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A Case of Tuberculous Infection in Dermoid Cyst of the Ovary

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					IL l. . T 1 DS'Ull l
   G P IISJlUND• •
                       TIll]               PRIMARY INFECTIVE POLYNEURITIS.                                 l .h s UARJE 25 1941.   :25

always a female tick engorged with eggs, but it can                       A Case of Tuberculous Infection in a
«asi lv be missed . Possibly this was th e ca use o f                            Dermoid Cyst of the Ovary.
I he i~ ho desia n episode, and a virus in th e tick may
ln- the active agent.
                                                                       By G. DRURY S H A W , kJ .C., M .R .C. S. , L.R .C.P..
    Since wr iting the abo ve I see an article 0!1 this                      M.B. , B.S . (L OND.) , F.R. C. S. E ., M.R .C..O .G. ,
subject , viz., the Guilla in-Ba rre Sy ndr om e, 10 the                     S enior G'\'Il a:cologist, l o lian n es bu rg Ge ne rol
 Lancet of Novembe r znd , 1940 . by Dr. Stuar t Ba rb er
of the R .A .F .O ., in whi ch the clinical hi story of
-even supposed ca ses is g ive n, four of wh ich were
                                                                  i          H osp ital ; - a nd O . S. H EYNS. M .A ., B.Se. ,.
                                                                             M.R. C.O.G., Se nio r L ecturer , Depart m ent at
                                                                             O bste tri cs and Gy na cology of t h e U niv e!"sit), of
milit ary pe rs onnel. This diagnosi s seems to .have
been ma de by Prof. J. A . Ry le , and concurred 10 by            I          the Wituiat e rsrand R egistrar, O bs te trics and
                                                                             GVlla: eology , f ohOl;lles burg G eneral H osp ital.
Dr. C. P . Sy monds, the eminent neurologist. The
latter g oes so far as to say that Gu~llai~ over-                 i
empha sised th e ace llula r hyperalbuminosis and
 Ho lmes the pre sence of fever. On top of th at I
                                                                  I    T H E voluminous literature cove ring tuberculous
                                                                            infection of ova ria n cy st s shows th at probably
ad vice one ca nnot r ead th e hist o r ies of the cases not more than 40 ca ses hav e been report ed .. The
                                                                  '
                                                                  I
g-i ven without more than a little misg iving as t o report of a case is the ref!?re justifie?                             Ordinary
their falling in the sa me category . T hey a dm it the r e pyogenic infection of ovarian cys t s IS much l.ess
was no co ntact between the cases what ever , comm o n th an is usually thought. 2-3 per cent. bein g
                                                                  I
althoug h th ey mostly came from the .same pa rt o f a high inc idence in large seri es of cases (F rank 1).
                                                                          In Europe and the D .S .A. tuberc~losis of tl~e
 the country , We k now that th e vir us of ac ute
po liomvelit is will pick out entirely unrel a ted pe r-
                                                                  I
                                                                       female g enital t ract is a c om.m o ~ disease. It. IS
sons . but it seems to me that on the ca se histories . thou ght to be rare in th e native 111 So ut h Afrtc~ .
and the inves t ig atio ns made for this syndrome, there
                                                                      True tuberculous inf ection of an o va ria n cyst IS
is no bett er evidence for it being of virus origin than
                                                                      universall y rare . At first sight thi s is surprising, as
fo r the cause lying with an allerg y, a biting insect.
or a chemical poison.                                                  fo rtuito us involvem ent , by direct sprea d for exam ple .
                                                                      should occur in an apprec iable proportion of cases
     The pur pose, however. of thi s pap er has bee n t o wh er e an ova r ian Cyst occurs.
em phasi ze the need of thoroughly considering the                        The ov ary itse lf 'seems to be fairly immune , as
poss ibility of cresy llic compounds.                   es pecially numerous ex amples an d sta tistics show .. One expla-
trio rthocresol phosphate . as the cause of an epidemic nation (Me rlett i) is th at thi s is fro m a ~l1n ely prot.ec-
of peri pheral multiple neuritis. which has the ti ve ac tion of th e perit on eum by ca using ex uda ti o n
cha ra cters of supposed inf ective polyneuritis of and adhes ions . M oench a lso poi nt s out that genita l
 virus orig in .
