A case of twisting of the leg of the broad ligament cyst with the displacement of the tumor to the opposite side of the pelvis and the growth here

Abstract

The doctrine of the twisting of the pedicle of the tumors of the uterine appendages (ovaries, steamer, wide ligaments, tubes) seems far from complete. By the way, a very interesting question about the cause of the twisting remains open to this day [1]. This question, as is known, was solved very differently

Full Text

The doctrine of twisting of the pedicle of tumors of the uterine appendages (ovaries, steamer, broad ligaments, tubes) seems far from complete. By the way, a very interesting question about the cause of the twisting remains open to this day [1]). This question, as is known, was dealt with very differently.
The twisting was not attributed to any one and, moreover, a permanent cause, but to various and random ones: uneven tumor growth, the presence of other tumors in the abdomen, including the pregnant uterus, emptying of the pregnant uterus, distended bladder urine, filled rectal colon, mechanical on the position of the tumor emerging from the pelvis into the abdominal cavity, the change in the position of the body and especially the fast movement of the woman, the peristaltic movement of the intestines and their swelling with gases [2]), and one author put one reason or another in the foreground. At the same time, they did not find any definiteness, constancy in the very direction of the twisting. Only Cario [3]) was inclined to accept the well-known certainty, considering the main reason for the rotation of the cyst around the longitudinal axis resp. twisting of the legs, instant action of the abdominal press with one-sided position of the intestines. In part, Thorn [4]) was inclined to accept that cyst rotation is more often from the inside out. But in the past 1891 from the Dorpat clinic prof. Kästner published two works, Kästner himself [5]) and Dr. Mickwitz [6]), which, on the basis of one and the same clinical material (37 Kustner's ovariants), prove the perfect legality of the direction of twisting and the constancy of the cause producing the last. They, firstly, think that twisting occurs incomparably more often than has been indicated so far. While Sp.-Wells found them in 2.4%, Tornton 9.5, Rokitansky 13%, Schröder 14%, Olshausen 6.3%, Howitz 23.2%, Freund 37.5 [7]) - Kustner found 20 twists for 36 all cases of ovarianotomy, if we understand twisting in a broad sense, according to Freund, that is, counting the twisting of a twist up to 90%. But even if we understand the twisting in the clinical sense, which leads to nutritional disturbances in the tumor (for which, according to Mickwtz, not less than 180 ° is required), then in such a case the twisting was observed in Kästner in 17 cases by 36, i.e. e. at 47.2%. This huge difference in their numbers with others, they explain, in 1-x, t другm, that other operators looked through those cases, where there were no sharp consequences of twisting before or during the operation, or by sharp anatomical changes in the conditions of the tumor, in the second clinics, where, due to the underdevelopment of the population, women turn not for the sake of a tumor in the abdomen, but for the sake of more or less severe seizures caused by it and mainly due to the twisting of the legs.
But if the last reason were of great importance, then with the ovarianotomy of Russian surgeons, twisting would have met no more than in the Dorpat clinic. And between tѣm, it is marked relatively lightly.
So, according to Soloviev [8]), in cases prof. Krassovskogo it meets in 6.2%, prof. Reina in 9.5%, prof. Slavyansky in 8.3%, prof. Sklifosovskiy in 2.8%; on all 736 cases of ovarіotomy collected by Dr. Matvѣev in 2.5%. And in the further messages of the twisting ovariants are indicated rarely. So, at 61 ovariotomy prof. Krassovskiy [9]), it is marked 6 times, that is, approximately 10%; on 33 ovaryotomy of Dr. Sutugin [10]) 2 times, that is, 6.6%; at 54 ovariotomy prof. Sklifasovsky [11]) 4 times, that is, 7.3%; at 83 ovariotomy prof. Fenomenova [12]) 3 times, ie, 3.6%; for 20 ovariootomy Tsadner [13]) not a single twisting; in all cases of the indicated surgeons and doctors Bereznitskago [14]), Tyshko [15]), Grammatiki [16]), Solovyov [17]), Khalafov [18]), Lenevich [19]), 17 of them are marked for 300 ovaryotomy, t that is, in 5.6%. Further, prof. Küstner and Dr. Mickzvitz deduce the following rule: the longitudinal rotation of the tumor, which causes the twisting of the leg, occurs from the inside - outward, that is, for the right tumor from the left to the right, or by the movement of the clockwise hand, if you look from above in front, and for the left in the opposite direction...
This legitimacy, in their opinion, they managed to find, thanks to the fact that they consistently marked the direction of twisting, which others did not do. In relation to the cases of Russian ovariotomy with twisting of the legs, the latter is quite fair, judging by the promulgated ovariotomies.

