Appendicitis Complicating Ovarian Cyst and Simulating Torsion of the Pedicle, with Three Cases. Presented in the Section on Obstetrics and Diseases of Women at the Forty-eighth Annual Meeting of the American Medical Asso- ciation at Philadelphia, Pa., June 1-4, 1897. BY X. O. WERDER, M.D. PITTSBURG, PA. REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, JANUARY 1, 1898. CHICAGO: American Medical Association Press. 1898. APPENDICITIS COMPLICATING OVARIAN CYST AND SIMULATING TORSION OF THE PEDICLE, WITH THREE CASES. X. O. WERDER, M.D. Appendicitis as a complication of an ovarian cyst and accompanied by symptoms strongly resembling those of torsion of the pedicle, does not seem to be of very frequent occurrence ; at least I have failed to find any cases recorded in the literature at my disposal. This is my excuse for reporting the following cases which came under my observation and in which the symptoms were supposed to be due to an axial rota- tion of the tumor when, on the operating table, an appendicitis was discovered to be the disturbing ele- ment which led to a wrong diagnosis. Case 1.-Mrs. C., age 56 years, mother of nine children ; one miscarriage; last confinement sixteen years ago, followed by fever; otherwise always healthy. Her present trouble dates from May, 1894, when she was seized with cramps in the abdo- men and vomiting, which continued for several days. She had at times most of her pain in the right side. She has had sev- eral attacks since then of a similar nature, in the last of which she was attended by Dr. A. Koenig, who discovered a tumor in the abdomen. When I saw her in consultation with him, her acute symptoms, pain, vomiting, temperature 103 degrees, had somewhat subsided, though her abdomen was still very tender on pressure, and tympanitic. It was enlarged by a tumor occu- pying nearly the mid-region, more to the left, indistintly fluct- uating and painful on palpation. The diagnosis as made was : Ovarian cyst, with possible torsion of pedicle. Her removal to Mercy Hospital was advised for the purpose of operation. Operation, Aug. 13, 1894. On the right and upper surface of the tumor the omentum and several feet of small intestine with the vermiform appendix, were adherent. The latter was not much enlarged, but congested and filled with pus. It was ligated and cut, and the stump covered by a peritoneal sleeve. The adherent intestines were separated with considerable diffi- culty, many points requiring suture with fine silk to control bleeding. The cyst wall was unusually red and congested. 2 Convalescence was interrupted by an attack of pneumonia at the base of the right lung, on the fifteenth day. The patient was discharged cured about six weeks after operation. Case 2.-Mrs. K., age 39 years, mother of seven children, youngest 5 years old. Shortly after last confinement she noticed a lump in the right iliac region that has been grad- ually growing larger. She was seen in consultation with Dr. Potter Dec. 1, 1896. Two weeks previously she was seized with severe cramps in the lower abdomen, accompanied by vomiting and followed by high fever. The abdomen became tympanitic and extremely painful and tender, requiring frequent opiates to give relief. These symptoms abated during the last few days, though the abdomen, and especially the tumor, were still quite painful to the touch. The tumor occupied the mid- dle of the abdomen, extending above the umbilicus, and showed indistinct fluctuation. She was removed to Mercy Hospital for operation, which was performed Dec. 6, 1896. The cyst walls were dark in color and the seat of extensive adhesions to abdominal walls, intestines and pelvis. The adhe- sions were freed, bleeding points of omentum ligated and re- moved. The appendix, which was about six inches by one half inch thick, hard, red and adherent to cyst, was freed, the meso- appendix ligated near the cecum, stripped from the distal end of the appendix; the appendix also ligated near the cecum, clamped one-half inch further out and removed by cutting be- tween ; stump mopped and covered by meso appendix which was stitched over it. Convalescence was uneventful; out of bed the twenty-first day, discharged the twenty-eighth day. Case 3.