Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 157

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

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there is a difference in the two sexes, it must be a local not a constitutional one, and we find a ready explanation le short and often relaxed urethral tract of the female.

BACTERIA IN THE NORMAL FEMALE URETHRA.

e bacteria usually causing cystitis are inhabitants of the le urethra, the percentage varying according to the char- of the cases examined and the methods employed. The bacillus has been found by all observers in from 12 per to 66 per cent of the cases. Recently Alsberg has found bacterium in 100 per cent of the cases. He selected six of pregnancy and examined the urethra each day for e days. By taking several loops of the secretion, and ig on Drigalski-Conradi media, he found the colon us in each case; if only one loop was taken, the results pot constantly positive on the successive days. He con-

lemale urethra.

The differences in results obtained by different observers are due to the methods used; some wiped the lower portions of the urethra with bichloride and did not wash away the excess, others simply wiped the meatus with sterile cotton. The findings were also proportional to the amount of ma- terial used. Some used the loop, others used the straight wire. In many the differences were due to the media and the exactitude of the bacteriological methods employed.

The staphylococcus albus and aureus were found by differ- ent observers in percentages varying from 14 per cent to 90 per cent.

The bacteria of the urethra enter the bladder in two ways: They are introduced with the catheter, or they may enter directly from the urethra.

Any one reviewing the histories of the cases thus far re- ported and the percentages of cystitis following catheteriza- tion, will be impressed with the fact that catheterization is a very serious procedure, especially when local conditions are present such as trauma following gynecological operations and labor, pressure due to tumors or pregnancy, prolapse, reten- tion, or paralysis.

The invasion of the bladder by microorganisms in the urethra is probably much more frequent than is usually sup- posed. The recent work of Albeck and that of Alsberg, who found infections of the urinary tract in 12 per cent out of a total series of 500 cases, seem to confirm this view. If a careful bacteriological examination were made in every case with mild bladder symptoms, we should find an ever increas- ing number due to the invasion of bacteria. This direct in- vasion from the urethra is favored by retention and inconti- nence, which produce a continuous column of fluid.

Nor is the male urethra a bar to the exogenous invasion of bacteria. The gonococcus does not seem to have any diffi- culty in invading the urethra and bladder. If the cases of non-gonorrheal urethritis were examined carefully and the etiology determined, we should probably find the cause to be the bacteria which usually cause cystitis. The staphylococcus, streptococcus, and a diplococcus were found by Eitner." The staphylococcus, colon bacillus, and an unrecognized diplococ- cus were found by Hume " in 11 cases examined. Other or- ganisms found were the pseudodiphtheria bacillus, influenza bacillus, and the Friedlander bacillus.

2. The frequent existence of bacteriuria without infection of the ureters in cases which have never been catheterized.

Those who adhere to the endogenous route of infection refer to the fact that pyelitis, which is usually due to the colon bacillus; often occurs without any demonstrable lesion in the bladder.

Albeck has shown that in 150 non-pregnant women 13.3 per cent had bacteriuria, in 70 per cent of whom the bacteriuria was due to the colon bacillus. To determine whether the ureters were also infected he selected 13 cases and catheter- ized both ureters; in 8 cases the urine was clear and sterile from both ureters; in 3 no organisms were found on cover- slips, and only a few colonies were found on the plates, which

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he concluded were accidental; in 2 only were the bacteria in great numbers. He justly concludes that in a great majority of the cases the infection originates in the bladder.

We know that the bladder is very resistant to infection, and that the mere introduction of the colon bacillus will not produce a cystitis. If, however, the urethra or ureter is tied, a cystitis or pyelitis develops. All that is necessary to con- vert a bacteriuria into a pyuria is a retention. Such a reten- tion is often produced during the second half of pregnancy, due to pressure on the ureters. Stone, trauma, or any of the accessory causes named above will produce the same result. If the retention or trauma affects the kidney, and not the bladder, a pyelitis develops without a cystitis.

The pathological and bacteriological studies of Schmidt and Aschoff (loc. cit.) of 16 cases of pyelo-nephritis confirm this view. They found that a microscopic examination usually gave the clue as to the route of infection. Where this failed, the microscopic examination supplied the information. The process always followed the tubules, and was ascending.

The preceding review thus shows that an ascending infec- tion is of very common occurrence in women, and is also possible in men, when no instruments have been introduced into the bladder.

In the two cases reported in this paper the infection was an ascending one. In Case I the infection was limited to the bladder, since there was no pain in the region of the kidney and since there was no fever. The congestion and pressure caused by the pregnancy supplied the accessory factors en- abling the organisms to invade the bladder.

In Case II (the husband) the infection certainly was an ascending one, since the infection started with a urethritis and since there was no fever until the infection reached the bladder. His symptoms started four days after the acute symptoms in his wife had developed, and were more severe, due possibly to the increased virulence of the organism which had passed through an intermediary host. The epididymitis must have been caused by the same organism, and extended by continuity along the seminal ducts as shown by the sequence of the location of the pain, and the gradual rise of the temperature. This case is particularly interesting in that it shows definitely an ascending infection of the bladder in the male by an organism other than the gonococcus. The general impression seems to be that unless instruments have been introduced, the infection of the bladder in the male must be by the blood route.