                                                                      tuberculos is is very often associa ted with thrombosis
                            REFERENCES.                               o f th e ov arian a rte ries . COIllY" S Her keley, 2 in a
                                                                      critica l re view o n g enita l t ub erculosis, g ives a goo d
['lIit ed S tat es Public H ealth R ep orts , V ol. 47. N u . historical survey of th e su bjec t.
                         :
       4 2 : O ,/t hreaJ of M ot or Ne uritis in Cin cin nati ,
       Ohio.                                                              Morg agni in 1744 was t he ~ rs t to r:po rt a case ? f
                                                                      undoubted gen ita l tu bercul osis. W hile eng a g ed In
F'nit cd Stat es P llblic Hflllth R ep orts , Vo l. 48, No . a po st-m ort em exa m ination on a wo m an of :20 wh o
       6: P hanna colog v and N euro pat ho logy of had died o f tube rc ulo us perit oni ti s, he dem on strated
       certain P henol Est ers .                                      th at bot h F all opi an tubes and ov a rie s were fi~l ed
S alllpso/l. B. F . : A n out break of P Olyneuritis of with a caseo us mat eri al . and a fte r a caref ul exarruna -
       un us ual o rig in , B ull , Offic e l ni ernat , d' Hy g.,    tion of th e disea sed st ruc t ure s. he ca me to th e co n-
       l 'u b. 1938. " . 30. 2601- 11 .                             I elusio n   th at t he perit on itis was seco nda ry t o the
Xu urr r, A . : El L ittlc-K noum Ty pc of P olvne urit is .          disea se with which th e v were a ffecte d . a nd t ha t the
       S cln oeis eris cli e M cdizin is c he W 0 eh en s ehrift. I disease was tu be rcu losis . P; ea rly a ce nt ury lat er .
       Dec . 2 , 1939.                                                Se nn a nd L ouis dr ew a tt entio n t o thi s typ e of case .
Hlacle ic, TV . K .. and Blair. D . M . : A Smull E pidemic rnte re st g rew, and a few yea rs late r gen ita l t ub e r-
       of l njc ctnre P olyn curitis , S. A f rican J 1cd . I nl., culos is wa s full y inv es tiga ted bv se ve ra l a ut ho r s.
       Fcb ruarv 10 . 1940.                                           Du rin g a ll thi s -ti me . and as l at ~ as I &~ , ovaria n
l r r bri . R .. and Bl o c. H . : T ricr esyl Ph os pliat c          t u bercul osis was reg arded by m ost obser ve rs as not
       I'oiso/li/lg lImo ng a S hi p's Crew. B ull . et Mem . occurrin g. Virc how him self being very sce ptica l o f
       So c. M'ed , H o pit , de Pa ris, 1938. D ec . 19 .            this po ssibility. But in 1887 T e rrillon repo rted three
                                                                      cas es of o varian t u bercle, a nd fr om th at time th e
ll a rre v Piric , J . H . : Ba ct eria! E n ceplialitis fr om the number has g re a tly increa sed. Sim mo nds 3 {ound
       Genus L ist er clla , /l 1/ ('«' dis ease of mall and
                                                                      80 cas es of ge nital tubercul osis in 6.000 ca da ve rs , 4
       an inta!s , S . A ]r. u,«. J III. . 1938. Vo l. 12, No . 3. of th e 80 sho wing ova ria n cyst s. H e m entions
 H . S t uart B ar ber; Polvra diculo ne uritis (Guillaill- ex pressly th at t he cys ts were o f lon g standing and
        Harre Svnd rom c y ill E as t A ng lia , Lance t , N o••. th at not on e of t he 4 cys t s sho we d tu bercul osis o f it s
       2 . 1940.                                                      wa ll o r co ntents .               .
