S
Williams & Davies 1974, Davies & Tizard 1975). If we consider children with an IQ below 70 (at present this must be an estimate for those born in 1969 and 1970), major and minor neurological handicap, moderate to severe deafness and partial sightedness, then 26/165 (15.7%) of the entire group are involved, 20.7% in 1961-64, and 13.1 % in 1965-70. The incidence of such handicap was 22.2% in those small for dates and 12.6% in those appropriate for dates at birth. When these results are compared with those reported in children of very low birth weight born in the late 1940s and 1950s (Lubchenco et al. 1963, Drillien 1964, McDonald 1967) it is realized that the proportion of handicapped children among survivors is now considerably less. Improvement in obstetric management must surely be one important reason for the change. Neonatal care has improved too, but pediatricians have to temper their pleasure at the improved results with the knowledge that much of the handicap in earlier years was iatrogenic in origin.
Acknowledgments: This work has been supported by the Nuffield Foundation to whom I am very much indebted. I am also grateful to Lady Jessie Francis-Williams and other psychologists for allowing me to use the results of their intelligence testing. REFERENCES Davies P A & Davis J P (1970) Lancet ii, 1216-1219 Davies P A & Tizard J P M (1975) Developmental Medicine and Child Neurology 17, 3-17 Dobbing J (1968) In: Applied Neurochemistry. Ed. A N Davison and J Dobbing. Blackwell, Oxford; pp 287-316 (1972) In: Lipids Malnutrition and the Developing Brain. Ed. K M Elliott and J Knight. Associated Scientific Publishers, Amsterdam; pp 9-29 Drillien C M (1964) The Growth and Development of the Prematurely Born Infant. Livingstone, Edinburgh Francis-Williams J & Davies P A (1974) Developmental Medicine and Child Neurology 16, 709-728 Gruenwald P M (1966) American Journal of Obstetrics and Gynecology 94, 1112-1119 Lubehenco L 0, Horner F A, Reed L H, Hix I E, Metcalf D, Cohig R, Elliott H C & Bourg M (1963) American Journal ofDiseases of Children 106, 101-115 McDonald A (1967) Children of Very Low Birth Weight. MEIU Research Monograph No. 1. Spastics Society. Heinemann, London Paine R S & Oppe T E (1966) In: Clinics in Developmental Medicine. Spastics Society/Heinemann, London; 20-21, 86 Tanner J M & VVhitehouse R H (1959) Lancet ii, 1086-1088
The following paper was also read: The Social Aspect Miss M R Powell (Nursing Officer, Sheffield Regional Hospital Board, Fulwood House, Old Fulwood Road, Sheffield, S10 3TH)
Section ofObstetrics & Gynacology
227
Meeting 26 April 1974
Clinico-pathological Meeting Urethral Metastasis from a Presumed Primary Malignant Melanoma Presenting as Postmenopausal Bleeding J F B Clarke MRCOG (Liverpool University) A 79-year-old nulliparous single patient presented with a two-month history of postmenopausal bleeding. She was found to have a lobulated, friable tumour 3 cm in diameter arising from a narrow pedicle on the posterior lip of the external urethral meatus. The pelvic organs were atrophic, no curettings were obtained and cystoscopy revealed a normal bladder mucosa. The patient was otherwise healthy. The growth was biopsied and histologically was an anaplastic tumour consisting of cords and clusters of large pleomorphic tumour cells with the overlying squamous epithelium intact. The initial opinion was of a primary urethral carcinoma and subsequent treatment by excision and radium appeared to be successful. However, seven months after her first attendance a solitary skin metastasis appeared over the right manubrium sterni to be followed over the next four weeks by the appearance of multiple skin nodules. Lung metastases were also demonstrated by a chest X-ray taken at this time. Histologically the skin nodules were found to be similar in appearance to the original urethral tumour. The widespread nature of the metastases suggested that they were blood borne and raised the possibility of a primary growth prone to such behaviour, such as malignant melanoma, or carcinoma of the bronchus, kidney or breast. From this point onwards the patient's condition rapidly deteriorated and eleven months after she had first been seen she died following a pathological fracture of her right femur. At post-mortem, in addition to malignant deposits in the skin and in the shaft of the right femur, metastases were found in the left ventricle, the liver and small intestine. Several deposits were present in both kidneys and in the bladder but the appearance of the tumour deposits was clearly that of secondary tumour. No glycogen had been found in any of the tumour cells and there was nothing suggestive of renal carcinoma in the tumour pattern. No tumour tissue was found in the substance of either breast.