So, on all ovaryotomy with a twisted leg in the book of Dr. Mataev [20]), the direction of twisting is never indicated. In the later messages mentioned above, the direction of twisting is also not indicated, except for one case (No. 33 of Dr. Sutugin [21]); it is not indicated even in separate messages of cases of ovarianotomy, which was shown by which the legs were twisted (Solovieva [22]), Zayaitskago [23]), Prokofieva [24]), prof. Ott [25]), except for the case of Dr. Shurinov [26]). Obviously, little attention was paid to this side of the soul. In Küstner's cases, for 10 twisting of the left-sided brushes there were 7 according to the specified rule and 3 against; from 7 right-sided 6 according to the rule and 1 against. Since the twisting of the legs is performed in the correct order, then, clearly, it is impossible to look for the reason for it in the specified random circumstances. Küstner sees this reason in the one-sided influence of the intestines, which always lie inside - behind the cyst and, with their stretching and movements, always exert pressure on it in the direction from the inside - from behind to the front - outward, that is, in the wrist direction of the indicated rotation. Mickwitz, agreeing with this, finds it necessary to admit other reasons, both permanent and random. To the first he refers to the effect of contractions of the transverse muscles of the abdomen, which, due to the immobile strengthening outside (near the skeleton), pull the muscle plate and the cyst lying under it, from the inside - out. The second ones include the indicated random circumstances and their influence, by the way, explains the twisting against the specified rule, if these reasons work in the direction opposite to permanent reasons and stronger than them. To the energetic contraction of the indicated muscles, and sometimes to the joint identical influence of any of the random reasons, he ascribes a rapid and extensive rotation of the cyst, resp. twisting of the legs, which must be recognized to explain the acute clinical picture of twisting. I allowed myself to dwell on this issue in detail in order to have the right to say how important it is to report in detail cases of twisting of the cyst leg, even if only for the sake of establishing the legality of this phenomenon and its reasons. But, of course, there is a question about twisting and other dark sides, which can be clarified from separate messages. The last in our Russian literature are more intelligent, that there are very few of them in it, in spite of the huge number of performed ovarianotomies. With all this in mind, as well as the fact that my case among those also has some interesting features, I allow myself to state it in detail. He is next.

