A Case of Acute Torsion of the Fallopian Tube with Hematosalpinx

W. L. BURRAGE
1906 Boston Medical and Surgical Journal  
The left ovary was enlarged to 2\ inches and cystic, and was also removed. The pelvis was found to contain a considerable amount of material similar to the contents of the dermoid cyst, and at the time it was not apparent how it came there, in view of the fact that none was spilled when the cyst was emptied. The cavity was cleansed and drained and the abdomen closed. The patient made a good ether recovery, but the pulse rose to 150 on the night after operation. There was some abdominal pain and
more » ... abdominal pain and moderate distention, relieved by enemata; the abdomen was always soft and not tender. The temperature had risen to 101°F. on the second day, with pulse at 160, and the patient died, apparently of shock, on the third day. The cyst measured 22 by 18 cm.; color, reddish to gray. On one side a thick pedicle with injected vessels and thickened walls. The whole surface of the cyst was roughened by adhesions, and the wall was 0.4 to 1.5 cm. in thickness. The cavity was filled with soft, yellowish, fatty material, showing cholesterin crystals, and embedded in this material were several balls of very coarse, golden-yellow hair; no bone or teeth were found. On what was, at the time of operation, the posterior surface of this cj'st was a smaller cyst containing a thick mass of inspissated material, but no hair. On the discovery of this subsidiary cyst, the presence of the material found free in the pelvis and above alluded to seemed to me adequately accounted for. It seemed evident that this smaller cyst had originally contained the material, and had ruptured long enough before operation for the opening to have closed before removal, or to have escaped detection afterwards. Pathological diagnosis: Dermoid cyst, with necrosis and inflammation. All authorities agree that " dermoid cysts are more likely to un lergo axial rotation than other ovarian tumors, and hence twisting of the pedicle is comparatively frequent in this variety of cystic growth."1 Malcolm Storer, in his valuable paper on axial rotation read before this Society nine years ago,2 states that " In about 83% of the 248 cases of torsion collected by him from various sources, the tumor was either polycystic, solid, or dermoid, that is, presumably, of more or less irregular outline and varying weight, the irregularities affording convenient points for the exercise of the force needed to produce rotation, and the varying weight tending to produce disturbance of equilibrium." Case V. E. P., aged fifty-nine, had had one normal labor and afebrile puerperium in 1872, and had been a widow for two years; she had not menstruated for fourteen years. She had had good general health, and said she had never had an attack similar to the present one. Three days before I saw her she had been seized with excruciating pain in the left lower quadrant ; the pain lasted one day, and the second day thereafter the pain returned and became general over the whole abdomen. There were no chills, but she had vomited and had had slight fever. The abdomen was distended, tympanitie throughout, and tender. The vaginal vault was puckered, and in the apex was a small atrophie cervix. On the left was a mass reaching nearly to the umbilicus and slightly movable independently of the uterus. The following day there was slight jaundice, which disappeared the next day ; pain disappeared in a few days. The diagnosis lay, to my mind, between cyst of the left ovary and pedun-culated subserous fibroid, with a possibility of malignant growth; and operation was advised and accepted. On opening the peritoneum a mass was found made up of adherent omentum, intestine, and a tumor proceeding from the left broad ligament; the tumor had the shape and appearance of an enormously distended Fallopian tube; the ovary could not be differentiated and was presumably involved in the tubal mass. The tumor had rotated once around from without inward, and the pedicle thus twisted was so small that it was tied off with a single ligature. The mass had a necrotic appearance, and it was obvious that degenerative changes must have taken place in consequence of the torsion of the pedicle. The right appendages were shrivelled and adherent, and were not disturbed. On the anterior surface of the atrophied uterus was a sessile, egg-shaped myoma, 4.5 by 3 cm., which was enucleated and the bed closed in with buried sutures. The abdomen was closed without drainage, and the patient made a rapid and uneventful convalescence. Subsequent examination of the strangulated tumor showed that it consisted of tube and ovary; the ovary, cystic, the capsule-like wall, tense, dull, dark red in color, slightly roughened by exudation, with dimensions 10.5 by 8 cm.; the contents consisted of dark, reddish-brown fluid in which were numerous blood cells and cholesterin crystals. The tube measured 7.5 by 1.8 cm., with walls dark red and softened and lumen distended with dark blood. On comparing the pathological conditions found with the patient's statement of her symptoms, it seems incredible that such extensive changes could have occurred in so short a time. It is a fair inference that the ovary was cystic and that the tube had been the seat of a chronic process for perhaps some time without having given rise to symptoms that led the patient to seek advice. And it is quite probable that the attack of excruciating pain occurred shortly after a sudden axial rotation of the tubo-ovarian mass, from whatsoever cause, with the consequent torsion of the pedicle, resulting in hemorrhage into the lumen of both tube and ovary, and in the inflammatory and necrotic changes noted. The patient, Mrs. H. M. W., twenty-six years of age, first came under observation Dec. 9, 1898. She was a blonde of average height, poorly nourished and anemic; five brothers and sisters enjoyed good health; her father died of cancer at sixty-nine years. She had been married two years and had not been pregnant; always considered herself delicate; menstruation painful for the first twenty-four hours, every twenty-eight days, five to six days' flow, three to four napkins. The catamenia had been irregular up to four years previously. She applied for treatment because of dysmenorrhea. The uterus was found to be anteflexed, enlarged (the cavity measured 3} inches) and retroposited ; the right ovary was prolapsed but not enlarged and not adherent; cavity of the uterus very sensitive to the sound and bleeding easily. I did a Dudley operation at this time, and careful examination under ether confirmed the diagnosis. The result was good and the patient was
doi:10.1056/nejm190603151541106 fatcat:vqdgkvwjoreglh4vq3c6cqbd4i