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The largest tumour was found in the lungs, in the basal part of the left upper lobe and this, supported by neoplastic deposits in both adrenals, suggested that the bronchial tumour may have been primary. The histological pattern of the lung tumour, however, in no way suggested the oat cell type of bronchial carcinoma usually associated with rapidly growing, widely spreading lung cancer. On final assessment, accepting that malignant melanoma also frequently metastasizes to the adrenals, the bizarre histological pattern and the Fig 1 Tubo-ovarian abscess illustrating the abscess widespread tumour deposits led to the conclusion cavity with sulphur granules and to the right the that the original tumour was probably an fallopian tubefilled with pus. x 3j amelanotic malignant melanoma. A firm conclusion is not possible because no pigment was ever found in any of the sections examined histologically and indeed it cannot be stated with certainty that the urethral tumour was itself secondary or primary.
- w~ ~ ~ ~ ~ ~ '
Comment Primary and secondary malignant melanoma of the female urethra are unusual. Black & Hotchkiss (1971) found only 35 cases of primary melanoma in this site reported in the world literature. REFERENCE Black N L & Hotchkiss R S (1971) Journal of Urology 105, 251
Fig 2 High power view ofa sulphur granule showing, the branching bacteria ofActinomyces israeli. x 233 the pelvis. In mobilization, a thick, creamy green, offensive pus drained.
Genital Actinomycosis H Wagman FRCsEd MRCOG (The London Hospital, Whitechapel, London El) R B, woman aged 29, para 2 +1. Caucasian History: Six months previously, a bout of lower abdominal pain and vomiting lasting one day. Unwell since, with anorexia and weight loss. Amenorrhoea for ten weeks. On examination: Ill-looking and febrile with an asymmetrical non-tender mass arising from left iliac fossa. Vaginal examination revealed tense, irregular swellings in both fornices; it was not possible to separate the uterus from these masses. Investigations: Hb 7.8 g/100 ml. WBC 13 600/ mm3 (neutros. 75%Y.). ESR 120 mm in one hour (Westergren). Operation 1 (29.11.72): Endometrial biopsy after blood transfusion. Histology showed a blood clot only. Operation 2 (6.12.72): Bilateral salpingectomy, left oophorectomy and appendicectomy. Findings: Bilateral tubo-ovarian abscesses (Fig 1), 1t4 x 10 x 6 cm, were densely adherent to the colon, ileum appendix, floor and side walls of 'Present Barnet General 3DJ EN5 3DJ address: Barnet General Hospital, Barnet, EN5 Hospital, Barnet, 'Present address:
Bacteriology: (1) Branching Gram-positive rods producing a profuse growtb of organisms resembling Actinomyces israeli (Fig 2). (2) Moderate growth of Gram-negative rods (bacterioides). Histology: Sections from the left and right
abscess sacs showed multiloculated abscess cavities surrounded by chrohic inflammatory granulation tissue, foamy macrophages and fibrous tissue. Many colonies of actinomyces present. Remnants of fallopian tube were recognizable from both sides and ovary on the left. Patchy fibrosis on the appendix suggesting healed, past acute inflammation. Discussion
Actinomycosis, a chronic granulomatous suppurative infection, uncommonly affects the female genital tract. Only 12 cases of genital actinomycosis have been described in the British Isles, the last by Stevenson (1957), recent reports have come from USA (Farrior & Rathbun 1969) and USSR (Egorova 1967). Actinomyces israeli, a normal commensal of the mouth, produces an endogenous infection and not an exogenous one caused, as formerly thought, by contaminated pieces of straw. The main mode of spread is by direct contact and this has led to the suggestion
Williams & Davies 1974, Davies & Tizard 1975). If we consider children with an IQ below 70 (at present this must be an estimate for those born in 1969 and 1970), major and minor neurological handicap, moderate to severe deafness and partial sightedness, then 26/165 (15.7%) of the entire group are involved, 20.7% in 1961-64, and 13.1 % in 1965-70. The incidence of such handicap was 22.2% in those small for dates and 12.6% in those appropriate for dates at birth. When these results are compared with those reported in children of very low birth weight born in the late 1940s and 1950s (Lubchenco et al. 1963, Drillien 1964, McDonald 1967) it is realized that the proportion of handicapped children among survivors is now considerably less. Improvement in obstetric management must surely be one important reason for the change. Neonatal care has improved too, but pediatricians have to temper their pleasure at the improved results with the knowledge that much of the handicap in earlier years was iatrogenic in origin.