On June 16, 1892, the patient Mrs. M., serving on the railroad, 32 years old, was admitted to the surgical department of the Gatchina Hospital of the Palace Administration. The patient is of small stature, generally rather weak in constitution, but before marriage she had a satisfactory nutrition. On the 16th year M. had regulations, which were repeated at the correct time, were of average strength and duration and without pain. She got married in the 27th year. A year later (on the 28th year) she gave birth to the first part safely, without any postnatal complications; got up on the 9th day. She fed the child herself for about a year, or a little more. After about 2 months after the birth, M. developed beads, quite strong, forcing the patient to go to the obstetrician (4-5 months after the birth). The last one on examination found a developing cyst of the right ovary. There was pain in the right side of the pelvis much earlier than this time (before pregnancy). After 1-2 weeks, another doctor found this diagnosis very dubious and suggested pregnancy in the beginning. Pregnancy, indeed, after some time was finally clarified, and the patient gave birth in 16 months after the first birth (that is, in 12-11 months after the indicated study of the obstetrician and after 111 / 2-10, finally, after 91/2 months of another doctor). Until the very birth, there were only dead beads. The second childbirth passed, like the first, safely. And the second child M. was fed herself for a whole year. After the child was taken away, the regulations appeared only after 6 months: during pregnancy and after childbirth, the patient was physically and mentally exhausted, due to difficult everyday conditions; Regulations were repeated after 5-6 weeks and were so abundant that the patient was weakened later. Soon after the removal of the second child, the beads appeared again, which, with some fluctuations in strength (in general, in a reduced degree), continued to this day. At this time, the general nutrition became rather satisfactory, but the nervous system became irritable. In the last time the patient began to suppress in the very lower part of the abdomen, more on the right side, a roundish, painless, mobile "lump, the size of a fist." In March of this 1892, during the period of regulation, M. suddenly had severe pains in the right - lower side of the abdomen, forcing the patient to lie down and disappearing only a day later. Before that, M. often raised her 31/2-year-old child, both during and after the regulation; besides, she very often jumped off on the move (quiet) of the train, approaching the station. On June 14, she again appeared suddenly, in the morning, severe pain in the entire lower abdomen, more on the right. At the same time, general health disorder, moderately high temperature, some abdominal distention, vomiting with bile and absence of excrement (within 3 days). Doctor Blyshev, who was soon invited to the patient, found, in addition to this, in the lower, more in the right side of the abdomen, a roundish corpulence, about the size of a seltzer bottle, easily mobile, painless, or, at least, not very painful. The disease was preceded by some special conditions: 1) the patient did not weaken for 3 days; in 2) from the 1st to the 7th of June, that is, a week before the illness, M. had especially abundant regulae with large blood clots, although M. strictly excludes any likelihood of graviditatis; c 3) the last week the patient had to work hard and worry a lot, which together with the regulations weakened her considerably. Both during regulation and later, M. usually walked, even, as before, jumped off a quietly moving train, repeatedly lifted her child, which became even heavier. Despite the deceased state of the ice, the pains increased over the course of a day and a half; the patient did not weaken, and the rest of the painful phenomena did not pass. On June 16 in the morning, M., with severe pains in the lower abdomen, was taken to the hospital. She's pretty thin and thin. The temperature is elevated, the pulse is weak and quickened. Nothing abnormal is found in the organs of the breast. Urination and urine are normal. M. complains of pain in the lower abdomen, that lying on his back, turning from one position to another, flexion and extension of the legs in the hip joint are painful. In general, the abdomen is slightly swollen, gives the usual tympanic tone and does not hurt, both by itself and under pressure, with the exception of its lower part. There is a slight longitudinal-weakly oval elevation, between the navel and the small pelvis, more on the right side. Here, however, a dull tone in the limited oval space, which does not reach the upper level of the navel by 1-1 1/2 of the transverse fingers, at the bottom goes into the small pelvis and goes slightly to the left beyond the middle line. Accordingly, a dense (not hard), rounded, not lumpy, very painful dullness is felt in the abdominal cavity, which is why its mobility is not explored. In view of the patient's fatigue from lying on the back and examining, the last day there was a break, and the patient was allowed to lie on his side. For the same reason, it was not possible to draw on the belly the outlines of the indicated body; but in the mournful sheet during the break, there was a schematic drawing of the position of the tumor. When the patient resumed (about an hour later, the patient was lying on the left side) of the study, the indicated dullness is determined by its much larger part on the left side. There is a lot of mucus in the vagina. Its walls are slightly loosened. The vaginal part of the uterus is thickened, loose, with small irregularities on the mucous membrane. The uterus moved forward. The boundaries of her back cannot be determined with the existing pain, but the upper boundary is palpable. The uterus seemed somewhat enlarged and softer than usual. There is a slight mobility of it from top to bottom and to the sides, and there is no substitute for the transfer of movements to the indicated body. The vaults are normal, but with pressure upward on the right, a painful density is felt. In general, it was impossible with clarity to examine both the pelvic organs and the indicated oval body, in view of the significant pain. Fluctuations in the oval body were not marked on the 1st day. The temperature in the evening is 38.5 °.

