Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 156

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

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runa the decision to reopen the school was reached. Thus March 6 a child in the Maternity Ward was found with a itive nose culture, on March 7 a student developed a posi- e throat culture, on March 16 another student showed the ection, and on March 19 one of the physicians in the dis- sary. On March 22 the room-mate of the last-named stu- it developed an otitis media which proved to be due to the ebs-Loeffler bacillus. Since that time no cases have ap- red either in the student-body or among the individuals ng in the institution. Altogether 66 cases of diphtheria 'e treated in the Johns Hopkins Hospital, to which should added 6 cases in orderlies or members of their families who various reasons could not be treated in the Hospital but › evidently contracted the disease there, a total of 72 cases. ir deaths occurred, three in children and one in an adult, le of them, however, being uncomplicated diphtheria cases. Ve shall probably never know the source of this epidemic diphtheria. Baltimore always has cases of the disease, and times during the winter season these cases may occur with le frequency. From these foci of infection in the city the base frequently extends into the Hospital, but at no time viously has there been evidence of any wide invasion of the spital population, nor has the fear been felt that such an asion was likely to occur. In the three and a third years n September 1, 1907, to January 1, 1911, there have been forty-four diphtheria patients in the Hospital. These cases urred in individuals living in widely separated parts of the ', of various ages and occupations. Occasionally several es have developed on or about the same time among the ses or among the medical students. Thus in May, 1908, 'e were 5 cases of this description. The infection died out during the next winter a few scattering cases appeared in

"Sattva cases of dipintitila admitted to the isolation waill, of whom six were in the Hospital population and two among the medical students. In 1910 there were altogether eleven cases, of whom four were nurses or pupil nurses in the Hos- pital. These cases occurred at longer or shorter intervals, and while they may have developed one from another, they may equally well have been simply extensions of the disease from the city. At no time was there any difficulty in controlling these infections, and at no time was there any fear that the disease would spread in our midst. This sense of security was rudely shaken by our recent experience, and the possibility that an infection of mild form and almost self-limited may at times assume the character of a rapidly spreading contagious disease will always be entertained here in the future.

Finally, the question arises as to whether the very drastic measures adopted to stamp out this epidemic were necessary and whether the cessation of cases was directly due to the introduction of these procedures. Such questions from their very nature cannot be answered. We can only say that at the time the measures were put in operation, diphtheria was spread- ing with great rapidity in the Hospital and Medical School. All the men intimately associated with the work, especially the members of the resident medical staff, were appalled at the way the cases were coming to light and it was generally be- lieved that unless drastic measures were employed a wide- spreading and serious epidemic of diphtheria might develop in the institution. With the inauguration of the various pre- ventive methods which were considered advisable the disease disappeared from our population, and we cannot help but be- lieve that this disappearance stands towards our activities in the relation of effect and cause and not in the relation of a sequence of events.

INFECTION OF THE URINARY TRACT BY THE BACILLUS LACTIS AEROGENES, WITH A CONSIDERATION OF THE MODE OF ENTRANCE OF BACTERIA INTO THE BLADDER.

By JOHN ARTHUR LUETSCHER, M. D., Instructor in Medicine, The Johns Hopkins University.

llowing the introduction of exact bacteriological methods och, there appeared, in addition to descriptions of mor- gy and motility, more or less accurate descriptions of ultural characteristics of the bacteria found in cystitis. om 1887 until 1892 a series of observations were made ench authors who found, in cystitis in man, a bacillus as host frequent cause of cystitis. This bacillus appeared various names. Morelle 1 and Denys' identified it as the ;tis aerogenes; while it was later definitely proven to be other than the B. coli communis by Achard and lt,' Reblaud," Krogius,' and later observers. Were it

not for the fact that these early observations are still classed under the B. lactis aerogenes," I should hesitate to give a more extended historical review.

A careful study of the originals in the light of present-day knowledge should leave no doubt as to the exact identity of this particular bacillus.

In 1887 Clado ' isolated the " bactérie septique de la vessie," stating that this bacillus had not been described by any one.

This bacillus had rounded ends, and was actively motile (" movements of translation " as distinguished from " move- ments of place ") ; it travelled rather rapidly, in some in-

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stances across the field of the microscope, and did not stain by Gram's method. The colonies on plates had an irregular outline, and the agar slant had a thin, opalescent growth.