As a summary of this review, the following conclusions may be drawn :

1. The B. lactis aerogenes is a rare cause of cystitis.

2. The great majority of infections are due indirectly to the introduction of instruments.

3. Infections of the bladder, in cases where no instruments have been introduced, are very frequent in women and rare in men.

4. In infections of the bladder in women, without a his- tory of the introduction of instruments, the route of infection is usually an ascending one and due to the direct invasion of 'acteria from the urethra.

5. Such direct invasion of the bladder also occurs iz: male, and probably much more frequently than is tri supposed.

6. The introduction of a catheter or instrumente int : bladder is a very serious procedure, since it may proJte pyuria if the local conditions are favorable, or a bacter :! which later may be converted into a pyuria when the . conditions become favorable.

BIBLIOGRAPHY.

1. Morelle, Aime: Étude bactériologique sur les cystite Cellule, 1891, VII, 241.

2. Denys: Étude sur les infections urinaires. Bull. Acal r" de méd. de Belg., 1892, 4 s., VI, 112.

3. Achard et Renault: Sur les rapports du bacterium commune avec le bacterium pyogène des infections urix Compt. rend. Soc. de biol., 1891, 9. s., iii, 830.

4. Reblaud, Th .: Ibid., 1891, 111.

5. Krogius: Note sur le rôle du bacterium coli commune (L. l'infection urinaire. Arch. de med. exper. et d' anat ;.: Paris, 1892, IV, 66.

6. Flügge, C .: Microorganismen, 1896, 11, 341.

7. Clado: Etude sur une bactérie septique de la vessie. T.M Paris, 1887.

8. Albarran et Halle: Note sur une bactérie pyogéne €. : son rôle dans l'infection urinaire. Bull. Acad. de méd., 19):, :

9. Doyen, cited by Cornil and Babes: Les Bactéries, 189), -

10. Rovsing: Die Blasenentzundüngen, Berlin, 1890.

11. Schmidt and Aschoff: Die Pyelonephritis, Jena, 1883.

12. Charrin: Sur la bactérie commune des infections urina Compt. rend. Soc. de biol., 1891, 9. s., iii, 851.

13. Warburg, F .: Uber Bacteriurie. München. med. Wchns." 1899, XLVI, 955.

14. Heyse: Ueber Pneumaturie, hervorgerufen durch Be .. rium lactis aerogenes, und ueber pathologische Gasbildung - thierischen Organismus. Ztschr. f. klin. Med., 1894, XXIV, 13

15. Burri and Düggeli: Beiträge zur Systematik der aerogenes Gruppe nebst Beschreibung einer neuen Methode : Untersuchung der Gärungsgase. Centralbl. f. Bakteriol. u. P .: sitenk., 1909, Erste Abt., Originale, XLIX, 145.

16. Wildbolz: Beitrag zur Kenntniss der Pneumaturia. C:". f. schweiz. Aerzte, 1901, XXI, 683.

17. Schnitzler: Ein Beitrag zur Kenntniss der Pneuma" Internat. klin. Rundschau, 1894, VIII, 265, 306.

18. Wilde, M .: Ueber den bacillus pneumonie Friedla :. und verwandte Bacterien. Centralbl. f. Bakteriol. u. Parast. 1896, Erste Abt., XX, 681.

19. Rovsing, T .: Klinische und experimentelle Untersucher: über die infektiösen Krankheiten der Harnorgane, Berlin, 1. 20. Melchior, Max: Cystite et infection urinaire, Paris, 19:

21. Escherich: Das Bacterium coli als Cystitiserreger. tralbl .. f. Bacteriol. u. Parasitenk., 1894, XV, 901.

22. Trumpp: Uber Colicystitis im Kindesalter. Milnchen. Wchnschr., 1896, XLIII, 1008.

23. Suter, F .: Zur Atiologie der infectiösen Erkrankungez Harnorgane. Ztschr. f. Urol., 1907, I, 97, 207, 327. - 24. Alsberg, P .: Die Infection der weiblichen Harnwege. f. Gynäk., 1910, XC, 255.

25. Brown, T. R .: Cystitis, pyelitis, and pyeloneph women. Johns Hopkins Hosp. Rep., 1902, X, 11.

26. Albeck, V .: Bakteriurie und Pyurie bei Schwangerte: Gebärenden. Ztschr. f. Geburtsh. u. Gynäk., 1907, LX, 466. 27. Eitner, E .: Zur Kenntniss der nicht-gonorrhoeische: thritis. Wien. med. Wchnschr., 1909, LIX, 2411, 2474.