                                                                                                                                                                   8 ..\ .
26        .J A S U ,\ R Y   25, 1941. J           'IT BEH( T l. OI'S I.\ F E( " I' IO :'\ 1:'\ ,\ D E H.\ I OllJ L' Y :ST,                                     [
                                                                                                                                                                          M ED 1C& L
                                                                                                                                                                      JO U RN& L .,



      As a ru le . tu berc le of th e o \'a ry is seconda ry t o                               II ea rl "",I 1./lII Y ,' : :'\ ot hing a b norma l d isco vered .
 disease o f the F all opi a n t u be s . perit o neum or ut e ru s.                           A b d om en : I n s pect ion sho we d a , we lli ng o f t h e lowe r
                                                                                           a bdo me n , m or e p ron ou m-ed on t h e left s id e an d e xt endi ng t o
 a n d o n ly \'e ry ra rel y m a y it be t hc o nly porti o n o f                         one in ch a bovr- t he u ru h i l ir-ns . On pa lpation a la rge cy s t ic
 th e ge nital a pparat us affec te d in pht hi sical worn e n .                           m a ss wa s felt : not f ....I·h · mo va b le . "l ig ht h' t e nd er: 110 flu id
      In a na lys in g- th e GISl'S of tubercul o u s o va r ia n Cyst                     th r ill.     T h e n ' was a ; ma ll ha rd 'W           'ISS ' o n th e le ft s id e
                                                                                           e x te ndi ng t o the m id lin t' I.elow the umh jlic us ; t his a p pea re d
  rep o rt ed : t ht: Io llo wi mr classes o f case mu st 'be                              more s u perfi c ia l a nd "' (lal'a te fr o m th e cy st ic ma ss-not
 om itt e d : tu be rcul o us abscesses . in fect ed follicle s .                          fre e ly mo vable.
 corp us lute um cyst s. a nd in fect ed pe r it on eal sa cc u la-                            Deepe r ma ss ft'lt on r i~.d lt s ide on level w it h um bi licus ,
 tions . . ' om e sco re of ea es fa llin g unde r th is head                              T he re was dull ness t o pe rc us sion o ve r th e s u pra p u b ic area
                                                                                           and t he lef t lower abdom en , ,\ res o nant note wa s ob t a ined
 have bee n c ited a s t nhe rc u lou o va r ia n cysts ,                                  on th e right , with a ban d o f res onance above th e umbi lic u s .
                              1
      X ot more t han _0 t ru e cases have been report e d                                    / ' .1,.;,. '.rllll/ ;II"I ;,," : Def icie nt peri n eu m r es u lt in g fro m o ld
 u p t o t he prese nt. Xl oench 1 m a de a critical s urvey                               t ea l' ex t t'l lIling u lmo s t to a nu s           Ye llow ish d isch a r g e on
                                                                                           vu lva ,       P os t er io r \'a g illal wall p rot rud ing at vulva, The
 o f t he lit e ra t ure a nd in 1923 iou nd t he Io llo wirur 34                          pou ch of Dou g la s up peared t o b e filled by a cys t ic mass w h ic h
 l'aSt:S : -                                                                               was p u"hi ng t he cervix a gai nH th e sy m ph ysi s pu b is . .:"ei th e r
     (I) v              .
                Ba um,l,:' artl' n . ( 2 ) Bert iu o , (3) Br on s , (4)                   cervi x 110 1' uterus ('o[ild b" f" lt. T he mass fe lt b elow moved
                                                                                           with t he a bd omi nal t umo ur. There was pro fus e ~' ell o w i" h
 Ce lle r , (5 ) E lsaes sc r . ((I) ( ;ade. (7) ( ilo ck ne r. (l-: )                     discharge on th e t~ xa JJl i fli Jlg fingp l'.