Acknowledgments: This work has been supported by the Nuffield Foundation to whom I am very much indebted. I am also grateful to Lady Jessie Francis-Williams and other psychologists for allowing me to use the results of their intelligence testing. REFERENCES Davies P A & Davis J P (1970) Lancet ii, 1216-1219 Davies P A & Tizard J P M (1975) Developmental Medicine and Child Neurology 17, 3-17 Dobbing J (1968) In: Applied Neurochemistry. Ed. A N Davison and J Dobbing. Blackwell, Oxford; pp 287-316 (1972) In: Lipids Malnutrition and the Developing Brain. Ed. K M Elliott and J Knight. Associated Scientific Publishers, Amsterdam; pp 9-29 Drillien C M (1964) The Growth and Development of the Prematurely Born Infant. Livingstone, Edinburgh Francis-Williams J & Davies P A (1974) Developmental Medicine and Child Neurology 16, 709-728 Gruenwald P M (1966) American Journal of Obstetrics and Gynecology 94, 1112-1119 Lubehenco L 0, Horner F A, Reed L H, Hix I E, Metcalf D, Cohig R, Elliott H C & Bourg M (1963) American Journal ofDiseases of Children 106, 101-115 McDonald A (1967) Children of Very Low Birth Weight. MEIU Research Monograph No. 1. Spastics Society. Heinemann, London Paine R S & Oppe T E (1966) In: Clinics in Developmental Medicine. Spastics Society/Heinemann, London; 20-21, 86 Tanner J M & VVhitehouse R H (1959) Lancet ii, 1086-1088
The following paper was also read: The Social Aspect Miss M R Powell (Nursing Officer, Sheffield Regional Hospital Board, Fulwood House, Old Fulwood Road, Sheffield, S10 3TH)
Section ofObstetrics & Gynacology
227
Meeting 26 April 1974
Clinico-pathological Meeting Urethral Metastasis from a Presumed Primary Malignant Melanoma Presenting as Postmenopausal Bleeding J F B Clarke MRCOG (Liverpool University) A 79-year-old nulliparous single patient presented with a two-month history of postmenopausal bleeding. She was found to have a lobulated, friable tumour 3 cm in diameter arising from a narrow pedicle on the posterior lip of the external urethral meatus. The pelvic organs were atrophic, no curettings were obtained and cystoscopy revealed a normal bladder mucosa. The patient was otherwise healthy. The growth was biopsied and histologically was an anaplastic tumour consisting of cords and clusters of large pleomorphic tumour cells with the overlying squamous epithelium intact. The initial opinion was of a primary urethral carcinoma and subsequent treatment by excision and radium appeared to be successful. However, seven months after her first attendance a solitary skin metastasis appeared over the right manubrium sterni to be followed over the next four weeks by the appearance of multiple skin nodules. Lung metastases were also demonstrated by a chest X-ray taken at this time. Histologically the skin nodules were found to be similar in appearance to the original urethral tumour. The widespread nature of the metastases suggested that they were blood borne and raised the possibility of a primary growth prone to such behaviour, such as malignant melanoma, or carcinoma of the bronchus, kidney or breast. From this point onwards the patient's condition rapidly deteriorated and eleven months after she had first been seen she died following a pathological fracture of her right femur. At post-mortem, in addition to malignant deposits in the skin and in the shaft of the right femur, metastases were found in the left ventricle, the liver and small intestine. Several deposits were present in both kidneys and in the bladder but the appearance of the tumour deposits was clearly that of secondary tumour. No glycogen had been found in any of the tumour cells and there was nothing suggestive of renal carcinoma in the tumour pattern. No tumour tissue was found in the substance of either breast.