In 1888 Albarran and Halle' isolated the "bacterie pyogène " from 35 out of 50 pathological urines obtained aseptically from the bladder. This organism was found 15 times in pure culture, and 20 times associated with other organisms.

This bacillus was 4 to 6 p long, with a diameter of 2 p, had rounded ends, and was motile in young cultures, but did not stain by Gram's method. The colonies on plates had rounded borders, and looked like drops of wax. In the gelatine stick, the culture formed a white stem with a white hyaline layer on the surface. They concluded that their bacillus was the same as that described by Clado.

In 1889 Doyen' isolated from urine in cystitis 10 bacilli and 4 micrococci. Of the bacilli, 9 did not liquefy gelatine, nor had they any other characteristics to distinguish them from the " bactérie pyogène " of Halle and Albarran.

During the same year Rovsing " isolated the cocco-bacillus urea, from 3 of the 29 cases under observation. According to Schmidt and Aschoff " this bacillus was probably none other than the " bacterie pyogène " of Halle and Albarran.

In 1889 Morelle (loc. cit.) found a non-liquefying bacillus in 13 of 17 cases studied, of which 6 were in pure culture. This bacillus was small with rounded ends, sometimes ovoid, and very variable in length. Its size was always influenced by the media. The bacillus was possessed of " movements of translation." No spores were found. On agar the colonies were round, glassy, smooth, and if discrete, reached 4 mm. in size. When translucent, an exquisite design of concentric lines was often observed. He noted both the opaque and the translucent type, presenting a pleomorphism which would lead one to believe them to be different species. The growth on potatoes was white to yellow, and showed bubbles of gas. It coagulated milk in two days, with acid production. It fermented glucose, with formation of CO2 and H.

He concluded that his bacillus was identical with (1) the " bactérie septique de la vessie " of Clado, (2) the " bactérie pyogène " of Albarran and Halle, (3) the cocco-bacillus urea of Rovsing, and probably with the 8 species described by Doyen.

After a careful comparison of the morphological and cultural properties, he concludes that his bacillus is none other than the B. lactis aerogenes of Escherich. In compar- ing it with the colon bacillus, he admitted that there was a great similarity, and that their pathogenic action was the same.

The differences cited were that the B. lactis acrogenes de- veloped on gelatine into higher and more circumscribed colonies, with regular outlines; that they were white and more opaque, while the colon colonies were gray and trans- lucent; also that the B. lactis aerogenes colonies were viscous, while those of the colon were more dry. He ends with the following sentence: "Still the similarity is great, and one may perhaps some day demonstrate that they are only two "ties of the same organism."

Achard and Renault (loc. cit.) were the first to call t: tion to the identity of the " bactérie pyogène" and the bacillus. They compared two strains obtained from Ale- and Halle, one strain obtained by Gilbert and Girode t- the bowels of a new-born, and various strains obtaine !! cases of pyelonephritis. All had the same morphokr. same motility under similar conditions, and the same ca characteristics. They also found the pathogenicity the s

At the same time Reblaud (loc. cit.) reported his or the previous year, from which he concluded that the ": térie pyogène " is identical with the colon bacillus. Ch- took the same view.

In 1892 Krogius (loc. cit.) examined 17 patiale: urines from cases of cystitis, and in 12 found a small z. bacillus with rounded ends, and of very variable dimite : The urine was acid, with a particularly fœtid odor. He .: pared this bacillus with the " bactérie pyogène" ct:2. from Albarran and Halle and found them identical. Itje into the bladder of rabbits, his bacillus produced the symptoms of purulent cystitis as the " bactérie progène also found that by growing the opaque type in sterilitet : mal urine for several weeks, it was transformed in transparent type.

Laruelle found that by growing the opaque form in : it was changed into the transparent type. Krogins va : | to confirm this result.

We have thus a bacillus termed variously the "ber septique de la vessie," "bactérie pyogène," coco -: urea, B. lactis aerogenes, B. coli communis, all possessia; same cultural characteristics and the same morphology, .. motility, and causing cystitis in 71 per cent of the examined.

Two points should suffice to prove that these culture: not have been the B. lactis aerogenes:

1. All were actively motile-" movements of transle :: 2. They occurred in about 70 per cent of the cases ?' titis, which figures correspond closely to the percenta. cases of cystitis due to the colon bacillus as shown by i the later investigators.