On the next day (June 17), the pains are stronger, although they are limited to the indicated body, which takes the same place on the left, but has become a little more. Fluctuations are marked. The abdomen is more swollen, not weak. There was a moderate uterine bleeding. The urine began to linger. T ° 37.9 in the evening.

On the 3rd day (June 18) the pains are weaker and are limited to the indicated body. The belly is even more swollen. Weakened at night. T ° 38.2 in the evening.

On the 4th day (June 19), the stomach was not swollen. Tumor in one position. T ° 37.4 in the evening.

On the 5th day (June 20) the swelling seems a little bigger and still hurts. T ° 37.4 in the evening.

On the 6th day (June 21), the tumor increased a little and was still painful, most of all in the left groin. She appears more sharply on the fallen belly, taking the same place. Completely clear fluctuations in the upper 2/3 of the tumor. Syringe Pravatsa turned out to be a watery pink liquid, which gives abundant clots when boiled. T ° 37.6 in the evening. On this day, Doctor Bulyshev noticed that the tumor in its present form is much larger than it was at the first examination of the patient.

On the 7th day (June 22), the tumor was in one position, but less painful. The bleeding has stopped. T ° in the evening 37.1.

On the 8th day (June 23rd), the abdomen was not swollen, the tumor was incomparably less painful and the study was free. The tumor is left and immobile, like the uterus. It was not possible to pass between them from behind and they here seem to fit tightly one to the other, but from above and from the sides the outlines of the uterus are defined quite clearly. Her body is deflected forward. On the right side, a little higher than the level of the uterine fundus, a dense, oblong body is not clearly felt, with a palpable upper edge, to the left unnoticeably merging with the tumor, painful with pressure. Analyzing this set of phenomena, I came to the following conclusion: there is a cystic neoplasm of the right ovary, the leg of which quickly twisted and caused hemorrhage, an enlargement of the tumor, limited by the tumor, peritonitis, which led to the adhesion of the tumor, which was displaced. The uterus is pushed aside by the tumor anteriorly and, in all likelihood, is spliced ​​with it. The indicated oblong body, coming from the right side of the pelvis to the tumor, is probably the leg of the last days.

On June 24, 1892, I gave an ovariootomy with the participation of comrades - Blyshev and Kolpakov. The usual preparation of the patient in these cases. The operation was delivered in a very comfortable and cleanly contained operation room. (The preparation for the operation of the necessary items, the sick and the active persons was carried out in the next room, assigned exclusively for this purpose and very purely content). The dressing material, towels, aprons, etc., were sterilized. Sponges were not used: the wound and abdominal cavity were cleaned with pieces of cotton wool wrapped in gauze and gauze napkins. (All the participants in the operation immediately before her took a bath and dressed in everything clean, and sterilized on top). The abdomen was opened but the median line with a layer-by-layer incision, starting 3 transverse fingers below the navel and ending directly above the pubis. The peritoneum was mistaken for the surface of the uterus and the finger was separated by 2 transverse to the sides in its middle third. However, I soon became convinced of the mistake and opened the peritoneum in the lower part of the incision, where it seemed to me free; from here it was cut on the finger, which previously (easily) separated it from the adhesions to the subject of neoplasm. The naked tumor had a dark violet color. Separating easily on some spaces of her adhesion to the abdominal wall, I released a brown watery fluid from the presenting cyst with a trocar. Since the other hand was not obscured, on the other hand, the tumor had decreased enough for extraction, the trocar was removed and the opening was closed with Freund's fenestrated forceps. Pulling out the tumor with my fingers, I gradually and easily separated it from the fresh adhesions over the entire surface. At the same time, a part of the tumor, which was enlarged to the left most deeply, came off and remained there on its adhesions. All tumor tissues were loose, and this one was especially: it was a soft, spongy, dark-brown mass, similar to a blood bundle. During the rupture, a small amount of blood poured out, but only hardly any blood: at least to me, it seemed to have changed, to the kind that was found in the tumor cavities. When extracting the last days, 2 loops of small intestines were pulled outward, wrapped immediately in sublimated gauze napkins. The same napkins were always placed between the tumor and the abdominal cavity. After complete extraction of the tumor, it turned out that the indicated body, going from right to left, represented its leg twisted one and a half times in the direction of movement of the clock hand (if you look from above - from the front). The stem was untwisted by the appropriate turns of the tumor; in the narrowest place she was two fingers wide. It is tied in two parts with thick silk (idoform) ligatures and one common ligature under them, after which it is cut 1 cm above the ligatures. However, it turned out that the ligatures too attracted one to the other two extreme parts of the tumor, one going from the inside, from the uterus, and the other. going outside, where the darkness of the uterus was somewhat attracted to the right. These two parts are tied separately below, the previous ligatures are removed. Only after the separation of the tumor, I was fully convinced that a piece had come off it; now it was carefully separated by the ends of the fingers from the splices and extracted.