228
Proc. roy. Soc. Med . Volume 68 April 1975
6
The largest tumour was found in the lungs, in the basal part of the left upper lobe and this, supported by neoplastic deposits in both adrenals, suggested that the bronchial tumour may have been primary. The histological pattern of the lung tumour, however, in no way suggested the oat cell type of bronchial carcinoma usually associated with rapidly growing, widely spreading lung cancer. On final assessment, accepting that malignant melanoma also frequently metastasizes to the adrenals, the bizarre histological pattern and the Fig 1 Tubo-ovarian abscess illustrating the abscess widespread tumour deposits led to the conclusion cavity with sulphur granules and to the right the that the original tumour was probably an fallopian tubefilled with pus. x 3j amelanotic malignant melanoma. A firm conclusion is not possible because no pigment was ever found in any of the sections examined histologically and indeed it cannot be stated with certainty that the urethral tumour was itself secondary or primary.
- w~ ~ ~ ~ ~ ~ '
Comment Primary and secondary malignant melanoma of the female urethra are unusual. Black & Hotchkiss (1971) found only 35 cases of primary melanoma in this site reported in the world literature. REFERENCE Black N L & Hotchkiss R S (1971) Journal of Urology 105, 251
Fig 2 High power view ofa sulphur granule showing, the branching bacteria ofActinomyces israeli. x 233 the pelvis. In mobilization, a thick, creamy green, offensive pus drained.
Genital Actinomycosis H Wagman FRCsEd MRCOG (The London Hospital, Whitechapel, London El) R B, woman aged 29, para 2 +1. Caucasian History: Six months previously, a bout of lower abdominal pain and vomiting lasting one day. Unwell since, with anorexia and weight loss. Amenorrhoea for ten weeks. On examination: Ill-looking and febrile with an asymmetrical non-tender mass arising from left iliac fossa. Vaginal examination revealed tense, irregular swellings in both fornices; it was not possible to separate the uterus from these masses. Investigations: Hb 7.8 g/100 ml. WBC 13 600/ mm3 (neutros. 75%Y.). ESR 120 mm in one hour (Westergren). Operation 1 (29.11.72): Endometrial biopsy after blood transfusion. Histology showed a blood clot only. Operation 2 (6.12.72): Bilateral salpingectomy, left oophorectomy and appendicectomy. Findings: Bilateral tubo-ovarian abscesses (Fig 1), 1t4 x 10 x 6 cm, were densely adherent to the colon, ileum appendix, floor and side walls of 'Present Barnet General 3DJ EN5 3DJ address: Barnet General Hospital, Barnet, EN5 Hospital, Barnet, 'Present address:
Bacteriology: (1) Branching Gram-positive rods producing a profuse growtb of organisms resembling Actinomyces israeli (Fig 2). (2) Moderate growth of Gram-negative rods (bacterioides). Histology: Sections from the left and right
abscess sacs showed multiloculated abscess cavities surrounded by chrohic inflammatory granulation tissue, foamy macrophages and fibrous tissue. Many colonies of actinomyces present. Remnants of fallopian tube were recognizable from both sides and ovary on the left. Patchy fibrosis on the appendix suggesting healed, past acute inflammation. Discussion
Actinomycosis, a chronic granulomatous suppurative infection, uncommonly affects the female genital tract. Only 12 cases of genital actinomycosis have been described in the British Isles, the last by Stevenson (1957), recent reports have come from USA (Farrior & Rathbun 1969) and USSR (Egorova 1967). Actinomyces israeli, a normal commensal of the mouth, produces an endogenous infection and not an exogenous one caused, as formerly thought, by contaminated pieces of straw. The main mode of spread is by direct contact and this has led to the suggestion