The differences in morphology and the cultural difer: on gelatine are now known to be insufficient and too rar.a to differentiate them as separate species.

From this period on, one finds the colon bacillus & causative agent of cystitis in 50 to 71 per cent of sl (* of cystitis, while the B. lactis acrogenes has only rarely - found. A careful search of the available literature reTE. only a few isolated reports.

In 1899 Warburg " reported a case of bacteriuria in ! ". 54 years old, who was admitted to the hospital for s. bronchitis. On the fifth day after admission he had a ( headache, and a rise in temperature to 39º C. fever continued for three days, and on the second de: : urine became cloudy. A catheterized specimen showed s: bacillus, often coccus-like, which was not motile. It d. : stain by Gram's method. On gelatine the growth was .. like; on potato whitish yellow; it coagulated milk in 1? ? in sugar bouillon it produced gas; it produced no ind-1.

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icy. She suffered from a "myelitis lumbalis ascendens," pletely paralyzing the bladder and rectum, necessitating heterization three to four times each day.

The urine was at first clear, acid, and free from albumen I sugar. On the fourth day after admission the urine be- e cloudy, containing pus and red cells. Four days later ympanitic tumor reaching to the umbilicus was observed, I the urine finally became alkaline.

The following organisms were isolated: a coccus which nefied gelatine, a non-liquefying coccus, and a non-liquefy-

bacillus. The last was identified as the B. lactis aero- es, and held by him as the cause of the pneumaturia. This bacillus had rounded ends, but was so often like cus that doubts were entertained as to its purity until atine plates were made. The bacillus was not motile and not stain by Gram's method. No spores were observed. growth on potato was several millimeters thick, grayish ite, viscous, moist, and shiny, showing numerous gas bub- 3. The bouillon was uniformly cloudy, forming a sedi- nt. Milk was coagulated in 24 hours. It fermented glu- e and lactose. The gas consisted of 63 per cent CO2, 27 cent H, and 8 per cent " undetermined rest." These portions of gas stamp it as a true B. lactis aerogenes, ac- ding to Burri and Düggeli."

n 1901 Wildbolz 1 reported a case of pneumaturia in a n 52 years old who was suffering from a gonorrhoeal cture which had to be dilated. Three weeks later he iced gas at the end of micturition. The urine was cloudy, 1, and had a disagreeable odor. A non-motile organism ; isolated which did not stain by Gram's method. It gulated milk rapidly, actively fermented grape sugar, but not form indol.

n 1894 Schnitzler 17 reported a case of pneumaturia in a lipara 46 years old. In the fall of 1893 she noticed the sing of gas at the end of micturition, but did not suffer n any other symptoms. On December 11, 1893, a cystitis eloped and the patient was catheterized by a midwife, n which time on she had to be catheterized several times ay. A short, plump, non-motile bacillus was isolated the urine. This bacillus did not stain by Gram's hod. The growth on gelatine was profuse. It formed gas ! on sugar-free media. No note is made as to growth on : or potato, the fermentation of glucose and milk sugar, formation of indol, or the presence of a capsule. His con- on was that his organism belonged to the colon group. an and Hamm think that in the light of present-day Fledge this bacillus really belonged to the lactis aerogenes p.

1896 Trumpp reported 29 cases of cystitis in children, of which was due to the B. lactis aerogenes.

y personal observations were made on two cases with the wing histories :

JE I .- Mrs. X, aged 28, during the second month of first preg- " complained of frequent micturition which direction as to uids, and rest did not relieve. The symptoms became aggra-

in bed with a diet of milk and water, also suppositories of opium to relieve the straining. She had no pain in the region of the kidneys, and her temperature was never over 99º F. The urine was light yellow, acid, and contained a sediment consisting chiefly of leucocytes with an occasional red cell. Albumen and sugar were absent.

Bacteriological Findings .- Each of two catheterized specimens taken ten days apart showed the B. lactis aerogenes in pure culture. The condition persisted for four weeks with a marked tendency to recurrence whenever the urotropin was omitted. Later cultures were negative.

CASE II .- On May 25, four days after the acute symptoms in his wife had shown themselves, Mr. X, husband of Case I, developed a urethritis, accompanied with a yellowish, watery, acrid dis- charge which contained a few pus cells but no gonococci. He suffered from frequent micturition and a marked tenesmus requir- ing opium suppositories. The urethral discharge disappeared after the first day of rest in bed, on a diet of milk and water. The tenesmus and frequency of micturition also abated. The temperature, which was at first practically normal, after four days reached 103º F., as shown in the accompanying chart.