I could not see the left ovary, and I didn’t look for it on purpose. The abdominal cavity was not washed, but wiped off with gauze napkins. Along the setting of the intestines, the wound was sewn with deep and superficial silk sutures. But the lower part of the wound remained not sutured: an iodoform-gauze tampon 11/2 fingers thick, inserted into the posterior Douglas space, passed through it. The tampon consisted of many, long, narrow strips, folded parallel to a bundle, wrapped outside by a wider strip. An antiseptic, pressure bandage was applied to the abdomen. A tumor the size of a dt (2-x-3-xl) head. It consists of a simple cyst, 11/2-2 fist in size, from the Fallopian tube, which runs along its upper surface, clearly adjacent to it, finally, from a dense, irregularly shaped part, the size of 11/2 chicken eggs lying downward from tubes and downwards inwards from the cyst. The walls of the cyst consist of 2 membranes, extremely weakly connected by a loose, wide-looped connective tissue: the inner one is thin, on the inner surface it is smooth, but not even, but covered with low elevations, then small ones are roundish, with a small deepening in the middle (warty) then large, thin annular. The outer shell is more dense and covered with the peritoneum. In the thickness of this shell, the Fallopian tube passes, the length of the top is 31/2, arcuate curved, gradually expanding from the uterine to the peritoneal end, from the thickness of the goose feather to the diameter of 11/2 of the finger, ending in a fringe on the very surface of the cyst. At the uterine end, in the place of its crossing, the pipe sharpens conically and is interrupted; here the channel for a length of 2 centimeters is not passable for the very thin probe. Farther outward, the channel widens more and more, finally, again sharply narrows before the fringes, between which it opens with a hole in a pencil, or in a goose feather wide. The tube, tightly connected to the outer plate of the cyst wall, is removed with its inner part both from the cyst and from the above-mentioned dense body: between them there is a plate of little-changed broad ligament. The dense mass consists, in turn, of 2 parts: the one lying posterior to the Fallopian tube is oval, and the antero-inferior one is of irregular shape with a concavity, which included the protruding bulge during twisting. They consist of a base, especially a loose one in the lower irregular mass, and many cavities embedded in it, ranging in size from walnut orchid to a pea and less. These cavities (as well as the cavity of the pipe), as well as the interstitial spaces, are filled with thickening, tarry blood. The torn off pieces turned out to be parts of a particularly loose lower mass. For microscopic examination, the whole preparation was delivered by me to the clinic of obstetrics and women's diseases, prof. Slavyansky.

Pieces, approximately 1 sntm. size, were taken from the walls of the cyst itself together with the adjacent broad ligament, from the fallopian tube, from the ovary and from the mass located between the plates of the broad ligament.