-Mrs. Wm. E. F., age 44 years, mother of three chil- dren, youngest 6% years old; normal convalescence. Last October, after some exertion, she noticed a swelling in her abdomen, which has remained ever since. February 26, I saw her in consultation with Dr. Ryall, who had been attending her through an attack which was started by severe abdominal pains and vomiting, which kept up for several weeks; reten- tion of urine, abdomen tympanitic and very tender. She was very much emaciated and quite feeble, though her acute symp- toms had pretty well subsided, excepting her temperature, which remained above normal. Physical examination showed a fluctuating tumor, filling up the pelvis and abdomen, of the size of a pregnant uterus at six or seven months, which was very tender on pressure. She was removed to Mercy Hospital February 28, and operation per- formed March 4, after vainly trying to improve her general condition. Extensive omental and intestinal adhesions were separated from the cyst; pelvic and uterine adhesions very firm and difficult to separate, leaving a torn and bleeding ute- rus. An elastic ligature was therefore passed around it, the body amputated, treating the stump extraperitoneally. The cyst, which was multilocular was exceedingly friable, break- 3 ing to pieces at the least touch, in a number of places. Its walls were dark colored, from one-half to one inch in thickness. Microscopic section showed the cyst wall to be necrotic. Con- tents of the cyst were semisolid, of dirty gray color. The appendix was adherent to the cyst, tense, enlarged and inflamed, containing an enterolith. The microscope showed catarrhal inflammation. The patient had lost considerable blood during operation and was pretty well collapsed when taken from the operating table, but gradually rallied under active stimulation and improved. March 7 she showed undoubted evidences of double pneumo- nia and was in a critical condition for five or six days. She finally improved and made an excellent recovery. The pneumonia occurring in these two cases was a mere accidental complication, though the lowered vitality and the forced recumbent position for weeks even before the operation, no doubt greatly contrib uted to its development. The symptoms, in connection with the knowledge of the presence of an ovarian tumor in these cases, cer- tainly justified the supposition that the complication was due to torsion of the pedicle; especially as the acute stage of the trouble had passed at the time they came under observation. Differentiation would prob- ably have been easier at an earlier stage, as long as the inflammatory area in appendicitis was more local- ized. The fact that in torsion of the pedicle there is usually a rapid increase in the size of the tumor, marked shock and perhaps a less prompt rise of tem- perature than in appendicitis, would also probably be of considerable value in differential diagnosis at the outset, but at a later period the symptoms of the two conditions, at least in the cases in which torsion of the pedicle does not lead to a rapidly fatal termination, are so similar that it would scarcely be possible to dif- ferentiate them. Fortunately both conditions demand the same treatment i.e., prompt operation; and a dif- ferential diagnosis has, therefore, more of a scientific interest than practical importance. A fact worth noting is that there was undoubted in- flammation of the cyst in all cases; in the last two cases this was particularly pronounced, as evidenced by the 4 dark red discoloration of the cyst and the marked thickening of its walls and its unusual friability; in the last case they were actually necrotic in numer- ous places; conditions strongly resembling those found in torsion of the pedicle and in malignant dis- ease. Malignant degeneration was seriously sus- pected, but the microscopic examination was negative on this point. There were no evidences of fresh hem- orrhagic effusions into the cyst cavity in any of them. That this inflammation of the cyst cavity was not merely an extension by contiguity seems to be demon- strated by the fact that not only a portion of the cyst, the one in contact with the adherent appendix, was involved, but that the whole neoplasm seemed in a state of active inflammation with marked hyperemia and thickening of its walls, and in one, even at least partial necrosis. We must, therefore, suppose that the inflammation was caused by an infection from the appendix and not by a simple extension of the inflam- matory process. In conclusion, I wish to call attention to the method adopted in treating the stump of the appendix in the last two cases. It is so simple that doubtless it must have been used before me by other men, though I have been unable to find any account of it. It consists in tying the meso-appendix and the appendix separately near its insertion into the cecum. The meso-appen- dix is then stripped of the distal portion of the ap- pendix down to its ligature, the latter cut off about half an inch above, and the stump covered with the freed meso-appendix, and attached by one or two superficial sutures. By this means the whole stump is completely buried under a layer of peritoneal tis- sue. This can be done with more rapidity than by inversion or covering the stump with a peritoneal sleeve, and it certainly answers the purpose in every respect. I have followed this plan in all my cases requiring appendicectomy during the last six months, where the meso-appendix had not sloughed away. It has been perfectly satisfactory.