 L m en ba um . (9) K e lly . ( 10 ) Kl eb s , ( 11) L a g o th t:-                          On re ct a l pa lpation a cy st i« ma ss was felt n ute ri orl v ,
 t o p u los , ( 12 ) M a dl c ue r . ( 13) M e r iel , ( 14) a nd ( 15)                   movin g with t he a hdom inal ma ss . Th e pelvi c ma ss wa s f';lt
 Xl ocnch, ( 16) :\ l' Um a lln . ( 17) Olsha use n . ( 1:-:) a nd                         to p rotru de ant eri orlv, I'a u"ing t he posterior va g ina l wa ll
                                                                                           to he p lls h l'd forwar d .
 ( 19) P oll o sson a nd Vio let , (2) P ruc sm an n . (2 11
                                                                                             /) ;11:/" " , ;,< : Ov n r i.. " , '.v ~ t w ith pr oba bl y mal ign ant c ha n ge ,
                                                                                                         <
 k ose n thal, ( 22) , ·al'ng- er. (23) Sca le ne . (24 ) a nd (2 5 )
 ~ chott l a ender . ( 2(.) a nd ( 2 7) Todo r ky , ( § ) W cch s-                          In vie w o f th e di.umo is a nd th e .fact t ha t on
 k r g'. (29) Spen ce r W e lls . (30) Tu sin i, (3 1)                                   a lm os t e ve r v d a v th e t emperature r ea c hed 1020 or
 tha rb cnnel a nd :\ acla !. (32 ) Co lm. (33) Fo rjrue a nd                            highe r. n o th iu u 'radi cal was done u nt il 6/ 9/38 .
 (h au vin. a nd 13-P ).( c)l'n ch,
                                                                                           Poste rior co lpoto my '-\'as 'perfo rme d o n 6 /9/ 3'0.
      :\iel sen :, fo und ti\'" m ore GISt:S re port ed a nd a dds                       Tw o pi nt s o f :T11 o w , o fie n s ~ \- e pu s , we re obta ine d .
ol1C o f hi s o wn , m a k iiu; a total o i -10 , The fi v e                             Tube rcle bac ill i were fo u nd m t he p u s .
 wv rc : 1 by Pri br. un ( \ 1)2 1 ), 1 by Bj o rk cnhcim ( 19 2 7) .
 I by Althabe a nd Xluin o s ( 1929) . 2 by K uec ken s
                                                                                            T u be rcl e b ac illi were n o t found in s p u ta e x a m ined.
( 1<)32) , W e hav e lxcu unable to di scove r a ny furth er                             n or did ~-rav of the lu ng s sho w any ac t ive t ubercIe-.
 re po rt s since th at t inu -.                                                         A radi ouram o f th e pelvis did. ho we ve r , s h ow
                                                                                         ca lcifica tio n t o 1)(' pre sent o n the righ t side n ea r t he
     .-\ m o ng th e fir st 34 tum ou rs , 7 were intralig a -                           mi d-lin e . On 11/ 9 /38 a co lpo t o my again p roduce d
m en to us . a bo u t a d o ze n we r e de rrn oid s . a nd only 2                       pu s, a nd a r u b be r d ra in was left in ,the w o u n d .
we re so lid g r o wt hs.                                                                P y rex ia pe r s ist ed . th e temperatu re vary ing bet w een
   O u r case history \\'a s a s fo llo \\'s : -                                         99° an d 102° .
