Segmental torsion of fallopian tube in a young virgin

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hymen is shown by the fact t h a t menstrual blood escaped through the apparent urethral meatus, and had the hymen been imperforate, the patient would have bad a hematocolpos in her early menstrual life. McKelvey and Baxter2 presented a case of marked developmental anomaly, part of which showed the vagina ending in a blind pouch caudally. This part they claim had all the characteristics of normal vaginal tissue. They fit their finding to Koff'sl conception or t h a t of Mijsberg3 the latter claiming that the lower part of the vagina is Wolffian in origin. Masson 4 illustrates a case similar to the one presented. I n his case there is less vagina caudally and a sinus connecting the vagina cephalad to the urethra. Similar •momalies occur in female pseudobermaphrodites and hermaphrodites of undetermined sex. 5 CONCLUSIONS

A case of aplasia of the lower female tract is presented which is believed to be due to a failure of the proliferating epithelial plug of the vagina to grow posteriorly and a failure of fusion with the sinovaginal bulbs. That the inferior aspect of the hymen enters into the formation of the anomaly cannot be doubted. REFERENCES (1) Koff, A . K . : Contributions to Embryology 24: 61, 1933. (2) McKelvey, J. L., and Baxter, J. S.: AM. J. O~ST. & GYNEC. 29: 267, 1935. (3) Mijsberg, W. A.: Quoting McKelvey and Baxter, Ztschr. f. Anat. 74: 684, 1924. (41) Masson, J. C.: Obstetrics and Gynecology, Curtiss 3: 670, 1933. (5) Young, H. H.: Genital Abnormalities. Hermaphroditism and Related Adrenal Disease, Philadelphia, 1937, The Williams & Wilkins Co.

SEGMENTAL TORSION OF FALLOPIAN TUBE IN A YOUNG VIRGIN S SAMUELA. WOLFE, M.D., F.A.C.S., AND DAVID KUPERSTEIN, M.D., BROOKLYN, N. Y.

(From the Department of Gynecology and Obstetrics, Greenpoint Hospital) in the Fallopian tube is uncommon and especially rare in the virgin. A T {gRSION review of the literature by McEachern in 1934, revealed only 9 cases. Additional cases in virgins are recorded by Stark, Davies, Rogers, Darner, Jefferson, Gillies, Corlette, Michon, Block, and Michael. A study in December, 1935 made by K. F. D. Waters revealed 17 recorded cases of tubal torsion in young girls, although in this paper virginity was not a prerequisite. I n the case abstracted below torsion has evidently occurred in a normal tube. This inference is supported by the age of the patient, virginity, and findings at operation. Miss M. E., aged 19 years, single, was admitted to the Greenpoint Hospital on Feb. 17, 1937, complaining of pain in the left lower quadrant. Childhood diseases included diphtheria and scarlet fever. Menstruation began at the age of thirteen, was always regular and of a twenty-eight day type, and of three days' duration. The patient had typhoid fever in March, 1936 and was in bed for four weeks. This was followed by a period of amenorrhea for two months. Menstruation resumed in May, 1936 was accompanied by severe cramplike pains localized to the left lower quadrant. Since then, menstruation has occurred every twenty-one days, for six days. P a i n in the left lower abdomen has since appeared three days prior to menstruation, persisting until two days after completion of bleeding. Upon admission the temperature, pulse, and respirations were normal. Head, neck, and thorax revealed nothing of note. The abdomen presented a n insensitive mass, *Presented at a meeting of the Brooklyn Gynecological Society, March 4. 1938.