There was marked prostration, headache, and some nausea. These constitutional symptoms so overshadowed the local process

May 29 20 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14. 15 16 17 18 19 20 21 22 23 24 25

105

104

105

102

101

100

Đ8

On June 9, fourteen days after onset, the temperature reached normal and remained so for two days, after which the patient began to complain of pain in the right abdominal region, extend- ing into the inguinal ring on the following day. Twenty-four hours later a marked epididymitis had developed. The tempera- ture reached 104° F., and the fever continued until June 26. The case terminated in a complete recovery with no recurrence.

that a blood culture was made on May 31, and a Widal test on June 3. In both, the results were negative. A physical exami- nation revealed nothing. The prostate was not enlarged or tender. The urine was acid and cloudy, the last portions being especially turbid. At times a decidedly bloody tinge was noted. On microscopic examination, the sediment consisted entirely of leucocytes and red cells.

A bacteriological examination of the urine was made on the ninth and fourteenth day of the disease, and each time the B. lactis acrogenes was found in pure culture. The urine was ob- tained aseptically by means of a silk olive-tipped catheter, after previously irrigating the anterior urethra with a sterile boric acid solution.

CULTURAL CHARACTERISTICS OF ORGANISMS ISOLATED.

In the hanging drop, Brownian motions were observed, but never independent movements such as to change the relative positions of the organisms. Cultures of different ages were tried, always with the same results.

Some difficulty was experienced in determining whether we

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were dealing with a coccus or a bacillus. Even in stained specimens there was doubt as to whether the culture was pure, until plates were made.

The organism was a small bacillus, with rounded ends ; coccus forms were frequent. It did not stain by Gram's method. Capsules were readily demonstrated.

On agar plates, the colonies reached the size of one milli- meter in diameter in 18 hours, and had a bluish opalescent appearance by transmitted light. Under the microscope, the colonies usually had a regular outline, while in some the borders showed slight undulations. They were translucent, with opaque and granular centers. The deep colonies were wedge-shaped and opaque.

The agar slants showed a bluish opalescent growth by transmitted light, one millimeter wide after 24 hours, and with raised edges.

On potato there was a heavy, yellowish white, viscous growth, several millimeters thick, rapidly covering the entire surface. The older cultures showed a deeper yellow color. No gas bubbles were observed.

Milk was coagulated in 24 hours with acid production.

Glucose agar stick cultures were much split up by the ac- cumulated gas. In the fermentation tubes, saccharose solu- tions showed considerable gas production.

The morphology, capsule formation, absence of motility, rapid coagulation of milk, together with the gas production, leave no doubt as to the identity of the organism. The rapid coagulation of milk excludes the Friedlander bacillus.18

MODE OF ENTRANCE OF THE BACTERIA INTO THE BLADDER.

The bacteria may invade the urinary tract through the urethra, through the kidney, or from an adjacent abscess or other inflammatory process.

It is usually assumed that when there is no history of catheterization the infection must be an endogenous or de- scending one. There are two considerations which controvert this view :

1. The greater frequency of cystitis in women than in men, when there is no explanation of the mode of entrance of the bacteria into the bladder other than difference in sex. 2. The frequent existence of bacteriuria without infection of the ureters when no instruments have been introduced.

1. Relative frequency of cystitis in men and women in which there is no explanation of the mode of entrance of bacteria into the bladder other than difference in sex.

In general practice I have been impressed with the fre- quency with which one meets with cystitis in women, and the rarity of cystitis in men, if one excludes the cases due to gonorrhea, tuberculosis, and diseases in which the bacteria are obtained by blood culture, such as typhoid, pneumonia, septicemia, etc., and in those patients on whom instruments have been passed.

The gynecologist sees only women and the male genito- urinary specialist sees only men, so that neither has an op- portunity to make a comparison. Nevertheless, the gynecolo- gist must be impressed with the great number of cases of

non-gonorrhoeal cystitis in women who have never be catheterized; and the male genito-urinary specialist mus : struck with the fact of the rarity of a non-gonorrhoeal ent. in the male who has never been catheterized, and who is fes from any urethral or prostatic disease. A review of the !! tories of the large series of cases reported bears out this (r. tention.