        Th e pati ent , F , A. • w,,, " coloured u f m ix ed lace wh o wa s                 19/ 9/38 , La paro to my wa s perfo r med by one o f
    a d nlitt ell to W a r. ! 17 .. I' th e .l oha n n6 b lll'1': :'\ on ,E u l'opea n   us (0. S, H .) u n d er ga s a nd o xyge n a n res t h es in
    l l os pi tu l u n 22 /8 / 38. lI o' p ita ! Ind e x .:"0, 6876, . he gal'"
    her ag e as 30 , but ,I", wa, probubly som e y eurs old er.                             A la rge mi d-l in e cyst ex te n ding t o th e um bilicus
        Th e co m plai nt wus "welling o f t h e abdome n a n d inte r                   wa s fou nd . Th e cys t w as so a d he re n t t o su r r o u n d-
    ru e ns t rual va g ina l d i"d liln: e. both of two y ears ' d u ra t ion.          ing st r uc t u re s tha t t ota l remO\·a l . a p pe a re d t o b e
        P reqnnncie» : 1. 1920, F ul l-t erm norma l pr eg na ney: labou r               im p o ssi ble . .-\ t r o c ~t r \\' <~ s plun g e d ! 1
                                                                                                                                                 ,ltO th e cys t a nd
   a n d puerperium noim ul. ~ o aborti on s.                                            th ick caseo us m at eria l wi thd r a wn . I here we r e larg e
        E/i.< lor!! : T wo yeal's ago th e pati ent noti ced a sw ell ing of             tuft s o f ha ir within the cyst wall.
   the abd omen, on t h e left si de , T he mass wa s hard b ut not
   t en der . and l.as gr adually in cr eas ed in s ize              F or the past           T he pat ient wa s in s uc h po or co nd it io n t ha t heroi c
   foul' months t h el'e h as b"en a mOl'e rapId innease in s ize .                      a t te m pts a t rem Q\'a l of t he cy st \\'ere not just ifie d .
  an d the re wa s pain. T he pa in r ecen tl y has be~n pl'esent cun ·
   t inuous lY. and Is felt al'l'OSS the lo wer a b do me n a s well as                  It \\'a s acco rd ingly decide d t o be co n te nt wi th d rain -
   ' n t he b a ck , I t is s t a b b in g in nat u..e a nd i" rel ie ved on             a g e o f t he abdo men . a n d t he \\'ound wa s st itched up .
  ly ing d o wn. K o I ta U ' ~ :1 0 1' Y     omit ing ,
        S h e ha s be en feel in!!; wo..se lat ~lv : s he f ~els fe vel'is h .
                                                                                            :\. sa m p le o f th e cys t con te n ts .\\' a ~ co lle cte d a t t h e
  " vea t s at nig ht , a nd le "," we ak er. Th en ' has b een a ma r ke d              o pe ra tio n a nd w a s se n t fo r e xam mat lOn . a n d tu bercl e
  los s of we ight.                                                                      bacill i w ere foun d pre sen t.
       "'n"" r lla' ;o ,, : 13/5 /28, R eg nla r . ~ I o d e r a t e los" n nti l t wo
  yea l's ago. wh en it b~ ..a nw pro fuse t ho ng h la"ti ng fo r unly
                                                                                            U n fo r tu na te lv th e pa ti en t d ie d o n th e ne xt da v
  fi VI' d ays. C lots p l'e,~nt.                                                        Sh e ha d bee n io s in g g ro u nd so rapid ly th at it w a ~
        D !ln llt nnr Th ,,',, : P a in a ccompani es Ao w on t h e firs t d ay .        felt t ha t lapa r ot omy m ig ht gi \'e he r ;~ cha nge. But
       L t u ro rr!lt~ a : P rof nse wh it :, h di scha l'ge ,      Offensi ve sin c"    e ve n a n ope ra tio n of very sho r t du rat Ion prove d t o o
  un set.                                                                                se \'e r e a st ra in .
       .lfir/ uTil ion : :\ 0 f reqnenc'y Or d.)o·su ria .
                                                                                            Po st- m o r t em: A t a u to ps y n othin g o f signifi ca nc e
       BOluls : R eg u la r , Da ily motion ,
                                                                                         wa s di sc O\'ered in the lu n g s. There wa s no e \' ide nce
       Ph ll,. iral f.'xami " fl l ;on : The te mp era tu re on a d m iss ion wa .
  l~ ' ·F .. pube llO . re , p irations 24. T on g ue m oist, coa t ed .