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2 or 3 on1. above the left P o u p a r t ' s ligament. This was dull to percussion but sensitive to touch. Pelvic examination revealed an intact virginal introitus. On rectal palpation the cervix was found to point anteriorly. The uterus was normal in size, retroverted and crowded over to the right. A tense, cystic globular mass about 6 or 7 cm. in diameter filled the left fornix and encroached upon the cul-de-sac. The laboratory d a t a were not unusual. A diagnosis of left ovarian cyst was made. Under ether anesthesia laparotomy was performed on Feb. 24, 1937 through a midline scar l0 cm. in length. About 30 c.c. of serosanguineous fluid was found free in the pelvic cavity. The uterus was snmll and pubescent. The right tube and ovary were normal. A Morgagni cyst about 2 cm. in diameter was found in the outer end of tbe right broad ligament. The left tube was converted into a retort-shaped structure, the dilated ampullar segment m e a s u r i n g about 5 cm. in diameter. Two twists were found at the junction of the middle and outer thirds of the tube, j u s t external to the outer edge of the mesovarium. The wall of the tube distal to the site of stranglflation was dark and hemorrhagic, the remainder was normal in color and appearance. The left ovary was normal in size and color. The left tube was untwisted, resected, and excised at its interstitial portion. The normal left ovary was retained. The raw surfaces were peritonized by the round ligament and the left ovary suspended. The Morgagni cyst on the right was resected and the posterior leaf of the broad ligament closed. The postoperative course was uneventful.

Fig. 1.--The tube is enlarged and dilated in its outer third. In tllis zone the color is blue black, the peritoneum lusterless. The pathologic report follows: The specimen consisted of a retort-shaped tube m e a s u r i n g 13 cm. in length, 5 ram. at the uterine insertion and 6 cm. in diameter in its distal third (Fig. 1). The external appearance was varied. The inner twothirds of the tube presented a smooth shiny peritoneal coat which was somewhat injected. A t the junction of the middle and outer thirds there was marked angula~ion. The twist previously described at this point was not well defined, probably the result of operative h a n d l i n g and fixation. The outer third of the organ was hemorrhagic, blue gray, and lusterless. The fimbriae were retracted and the abdominal ostium as such was no longer recognizable. The mesosalpinx in this zone was thickened and hemorrhagic. On section the dilated tubal segment was filled with blood which shelled easily f r o m the underlying endosa.lpinx. The latter was smooth and blue g r a y in appearance. All folds had been obliterated. The tubal musculature was hemorrhagic and markedly atrophic. Through the inner two-thirds the lumen was normal and free f r o m blood. T h e folds were grossly normal. The muscle was slightly edematous. The seroea was inj0ert~d. Microscopically, section t h r o u g h the isthmic segment of the tube also included a zone of the muscular coat of the uterus. The tube lumen though narrow was norma~~and free from blood. The folds were short. The inner longi£ndinal muscle coat was well defined. The broad circular muscular coat was sharply differentiated and i n turn was succeeded b y a second longitudinal coat which fused with the uterine musculature. A zoae of loose areolar tissu% however~ intervened. This contained several v e ~ t s

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about which were collections of lymphocytes especially prominent about the veins. The muscle fasciculi of the uterus showed slight edema and capillary engorgement. J u s t beneath the perimetrium the capillaries contained an occasional polymorphonuclear leucocyte. About them too were moderate numbers of lymphocytes and occasional plasma cells. I n the outer segment of the tube, distal to the point of torsion, the tube lumen was widely dilated. All the folds had been obliterated (Fig. 2). The lining epithelium and muscle fasciculi were all necrotic for the nuclear elements had disappeared and only cell shadows remained. Edema was evidenced by wide separation of the muscle cells and the presence of granular fibrin between the interstices. At the periphery a narrow segment of viable muscle and connective tissue fibers was found. Zones of interstitial hemorrhage were present. An occasional lymphocyte was encountered. The detached blood clot found in the tube lumen was free from chorionic villi. Torsion and necrosis of the distal third of the tube found at operation was accordingly confirmed. Inflammatory reaction in the viable segment was evidently secondary.