Of Rovsing's " 87 cases of bacteriuria and cystitis, 66 ver male, and 21 female. Of the 66 male patients, definite na. tion of catheterization, fistula, or neighboring abscess TE made in 51, or 88 per cent. Of the 15 remaining cases, c. had phymosis ; three had incontinence (one of which wach to tabes) ; five had retention due to stricture; and one E! enlarged prostate. These therefore had a continuous cokz of urine through which the bacteria could readily hare puis: entrance. One case had pneumonia and another septiczz in both of which the organisms could probably have been tained from the blood. This leaves only two cases, or 3 }: cent, without sufficient explanation as to the mode of in' - tion. Of these, one case was a boy 19 years of age with te: teriuria, who had renal infection, while the other was a zur of 78 years with bacteriuria who had cancer of the kidner.

Of the 21 women, only 7, or 33 per cent, had been cattet: ized. In the remaining 14, or 66 per cent, the bacteria pr- ably gained entrance through the short urethral tract. the latter, 3 were girls aged 6, 7, and 21 years respecti- 2 cases followed painful coitus; two suffered from slight e" stipation; one had a tumor of the bladder; three were w.n. 76 years old who had never been catheterized; one : hematuria; one had a stone in the right kidney.

His cases of pyelitis without cystitis are even more c .: vincing. Of 21 cases, 16 were women and 5 men; of the men, 2 had been catheterized or treated locally; 1 h. large prostate with complete retention; in only 2 cases ou. the 5, or 40 per cent, was there no explanation as to : cause of the infection.

Of the 16 cases in women, there were 15, or 93 per ek: without any explanation as to the mode of infection.

Of Melchior's " 35 cases, 20 were men and 15 women. Of the 20 men, 16, or 80 per cent, had been catheter ... 1 had tuberculosis; 1 was an old man with a large prez; who had incontinence; another had a large prostate v. complete retention. This would leave only one case, or 5 ? cent, without explanation as to the mode of entrance of : bacteria into the bladder.

Of the 15 women, 7, or 46 per cent, had been catheter : 1 had tuberculosis; another was suffering from a ty: cystitis. This would leave 6, or 40 per cent, without erra tion as to the mode of entrance.

Escherich " reported 7 cases of cystitis in children bet: the ages of 6 months and 9 years, all due to the colon be: Since all occurred in girls, and since several had a : vulvitis, he concluded that it was most probable the ta entered through the short urethral tract.

Trumpp " reported 29 cases of cystitis in children *! Escherich's clinic, of whom 21 were girls and 8 boys.

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83 ectogenous or instrumental. Of the 35 endogenous :s, 15 were men and 20 women.

If the 15 men in whom the infection is supposed to have irred by the endogenous or descending route, one had orrhoa, stricture, and hypospadia; one had gonorrhoea 1 a very narrow stricture; one had gonorrhea and pros- tis; one had prostatitis and epididymitis; one had epididy- is, large prostate, and residual urine; one was cysto- ved, after which procedure a severe cystitis followed; one a cystotomy performed two years before for hematuria. of these should be considered as ectogenous. This would e 8 cases in which the histories are not complete enough determine the route of infection, and as Alsberg " has , not one of which is convincing in regard to the endogen- route.

f the 20 women, only 2 were catheterized, leaving 18, or per cent, without explanation as to mode of entrance.

f his 83 cases classed under the heading of instrumental ctions, only 5 were women.

hus in his total of 118 cases 93 were men, in 87 of whom origin of their cystitis was ectogenous, leaving only 6, 5.4 per cent, without explanation as to the mode of in- ion.

Brown's " series of 24 cases of chronic cystitis in women, had never been catheterized, leaving 41.6 per cent without anation as to route of infection.

o show how frequently women are infected, Albeck " re- s the following cases : Of 150 non-pregnant women, 13 cent had an infection of the urinary tract; in 392 preg- t women, 17 per cent had an infection; in 392 puerperal ten, 14 per cent had an infection.

1 Alsberg's series of 126 pregnant women, 12 per cent had nfection of the urinary tract; in 203 puerperal women, er cent had an infection; in 41 cases of abortion, 17 per had an infection.

› summarize: In 192 men with cystitis or pyelitis, only or 10 per cent, were without explanation as to the mode ifection; while in 129 women, 81, or 62 per cent, were out explanation as to the route of infection.

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 156

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189