                                    '                                                    o f tu bercul o sis .
8 . A . TT DS IUlI F
   G ~ NEESln]ND[ .
                       VU ]               T UBE RC ULO ' S I N FECTION I N A DERMOID CYST.                      [ .l.\ S t: .\ R I E   25 1941.     '27

   U n t he a nte rio r wall of th e ut e r us th ere was a larg e        O n cl ini cal exam ina t io n th e cyst was foun d t o
inte rstiria l fibro myoma . Th e ca vity o f t he uterus reach ve ry low between rectum a nd va gi n a . The
was th e sea t o f tu berculo us g ra n ula tio n ti ssu e . T he p ost erior va g inal wall wa s p rot ru ding a t t h e vu lva .
Fallo pia n tu bes were thick ened by 'c h ro nic t ube r- The fact t hat this prot ru si on was ca used by the cy st
culo us sa lping it is , in particul a r t h e right t ube . There it self was co n firm ed a t t he ab do mi nal op eration a n d
was no pyosa lpinx . The ri g ht ov ary was the se at at a uto ps y.                       O ne ca n , t he refore . say that th e
o i a large cyst lyi ng posteriorly between t he uterus co lpo to m y punct ure wa s m a de dir ect ly into th e
a nd t he rect um . The le ft o va r v was sm a ll a n d I derm oid cyst. The r ig ht F all op ian tu be , the most
vystic.                                        •                       heavi ly in fecte d o rg an in t he pel vis, wa s n o t
   T he cyst o f th e ri ght o va ry had a thick ened wa ll sit ua t e lo w in t he pelvis . O u r specime n shows it t o
co nta ining ca se o us m ate ri a l an d a bu nda n t ha ir . O n he sig m o id a nd m easuring not m ore th an 3t inches .
the a nte rio r wall t he em bry o n ic r ud im ent wa s p re- Relat ive t o co llect io ns o f pu s. neit he r tube s ho wed
sen t. Some o f th e ti ss ue a ppea red t o be bone . Th e a py osalpinx , n or was a ny o t he r acc um u la t io n of pu s
cys t wa s bo und do wn t o th e po st erior a bdo m in al wa ll fo und in t he pel vis o ut side t he o va r ia n cy st.
j,y de nse ad hes io ns .                                                 :\ o w tube rcl e bacilli we re eas ily found in th e fluid
   T he pa t ho log ist t o t he Ge ne ra l H ospit a l co ncl ude d , o bta ined a t th e firs t colpo tom y and a t th e
o n t he a uto psy as follo ws : D erm oid cys t-c hro n ic la paro t om y . \ Ve su bm it th at this would not h av e
t ube rculo us sa lping it is .       Se con da ry in fect io n of     been pos sible if t he cyst had bee n co nt am ina t ed by
der moid cys t.         O pe ra t io n: perfo ra t io n o f cyst.      need le o r troca r. N o r it is likely th at a g ro w t h o f
T errn ina l pe rito n iti s-g e ne ra lized ,                         ba cilli co u ld hav e ta ke n place in th e spa ce of 13
                                                                       da ys . i.e , t he period th at ela pse d be tween th e da t es
   An unfo r t una t e fea t u re of th e ca se was th e fac t of th e tw o o pe ra t io ns m e nti o ned a bo ve . It seems
t hat hist olog ica l co n firmat io n was no t a va ila ble           rea so na ble t o co ncl ude th at t he cyst was no t co n -
beca use th e es se nt ia l ti ssu es we r e mi sla id .               tam in at ed a t o pe ra t io n, a nd th at we we re dealing
   A specimen sho wing ute r us a nd tu bes is sti ll in with a patho lo gi cal t ub e rcu lo us infection o f the co n-
our possessio n , a nd sectio ns h av e bee n m ad e of                ten ts o f a n o va r ia n cy st.
