 2.
r3. 14.
of Norma1 Ovar)
gangrene of normal ovary and simulating acute appendicitis. Arch. Pediat., 40: 787, 1923. DOWXEK, I. G. and BRINES, 0. A. Torsion ofundiseased uterine adnesa in virgins. Am. J. 06.~. P Gynec., 2 I : 665, ~93 I. NOK.I.IIC~~T,J. D. and BAKO~, C. Torsion 01 normal ovary and tube with rupture of the ovary and review of aI1 litcx~turc to date. heentuck).M. J.. q: 590, ,931. B -\Ko’L, (1. Torsion of the normal ovary. J. A. M. 4., 102: 1675. ‘934. HICKE.Y, N. F. and RASMUSSEN, L. P. Intraperitoneal hemorrhage caused by stranguIation and rupture of a normal ovary in an eight year old girl. J. Pediat., 18: 652, 1941. NEEL, f I. B., LEA, A. and VIRNING, 11. P. Torsion of the uterine adnesa in childhood. Am. J. 06~. ti+ Gp-WC., 45: 326, 1943. FOWLIE, J. A. Twisted ovarian cyst in children. Am. J. Surg., 64: 285, 1944. Gor-rn, A. IH. Torsion of ovarian pedicle in a two
I j.
16. 17.
18.
19.
(linical (lmfercncc. C:tsc 3. Torsion of the f:dIopi:~n tube and ovary with inf:trction of the, ,lv:~r\. .I. l’ediat., 36: 52r, I950. 'I‘AYLOH, S. Torsion of ov;,r> it1 ~hiltlh~~c~tl. .4r_rb. Dis. Chid., 27: 368, ,952. KORINS, A. I. Torsion of tube and ov;gr?- complicatlng pregnancy: report 01 two c:~ses. ,I\~n. .J. Obst. c’++w., 68: 932, 1954. SIEBEK, \\‘. E;. Torsion of normal utcrint, adncxa in infancy and childhood. I’ediatrics, 14: 663, ,954. PIANOS, T. N. Torsion of uterine adneua: report of :L case in n gir1 three years oId. Obio .$,I. J., 50:
559, 1934. 20. HINSHAU-, D. B. and KUC.EI., A. I. Torsioll and infarction of the normal ovary. tl~. J. 0i.s. Chilii., 92: 57, 1956 21. SARASON, E. L. and PRIOK, .J. T. Acute ;tbdomin;~l pain due to torsion and infarction of :t nornxtl r)var\-. Surg. GAxec. 6:s Ohst., 107: --I. ro;X.
7’9