The prepared samples were stained in Grenacher's alum carmine. Microscopic examination, made by Dr. Brandt, showed the following:

On the preparations made from the cyst wall, it can be seen that the basis is formed by the extra connective tissue, which is quite rich in cells. The spaces between the individual fibers of the connective tissue are slightly widened. In some places, small-caliber vessels filled with blood balls are tried. In places, there are small foci of small cells infiltration, located mainly around several dilated vessels. The inner surface of the studied wall, lined in places with the still preserved cylindrical, sometimes ciliated epithelium, the nuclei of which are beautifully stained in an extra violet color. subject to fatty breakdown. The loops of this network are filled with blood balls and fine-grained decay. In the parts closer to the inner surface of the broad ligaments, there are thicker fibrin, there are more blood cells, closer to the center, a more fine-grained mass prevails, consisting of destroyed fibers of the parametric tissue and disintegrated fibrin and red blood balls.

In addition, in the field of vision, large fatty cells are also encountered in rather large quantities.

The drug is stained with alum carmine very badly. On the basis of prepared through the entire thickness of the pipe, it can be seen that the mucous membrane is almost completely absent and only some mucous membranes are visible. The lumen of the tube is filled with blood cells, between which are scattered more cells of the cylindrical epithelium of the tube mucosa.

The entire mass that performs the lumen of the pipe is embedded in the network, consisting of fibrin fibers. This network is especially dense and is located in the form of separate layers in the places of adherence to the destroyed mucous membrane. In the walls of the tube there are extensive hemorrhages, strong dilatation of the vessels, and along the places in the thickness of the muscle layer around the vessels, a small cell infiltration is observed. On the free surface of the cortical layer of the ovary, in some places the cylindrical epithelial cells are preserved. In the very cortical layer, consisting of dense connective tissue, in a very limited amount, Graaf's vesicles, highly dilated vessels and hemorrhages, reaching a very large size, meet. In exactly the same way, strongly dilated vessels and extensive hemorrhage are also present in the part of the ovary approaching hilus ovarii. In addition, cavities of various sizes are encountered, surrounded by fibrous connective tissue and filled with a weakly grained mass, into which single glands, as if cylindrical in shape, with a strongly stained core, meet. In some cavities there is also a significant amount of red blood cells.
On the basis of similar data of microscopic examination, it must be assumed that the removed tumor is a vapor cyst; the masses between the plates of the broad ligament are nothing more than blood clots, formed during the course of hemorrhage between the loops of the parametric tissue. In the tube - haematosalpinx, and in the ovary - small-cystic degeneration of Graaf's bubbles and severe hyperemia with hemorrhages in the stroma of the ovary itself.
The leg of the cyst, therefore, consisted of a broad ligament, an ovarian ligament and a tube. The last twisting was completely atrophied before the break. The postoperative course was good and the patient ended in recovery.
In it, I find it necessary to note the following circumstances.
Temperature [27]) on the first evening of 37.7, further below 37.5, with the exception of 17-20 days for the operation, when the fever undoubtedly depended on cystitis caused by prolonged catheterization. The abdomen was not swollen and painful all the time. The tongue was not dry or obtusely coated. Vomited only on the 1st day 2 times: one after the intake of the opium, the other from the really disgusting smell of iodoform gauze treated with carbon dioxide. The urine was discharged in the first two days in a small, then in sufficient and normal qualities, until the development of cystitis, the stitches (removed on the 10th and 14th days) did not cause any reaction. The wound healed primarily (except, of course, the place of the tampon). The tampon did not actually cause suppuration: the walls of the surrounding canal represented healthy granulations, which gave extremely little discharge. On the 10th day (the first change of the bandage), they were taken out with a slight effort, one by one, 2/3 of all strips of the tampon, which did without any bleeding, but was accompanied by pain. On the 14th day, the rest of the tampon is removed; drainage was inserted into the canal and the wound was washed and bandaged daily. On the 6th day, the patient began to eat. After a month, according to the operation, the wound was completed and mostly healed. On the 33rd day the patient retired with a small wound, which soon healed completely.