nume ro us po rt io ns of t his spe cime n in a n a ttem pt t o           \ Ve a rc inde bte d t o the So ut h Africa n Ins t it ut e
find a cyst wall a nd p rov e t he presence o f tube rcu lo u s for Med ical R esea rch for th e invest iga t io ns do ne.
infect io n of this wal l. No sa m p le of th e cys t was pa rticula rly t o O r. F. \ V. Sim on fo r t he hist o lo g ical
reco ver ed in t his way .                                             pre para t io n s m a de : a nd t o O r. A . S . S t rach a n for
    It is of inte res t t o no te t ha t th e left o va r v s ho wed per mi ssion t o use th e post-m o rt em rep o rt.
 no tube rculous in fect ion , t ho u g h se ria l sect io ns we re
n ~t cut.       Bot h tu bes sho we d m ac ro sco pic a nd                                        }{ EFE RENCES .
mi croscop ic tu be rc u lo us in fec tio n, t he lumen of the         1 F rank , 1<.     T.: G    'Ylla? eolo g ieal and O bste trical
rig ht tube conta in ing caseo us m a teria l. The uterine                   Patli olo gy, 211 d E d., p. 367.
c l\'ity was line d wit h tubercu lo us g ra n u la t io n t issu e. 2 Be rk eley, C 0 1ll)' II S : J. Obstc t . ( ;Y II(J!(. . 1903 , N o .
                                                                            3, p. 3 1.
                              DI S CU S S IOX.                         3 Sim m o nds : .4 reil. G·Y llac k ., ~. 29 .
                                                                       < M ocn ch , G . L. : .4 III f r. J . Ob st et .          (;."IIa? e..     1923.
    In this ca se o f tu be rcul o u s in fect io n o f a d e rmoid
                                                                           6. 478.
~'y s t of t he o va ry it mi ght be co nte nde d t ha t. first .
                                                                       5.Vie/s f n. M . : A cta Ob s tct ,     ( ; -,"I Ce.       Seand .. 1933.
infecti o n of the wa ll of t he cy st was not p ro ved; a nd
seco ndly . th at in fect io n o f t he cys t co nte n ts wit h             13· 3·
tu be rcle bacilli may ha ve fo llo wed colpo t om y
puncture . Th e latter o bject ion ca nnot be recon c iled
with ce rta in fea tu res o f th e ca se .                                We w ish to draw the attention of newly
    A ch ro no lo jrica l s um rna r v o f t he case revea ls t he     registered men to the advantages to be derived
foll owing poi nts :                 '                                 from registering also at the Medical A gency which
    Ad miss ion 22/8 / 1938.                                           is one of the subsidiary in t er es ts of the Associa-
    6/ 9/ 38. Colpo t om y. T wo pint s of pus. T. B.                  tion . The Agency has branches at Cape Town and
found .                                                                Johannesburg and caters for both principals and
    11 / 9/ 38. Co lp o t om y . Dra ina g e .                         assistants, supplying locums and negotiating
    19/ 9/ 38 . Lap a rot omy .        T . B. fo un d III cy st        partnerships and sa les of practices. All newly
co ntent s.                                                            qualified men should make a point of registering
   It is clea r th a t , if th e cvs t wa s infect ed bv the           with the Agency. Particulars may be had on
ope rat ion . t he re a re two po s ible wa vs in whi ch th is
                                                                       application to the Medical Secretary or the Busi-
may ha ve occu rred : th e needle o r trocar o n its way
t? t he .cyst may hav e t rav ersed o n th e one hand                  ness Manager, Medical House , 35 . Wale Street, or
tiss ues u~ fec t e d wit h tubercle bac illi. or o n t he ot he r     Box 643 , Cape Town , or to Mrs. Coppinger,
a co ~lec t lO n o f pu s co nta ining th e se bacilli . Let us        Medical Association House, S, Esselen Street,
co nSIder th ese po ssi bilit ies .                                    Hospital HilI , Johannesburg .

				
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