Ruptured Graafian follicle and corpus luteum with intra-abdominal hemorrhage simulating acute appendicitis and ruptured ectopic pregnancy

S OF CASE HTSTORIEP CASE I.--Mrs. C. H., a white female, aged 31 pears, para ii, entered the hospital on Oct. 1, 1937 with a history of having missed her menstrual period in August. However, on September 14, she began having severe menstrual-like cramps, followed by slight vaginal bleeding. Three hours after the onset of pain and bleeding she began to hemorrhage and passed clots and some pieces of (‘flesh” which she identified as fetal membranes. Ever since this episode she has had dark brorrn vaginal discharge and irregular vaginal bleeding. Two days prior to her admission she had a sudden pain in the left lower quadrant whic~h made her very weak; however, she did not faint. Following her attack of sudden pain there followed persistent soreness throughout her lower abdomen. On physical examination the patient did not appear acut,ely ill. The abdomen was scaphoid, there was definite direct and rebound tenderness in the left lower quadrant. No mass could be palpated. Colostrum could be expressed from the breasts. Pelvic examination revealed some blackish vaginal discharge, and a patulous, multiparous cervix which felt soft. The uterus was slightly enlarged and soft. Motion of the cervix caused pain in the left adnexal region. The latter presented a small tender mass. There was no bulging of the cul-de-sac. of Douglas. The laboratory findings revealed a white blood count of 7,100, 82 per cent neutrophiles, red blood count 3.R million and hemoglobin 12 gm., 78 per cent. The urine was negative. The preoperative diagnosis was left ruptured ectopic tubal pregnancy. A dilatation and curettage revealed a moderate amount of tissue grossly identified as decidual tissue. A midline abdominal incision was made and a moderate amount, of free and clotted blood was found in the cul-de-sac of Douglas. The left ovary showed a large recently ruptured corpus luteum which contained a firm clot and was not actively bleeding. The right ovary contained a normal appearing unruptured corpus luteum. A left salpingooophorectomy and appendectomy was done. The pathologist reported that the appendix measured 91/1L by Y’ cm., a.nd appeared grossly normal. The ovary showed a large hemorrhagic corpus luteum with diffuse hemorrhage. Endometrial curettiw showed chorionic villi. The tube and appendix were microsc,opically normal. The final diagnosis was: (1) incomplete abortion, (2) ruptured left corpus luteum with hemorrhage, (3) intact right corpus luteum. CASE 2.-L. F., aged 25, single, office worker, was admitted to the hospital Aug. 5, 1937 with a diagnosis of possible acute appendicitis. She had always been in excellent health; however, twenty-four hours prior to admission, while riding in an WEIL : RUPTURED GRAAFIAN FOLLICLE 293 auto, she was suddenly taken with sharp knifelike pains in right lower quadrant. She went directly home and obtained partial relief by lying in bed. She experienced some nausea but no vomiting. There had been no constipation. The pain which was in the right lower quadrant changed to a dull ache, spreading over the entire lower abdomen and was made worse on motion. The next day the patient went to work but she did not feel right. She was advised to enter the hospital. The last normal menstrual period occurred July 22, 1937 and was uneventful. Physical examination was negative except for tenderness in the right lower quadrant below McBurney’s point. There was slight right rectus spasm. Pelvic examination was negative except for a tender right ovary. On August 6, the white blood count was 9,000 with 57 per cent neutrophiles and the urine was negative. On August 7, the white blood count was 9,800 with 74 per cent neutrophiles. On August 8, the white blood count was 6,200 with 70 per cent neutrophiles. The patient remained in the hospital under observation for three days during which time she recovered completely and was discharged with a diagnosis of ruptured right Graa6au f olliczle with slight hemorrhage. C‘$28~, 3.-E. R., a single girl, aged 19 years, was admitted as an emergency case Jan. 22, 1936, because of right lower quadrant pain which came on suddenly about twenty-four hours previously. The patient stated that the pain was sudden and knife-like, causing her to sit down. Later she became weak but did not faint. Gradually the pain became dull and spread over the entire abdomen. She had vomited four times in the past twenty-four hours. The last normal menstrual perioif accurred Jan. 12, 1936. Physical examination was negative except for direct and rebound tenderness over the lower abdomen, slightly worse over the right side. All the abdominal tenderness seemed centered in the pelvis. Pelvic examination was negative except for right adnexal tenderness. The right ovary seemed larger than normal. The white blood count \vas 15,300 with 77 per cent neutrophiles. The urine was negative. The patient was given an enema lvhich did not relieve her condition. The diagnosis on admission lay between possible acute appendicitis, possible acute salpingitis and possible ruptured right, Graafian follicle with mild hemorrhage. The patient remained in the hospital five days during which time she gradually (third day) recovered, with a gradual recession of the leucocyte count from 13,200 on January 23 down to 6,000 on January 26. The final diagnosis was ruptured right Graafian follicle with mild hemorrhage. Cas!s 4.-M. L., aged 15 years, while in the process of getting out of bed Jan. 15, 1937 was taken suddenly with right lower quadrant pain which made her cry out and double up. She became weak and nauseated but did not vomit. The pain gradually became dull, and spread over the lower abdomen. Since the patient had been pre. riously told she had a bad appendix she was immediately taken to the hospital. On admission she stated that she had had in the past year several similar attacks of lower abdominal pain but never so severe. Her last normal menstrual period was Dee. 311, 1936 and was uneventful. There had been no constipation. The physical examination was negative except for some muscle spasm over both right and left lower quadrants. There was direct and rebound tenderness in the right lower quadrant below McBurney ‘s point. No masses were palpated. Rectal examination revealed pain referred to the right side on motion of the cervix. The right adncxa were larger than the left and definitely tender. The white blood count was 10,000 with 6S per cent neutrophiles. Temperature was 99.2” F. and the pulse was 90. The patient remained in the hospital for three days during which time the symptoms completely disappeared. The white blood count was 6,000 with 52 per cent neutrophiles on the day of discharge. The final diagnosis was ruptured right Graafian follicle with slight hemorrhage. CASE 5.-L. Me., aged 22 years, a nullipara, entered the hospital as an emergency on &Parch 7, 1936 because of a history of sudden knife-like lower abdominal pain 294 AMERICAN JOTJRNAT, OF OlwWIWCS AND GYNECOLOGY coming on during coitus. The patient saici *IIC hecame weak, nauseated, and vomited ouce. These symptoms came on about tcl11 minutes after the pain. Her last normal menstrual period was Feb. 26, 19:X and was uneventful. The physical examination was negatirrx except for tenderness in the right lower quadrant. Pelvic examination Irrealed normal internal genitalia except for the right adnexa which were very tender on palpation. They did not seem enlarged. Motion of the cervix caused right sided pain. The white blood count was 11,800 with 89 per cent neutrophiles. The urine was negative, and the temperature and pulse rate were normal. The tentative diagnosis \>-a~ rupt,ured right Graafian follicle with slight hemorrhage. The patient remained in tile hospital for three days during which time she recovered completely. The white blood count, on t,he third day returned to normal. CX,E G.-J. L., aged 17 years, unmarried, had her last normal menstrual period on Sept. 16, 1936. While at work in the hospital on Sept. 2’9, 1936 as an undergraduate nurse, she vas suddenly taken with a sharp right lower quadrant pain which caused her to double up. She stated that for the nest half hour she bec2ame very weak and nervous. The pain was sharp at first, changed to a dull ache throughout the lower abdomen, and lvas worse lvhen she walked. She had never experienced anything like