Judging by the well-known casuistry, the cases of twisting of the cyst leg, recognized before the operation, are rare. Doctor Soloviev [28]) from the foreign literature indicates 16 of them; from Russian - none. In the individual cases of ovarianotomy and whole series of tanovs published since that time, I could find only the indicated 5 cases: Zayitsky 1, Shurinova 1, Prokofieva 2, and prof. Otta 1; In total, with my case, and Solovyov will be 7. Between the abundant twisting of the legs of Kustner's ovarianotomy, only two twisting was recognized before the operation (No. 8 and 37).

This indicates that twisting is more often committed chronically and is not accompanied by acute phenomena that force patients to immediately seek medical help, and that, on the other hand, even acute twisting does not always give typical symptoms. So, apparently, in the 169th department of the professor, Krassovsky and the 33rd Sutugia, the twisting was fresher, and in the 2nd case of Zayitsky, however, it was not diagnosed before the operation, in the first case, in the second, the third pregnancy was diagnosed in several assumptions have been made, but it is not about the twisting of the legs. - In all diagnosed cases, there were typical signs of twisting, with the exception of Shurinov's case, where the twisting was most likely recognized on the basis of no other inexplicable ascites, with the undoubted existence of an ovarian tumor. But some other cases had their own characteristics. So, in the case of Dr. Zayitskago, it was possible, with the usual gynecological examination, to feel the twisting of the leg, to determine its direction and the number of turns. It is almost uuicum of its own kind. The first of Prokofieva's cases was noted that during the course of the illness, attacks from time to time were repeated, reminiscent of attacks of kidney stones; at the same time, each tumor increased. In my case, it was special that in the course of the course and the data of manual examination, it was possible, with some probability, to assume that the tumor was shifted to the opposite side of the pelvis. Such a displacement seems to be very rare. I know of 2 such cases: the first case of Röhrig [1]), where cystic-degenerated and underwent long-term degenerative changes, due to twisting of the leg, the left frontal ovary was blistered in front of the second case of Zayitsky. where the head of an adult cysto-fibro-sarcoma of the left ovary with a twisted leg was contracted and augmented to the right half of the abdomen [2]). Apparently, a similar case is described. Crushier, where a vaporous cyst with a twisted pedicle “wrapped around the uterus in such a way that it impeded the outflow of blood from it” [3]). - In my case and in some others, in contrast to the opinion that simple cysts are rarely twisted, the cyst was single-cavity and undoubtedly intraligamentary. In the first case of Zayitsky, there was also a single-lumen ovarian cyst. In the case of prof. Otta had a tubal-vaporovarial cyst; a vapor cyst is indicated in one case (33) by Sutugin, in several cases by Kustner and indicated by Crushier. In the rest, there were either multi-cavity or more dense (dermoid, cyst-sarcoma) neoplasms of the ovary. In the fact that vapor cysts undergo twisting, nothing is surprising, because although such tumors often lie inside the broad ligament, near the cervix, they can also have a long stem [4]). In my case. The fallopian tube was undoubtedly enlarged, albeit dimly, and filled with thickened blood (hydrosalpinx), although only the inner end of it was closed, the outer one was open to the width of a quill or pencil. The question is: how could blood accumulate under such conditions? It is possible to think that the expansion already existed before the hemorrhage, and the blood, having forced out the contents of the tube, took its place: and in. That and in another case, the opinion of some authors (Kehrer, Landau [5]) would be justified that cyst-like expansion of the tube is possible when only one uterine end of it is closed. But it is possible to admit an acute expansion (hemorrhage) of the tube, the outer end of which was closed with fresh peritonitic adhesions. - In the indicated cases, where the direction of twisting was noted, in 3-x (Sutugin, Zayitsky and Shurinov) it was like the opposite of what it should be according to Kustner and only in mine did it correspond to his theory. Anyway, heavy climbs; Frequent jumps in one direction involuntarily force them to take into account in order to explain the sharp and suddenly expressed phenomena of twisting.

