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AN EXTRAORDINARY CASE 
OF 
TWISTING OF THE UTERUS 
AS THE 
PEDICLE OF A LARGE FIBROID TUMOR OF 
MANY YEARS’ EXISTENCE. 
BY 
JOHN HOMANS, M.D., 
Instructor in Harvard University: Surgeon to the Massachusetts General Hospital, 
Boston, Mass. 
Reprinted from the American Journal of Obstetrics and Diseases 
of Women and Children, Vol. XXY., No. B, 1892.] 
NEWYORK: 
WILLIAM WOOD & COMPANY. 
1892. AN EXTRAORDINARY CASE 
OF 
T WISTINO OF THE UTERUS 
AS THE 
PEDICLE OF A LARGE FIBROID TUMOR OF 
MANY YEARS’ EXISTENCE. 
BY 
JOHN HOMANS, M.D., 
Instructor in Harvard University; Surgeon to the Massachusetts General Hospital, 
Boston, Mass. 
Reprinted from the American Journal of Obstetrics and Diseases 
of Women and Children, Yol. XXV., No. 8, 1892.] 
NEWYORK: 
WILLIAM WOOD & COMPANY. 
1892. AN EXTRAORDINARY CASE OF 
TWISTING OF THE UTERUS 
AS THE PEDICLE OF A LARGE FIBROID TUMOR OF 
MANY YEARS’ EXISTENCE. 
Miss F., 58 years old, was attacked with sudden agonizing 
pain at 3 a.m. on February 3d, 1.891. She was aware that she 
had had a fibroid tumor of the uterus for sixteen years. A 
subcutaneous injection of morphia made her more or less 
comfortable. The temperature was normal and the pulse 
80 per minute. On the 6th, when I saw her for the first 
time in consultation out of the city, her temperature had 
risen to 100° and her pulse to 90, I found the abdomen very 
tender and filled with a hard, round tumor extending above 
the umbilicus and to either iliac spine. She had been vom- 
iting—as the attending physician thought, from the morphia, 
but very likely from the peritonitis—but was able to take and 
retain milk and granum. I thought that the pain, tenderness, 
and vomiting were caused in some way by the fibroid tumor, 
and yet there was no obstruction of the bowels. If the tu- 
mor had been an ovarian one I should have known at once 
that its pedicle had become twisted, but I never dreamed 
that a large fibroid which included the uterus could twist 
that organ and become strangulated. I suggested immediate 
laparatomy, but it was not acceded to. I could not promise 
a cure, but I said that operation was the only thing to be 
done. The vomiting gradually ceased, and as the days went 
on the temperature gradually rose to 102,5° on the Bth of 
February, and the pulse to 110. The tenderness and mode- 
rate distention remained the same, requiring morphia. More 
or less cough and rapid breathing developed (pneumonia), 
with purulent expectoration. I saw her again on the 14th 
of February. At this my second visit the temperature was 
104° and the pulse 130. When not under the influence of 4 
HOMAXS: TWISTING OF THE UTERUS 
morphia the cough and any movements of the body caused 
great pain. Having settled her business matters, she was 
desirous of the operation, which she thought would end her 
sufferings and her life, but she did not expect to recover. 
It seemed to me hopeless to operate. The only chance was 
within the first few days of the attack. 
The bowels had moved on the 12th. There was now, in 
addition to the peritoneal irritation, some pneumonia and 
considerable cystitis. 
On the lYth there was some exaltation, talking almost in- 
cessantly, and even singing. The temperature gradually fell 
until, on the 2d of March, it was normal. The abdominal 
tenderness also diminished, but the cystitis increased and the 
bladder was washed out. At this period she was taking only 
one-third of a grain of morphia in twenty-four hours. From 
this time onward she had no marked symptoms except in- 
creasing loss of strength and occasional pain. The tempera- 
ture and pulse gradually rose to 102° and 140, respectively, 
and she died on March 14th, on the thirty-ninth day of her 
illness. There seemed to me no time when she could have 
been etherized and operated upon with any hope of success 
after the first week. I have given this condensed clinical 
history of the case in order to introduce an account of the 
very remarkable state of things revealed by the autopsy. 
Autopsy.—Body of a small, emaciated woman. Head not 
opened. Heart small, slightly opaque, flaccid, otherwise not 
abnormal. Lungs contained a little frothy fluid. In the 
right lung, at the middle of the lower part of the upper 
lobe, was a solidified mass the size of an orange, opaque and 
greenish on section. The peritoneum was covered with a 
purulent and fibrinous exudation, and the coils of the intes- 
tines were glued together. The lower part of the abdomen 
was occupied by a large, smooth, rounded growth arising out 
of the pelvis to a point above the umbilicus. The omentum 
was spread out over this growth and was adherent to it. The 
tumor was dark-colored on the outside and reddish-purple 
within. To it was attached* another smaller, rounded mass 
into which the Fallopian tubes entered, and to which were 
attached the broad, the round, and ovarian ligaments and 
ovaries, and in which was contained a cavity, smooth-walled, AS THE PEDICLE OF A FIBROID. 
5 
recalling the cavity of the uterus. To this was united the 
cervix uteri by a broad, flattened band of fibrous tissue, 
forming a pedicle which had been twisted one and one-half 
times on its axis from left to right. The twist was very 
tight, resembling a rope, and in it were contained, in addition 
to the flattened body of the uterus, both broad ligaments 
with their contents, and both ovaries more or less cut off 
from their blood supply. The circulation in the tumor had 
been completely cut off and it was strangulated. Careful 
examination failed to reveal any passage leading from the 
cervix to the fundus of the uterus through this fibrous band. 
Section through the large tumor showed it to be of a fibro- 
myomatous structure and infiltrated with blood. The mu- 
cous membrane of the bladder was covered with crustaceous 
masses and inflamed. The other organs presented no marked 
changes. 
Diagnosis.—Fibro-myoma of the uterus. Congenital (?) 
separation of the fundus from the cervix uteri, twisting of 
the pedicle thus formed, and strangulation of the mass above. 
Acute purulent peritonitis. Lobular pneumonia. lam sorry 
the exact weight and dimensions of the tumor cannot be 
given. I should say the weight was about six pounds and 
the diameter about nine inches. 
How this great solid mass could have been twisted on the 
middle of the uterus as its axis is a mystery. Whether this 
partial separation of the body of the uterus from its neck 
was congenital, or whether the twisting had come on gradu- 
ally and thus had elongated the junction of the cervix and 
body of the uterus until it had become a mere band, cannot 
easily be determined. I think the separation and elongation 
must, however, have been gradually produced. The case is 
worth putting on record on account of its extreme rarity. 
Indeed, I have never seen or heard of a similar case, but I 
have made no special search to find one.