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A Case of Fibro-myoma of the Uterus undergoing Necro- biosis complicated by Torsion of the Uterus and Impaction of the Tumour.

By ARNOLD WALKER, M.A., M.B., B.Ch.(Cantab.). (:yna?cological and Obstetric Registrar and Tutor to the

Middlesex Hospital.

(From the Gynacological Department of the Middlesex Hospital.)

The following case presented certain features which seem to be worthy of publication.

The patient, F.T., aged 30, single, gave a history of having had diffuse pain down the front of both thighs for several months. The pain was fairly continuous but had not prevented her from carrying on her normal occupation as a cook, nor had she consulted a medical man. It seems very improbable that the pain was in any way severe as the patient was of a highly excitable and neurotic disposition. The menstrual periods lasted four days every twenty eight days and were not excessive and no change had been noticed since the periods started at the age of fourteen. There was no dysmenorrhoea. Micturition and defaecation were normal.

On April 13th 1926, the pains in the legs became very much worse and extended to the front of the abdomen. The patient was unable to extend the thighs and could only walk with difficulty, and a doctor whom she visited that evening sent her to bed. The doctor examined her the next day and, having dkxovered a pelvic turnour ordered her immediate removal to the Middlesex Hospital.

She was admitted under Mr. Comyns Berkeley at noon on April 14th. On admission the temperature was I O I O F , pulse-rate 100, respirations 28.

On examination, a round, mid-line swelling was visible and pal- pably rising from the pelvis. It rose to the level o f the umbilicus. The lower abdomen did not move on respiration and was rigid and tender on palpation. Vaginal examination was impossible. On rectal examination, a tumour could just be felt high up in the pelvis.

Torsion of an ovarian cyst was diagnclsed. At the operation on the same day, a dark red tumour presented

on opening the abdomen. It was hard and firmly imparted. The tumour was found to be the uterus containiag a single large

Fibromyonia of the Uterus. 425

interstitial fibroid. The whole organ was twisted through about 120~. The left Fallopian tube and ovary lay in front and to the right.

The axis about which rotation had taken place was found to be at the level of the isthmus uteri. There was no sign of thrombosis of either the ovarian or uterine veins, and the spiral groove at the point where rotation had taken place rapidly disappeared. The uterus occupied the anterior and lower portion of the mass.

The capsule was incised anteriorly and a fibroid 4 i inches in diameter was enucleated.

X posterior hood was fashioned from the capsule, and after obliterating the site of the cavity, was sutured to the anterior wall of the uterus.

After reconstruction, the uterus was 4 inches wide with a suture line running across the anterior wall. The Fallopian tubes and round ligaments joined the anterior wall of the uterus.

Each cornu of the uterus was sutured to the albdominal wall on its own side, and the anterior wall of the uterus mas lastly attached to the abdominal wall by ventral fixation.

Convalescence was rapid and uneventful. The pain referred to the thighs completely disappeared.

On section, the tumour presented all the appearances, both macroscopic and microscopic, of necrobiosis.

The axis about which rotatioa took place is probably the most common site in this uncommon event.

The absence of thrombosis and the disappearance of the spiral groove suggests that torsion may have been taking place at the time ot operation. If this is the case, it does not seem to be unfair to assume that the rapid increase in size of the tumour nlhich accompanies necrobiosis nas, in some way responsible, although it is difficult t o understand the actual mechanism.

The localiz~tion oE the pain which was the only symptom seems inexplicable, as none of the three upper lumbar nerves, which supply the area affected, enter the pelvis in any part of their course.

I have to thank Mr. C”omyns Herltelep for his permission to publish this case and for his kind help and advice in the performance of the operation.

Delivery into the wound was difficult.