Although the peritonitic phenomena in my patient began to subside, the enlargement of the tumor stopped and the patient, apparently, was not in imminent danger, however, I decided to remove the neoplasm. In 1) it was impossible to guarantee that the restored (weak) equilibrium in the nutrition of the tumor would not be disturbed again, due to the influence of even insignificant reasons, which could lead, among other things, to pernicious regressive processes: suppuration, or gangrene; 2) a tumor in such abnormal conditions would inevitably support the known time of irritation in the abdominal cavity, disturbance of blood circulation and inflammatory phenomena around itself; vb 3) the tumor would still, sooner or later, need to be removed, only under the worst conditions: large and stronger spliced ​​over its entire surface. To illustrate the dangers indicated in paragraphs 1 and 3, I will cite a very typical 37th case of Kustner [6]). From the dead cyst from twisting by embolism, bilateral putrid pleurisy developed. Ovaryotomy is not over, due to the complete fusion of the tumor with the surrounding parts of the abdominal cavity. The patient died of pleurisy.

Considering everything that I noticed during the operation, and discussing the properties of the extracted tumor, I am inclined to think that by the time of the operation, nutrition in it was either completely stopped, or existed in the weakest degree, so that the patient was in danger of dying from the tumor.

[1] Olshausen. Diseases of the ovaries, p. 91.

[2] The quoted work of Zayitsky.

[3] Pruzhanskaya. A brief review of gynecological literature for 1884 Medits. Review. T. XXIV, p. 244.

[4] Olshausen. Diseases of the ovaries, p. 149

[5] Voskresensky. About the accumulation of fluid in the fallopian tube. Zhurnal obkush. and women. sickness. 1891

[6] See the cited work of Mickwitz.

[1] Olshausen. Ovarian Diseases, 87 pp. And cited works by Küstner'a and Mickwitz'a

[2] Ibid, pp. 87-88.

[3] Quoting from Mickwitz’y, see below

[4] Idem.

[5] Das Gesetzmässige in der Torsionsspirale torquirter Owarialtomorsstiele

[6] Ueber die anatomische und klinische Bedeutung der Stieltorsion. Ein casuistischer Beitrag zur patologie der Eierstockgeschwülste. 1892

[7] I quote from no Mickwitz'y.

[8] Twisting of the leg of the ovarian cyst in a number of urgent indications for ovarianotomy. Journal. obstetrics and women's diseases 1887, p. 907

[9] The same journal. 1883 No. 10 and 11 and 1892 No. 2 and 3.

[10] 55 gluttons produced in Moscow.

[11] Clinic report from 1884 to 1890

[12] Doctor 1888, No. 1-3. 34 gluttony. Doctor 1890, No. 16-19. One hundred wombs

[13] Doctor 1890, No. 48. 35 wombs.

[14] Journal. obstetrician. and women. bol. 1888 p. 645. 5 cases of ovarianotomy

[15] Idem. 1892, No. 7-9. 12 wombs

[16] Doctor 1888 19-20. 5 cases of ovaryotomy.

[17] Honey. Review. XXIX T. 679 pages

[18] Honey. Review. T. XXIX. 365 pp.

[19] Heer. Vѣst. 1890 p. 448.

[20] Materials to the question of the goods in Russia. 1886 Dissertation.

[21] Work cited.

[22] Work cited.

[23] Medical Review 1891 No. 12.

[24] Journal. obstetrician. and wives. bol. 1891 p. 737.

[25] The same journal. 1892 p. 757.

[26] Idem. 1888 p. 575.

[27] Temperature, pulse and respiration in the first days were as follows:

	Temperature.	Pulse.	Breath.
	Mornng Evening.	Mornng Evening.	Mornng Evening.
1-й	37.4—37,7	98	—23
2-й	36,9—37,4	92 — 96	18 — 18
3-й	36.4—37,1	86 —104	18 — 22
4-й	36,8—37,1	82 — 88	18 — 22

[28] The specified work. Zh A. and Zh. b. 1887 g.