Fig. 2.--X80. A segment of tube wall through the dilated and necrotic ampullar zone. All folds have been obliterated. The muscle and connective tissue fibers are necrotic, only the cell shadows remain. No exudate is present. The blood clot was artificially removed from the tube lumen. I n retrospect, this case may be considered as one of torsion beginning with the first menstruation after an attack of typhoid fever, terminating in complete necrosis of the twisted segment. Pre-existing inflammation was not a factor~ for the hymen was found intact and no pathology was present in the uterus and right adnexa. Furthermore the involved tube showed no evidence of inflammation in mucosa or muscle proximal to the site of occlusion. CONCLUSIONS A case of segmental torsion and necrosis of the l e f t tube occurring in a virgin is herein recorded. The onset was sudden in the early menstrual phase. The left sided pain recurred monthly until admission to the hospital. A twisted tube with two complete turns at the junction of the middle and outer thirds w a s erroneously interpreted as an ovarian cyst. Pathologically, the dilated portion of the t~.be, W~S the seat of an old hematoma and the wall was completely necrotic distal

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to the site of torsion. There was no evidence of inflammation. The opposite adnexa were normal. This case may be therefore viewed as one of segmental torsion and necrosis of a previously normal tube occurring in a young virgin. ]530 PRESIDENT STREET

MELANOMA

OF

TtIE

V U L V A ~:~

R . CHARLES NUCCI, M . D . , F . A . C . S . , PITTSBURGH, PA.

(From the 1)epart,ment of Gynv(~ology of the Elizabeth ~gteel Magec Hospital and the University o1 Pittsbt~r.qh.) UPANG the past year it has been the writer's goo(] fl)rtune to chance upon a very infrequent ~ype of malignancy of the vulva, namely, malignant melanoma. Mrs. M. I., a 76-year-old white woman, was seen in the Magee Dispensary complaining of "~lumps" in the vulva and both inguinal legions. The patient stated that she h~t always had a small mole on l]Jc righ~ labium majus. In October. 1932 she first noticed black " l u m p s " on the right vulva, which were painless. Four months later they began to bleed and were considerably larger. On Feb. 13. 1936. " l u m p s " were observed in the right groin, following three operations a month previously under local anesthesia. Six weeks before admission the patient felt additional " ' l u m p s " in the left groin. At this time she had had a serosanguineous vaginal discharge for about eighteen months. The " l u m p s ~' had been painful for about two years and were becoming progressively larger. She had lost only a slight amount of weight. Associated symptoms included headache, blurring of vision, tinnitus, and episodes of abdominal discomfort following ingestion of fried foods. The menstrual history was normal and the menopause occurred at the age of fifty. She had had two normal ~ull-term pregnancies. The past medical history included ~yphoid, measles, influenza, and diphtheria. The famil$ history was negative for malignancy. There was marked wrinkling of the skin. The vessels were hard, tortuous, and sclerosed. She had complete dentures. The tonsils were enlarged. The heart was not enlarged but a few premature bea~s were noted. There was slight 1)retibial edema. The vulvar lesion (F~g. 1) consisted of a large somewhat nodular mass. irregularly the size of a ~angerine, occupying the entire right labium minor and of a purplish color. The lower surface of the mass presented some ulceration and extended out to the clitoris, prepuce, upper part of left labium minor, and had infiltrated through so that there were several pigmen?~ed spots, of various sizes, on the outer surface of the right labium major. There were large firm masses in both inguinal regions. Laboratory findings. The urine was negative except for a few white blood corpuscles. I t was negative for melanin. Blood count: 1~. B. C., 3,690,000; W. B. C., 5,550; polymorphonuclears, 56 per cen¢; lymphocytes, 43 per cent. The blood sugar was 120 mg. Nonprotein nitrogen was 24.3 mg. Kahn was negative. Sedimentation time was 20 rain. Course ~ hospital. On Dec. 21. ]936, under gas-ether anesthesia a biopsy was taken and four radium needles, containing 1 2 ~ rag. of radium each, were inserted directly into the vulvar mass. for a period of forty-eight hours (2,400 rag. hr. of radiation). Pathologiv tCvport l~'rom Biopsy. The tumor (Fig. 2) was composed o f a itleoo morphic type of ceil, varying from spindle cell type to a large epithelial type. The cells varied in their melanin content, some o f them being melanin free, aad othera

D

*Read at a meeting of the Pittsburgh Obstetrical and Gynecological Society, February 7, 1938.