28. Hume, J .: An inquiry into the causation of non-s ;- urethritis. J. Am. M. Ass., 1910, LIV, 1675.

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THE OVARY .*

By ERNEST K. CULLEN, M. B., Resident Gynecologist, The Johns Hopkins Hospital.

je association of malignant epithelial and connective e tumors in the same organ is well known. Carcinoma sarcoma have frequently been found associated in the is. . Each process has, however, been well defined and oly differentiated from the other. The combination of : two processes in a single tumor is seldom observed. h interest has been manifested in this combination since work of Ehrlich ' and Apolant on the transplantation of nomatous tumors in rats. From a purely carcinomatous r, they were, by repeated transplantation, able to procure xed tumor of carcinoma and sarcoma, and finally a tumor ing pure sarcoma. Their findings have been corrobor- in Bashford's' laboratory. To use Bashford's words : ring transplantation of a rather slow growing adeno- noma with a somewhat fibrous stroma, a sarcomatous stitial tissue has appeared in several separate strains. has outgrown the carcinomatous elements in subsequent rations and given rise to a pure spindle-cell sarcoma." ted cases showing these combined processes have been rted. In 1904 Nebesky ' reported a case of adenocarci- 1 of the body of the uterus, showing a stroma of mixed- sarcoma. Taylor,' in 1909, reported a case of adeno- noma of the thyroid gland with a stroma of mixed-cell ma, the latter process being the more vigorous.

careful search of the literature for such a tumor occur- in the ovary has been unsuccessful. It was therefore led of sufficient pathological importance and interest to 't in detail the following case :

38 S., white, aged 50. Admitted to the Church Home and nary in the service of Dr. T. S. Cullen, November 11, 1909. everal months she has had a great deal of pelvic pain and he past two months has had considerable dysuria, neces- ng frequent catheterization.

pelvic examination, the cervix was found to be forward, terus back, and there was considerable edema of the vaginal

together with some slight induration. The pelvis and abdomen were filled by a rather tender hard tumor mass. : was strong suspicion of malignancy, so an immediate ex- :ory operation was indicated.

ration, November 13, 1909. When the patient was ex- 'd under ether it was deemed advisable to do a pelvic ure. A considerable quantity of free fluid and a great deal od were obtained, but there was no diminution in size of imor mass. The abdomen was at once opened and the mass felt on ether examination found to be a malignant

report of the original tumor was made before the Johns ns Hospital Medical Society April 18, 1910.

rlich, P., and Apolant, H .: Berl. klin. Wchnschr., 1905, 871.

shford and Haaland: Imperial Cancer Research Fund. 1 scientific report.) London, 1908, 248.

besky: Arch. f. Gynäk., 1904, LXXIII, 653.

Flor: J. Path. and Bacteriol., 1908, XII, 440.

growth of the left ovary. The bladder was drawn high up over the tumor and adherent to the posterior surface; thus account- ing for the dysuria and the necessity for catheterization. The tumor, together with the uterus and appendages from the oppo- site side, was removed as rapidly as possible. During removal it was found that the right ureter was densely adherent to the tumor and there was involvement of the peritoneum in the right side of the pelvis. The right ureter was dissected free by. splitting the anterior part of the broad ligament, which enabled the operator to expose the ureter with considerable ease. Fully one-third of the pelvic peritoneum was removed with the tumor, and as far as could be seen macroscopically, no malignant tissue was left. An iodoform drain was placed down through the pelvis.

The patient made an uneventful convalescence.

GYN. PATH. No. 14414. Pathological Report .- The specimen consists of a uterus which has been removed supravaginally, to- gether with a mutilated mass of tissue representing the append- ages from the right side and a solid tumor of the ovary from the left side. Attached to the tumor is the left tube.

The uterus, apart from adhesions laterally, shows nothing abnormal. The right tube and ovary are bound in adhesions and the ovary is cystic. Fig. 1.)

The ovarian tumor in its present flattened condition measures 15 x 14 x 7 cm. It is generally smooth on the surface but in a few places old tags of adhesions are present. It has been at- tached by a pedicle about 3 cm. in diameter. Coursing over the tumor and attached to it by thin mesosalpinx is a tube, which has been converted into a hydrosalpinx. The surface of the ovarian tumor is somewhat irregular and nodular. It is greyish- yellow in color and numerous congested vessels are visible upon the surface. These vessels are most prominent in the valleys between the slightly nodular elevations. On section the tumor is found to contain a central shallow cavity measuring 5 x 9 cm., and at one point near the periphery it reaches a depth of 2 cm. (Fig. 2.) The floor of this cavity is smooth and is lined by a thin yellowish-white fibrillated membrane. It resembles very much a markedly enlarged kidney pelvis. Surrounding the cavity and occupying the space between it and the cortex are irregular lobulated areas which are greyish-yellow in color and in places present a finely granular honey-combed appearance. (Fig. 2, a.) In some places distinct hemorrhagic areas are visible and in others there is simply a brownish coloration of the tissue. At other points about the periphery are irregular firm whitish areas varying from 8 mm. to 2 cm. in diameter. (Fig. 2, c, g, e.) In some places these areas show evidence of breaking down with slight cystic formation. The picture pre- sented is a distinctly malignant one. In some places the tissue appears carcinomatous, in others it resembles sarcoma.

GYN. PATH. No. 14414. Microscopic Examination .- Sections were taken from eight different portions of the tumor, represent- ing every gross type of pathological process present. The tumor is found to consist of a well-defined adenocarcinomatous process and an equally well-defined sarcomatous one. In certain parts of the tumor these two processes are side by side. In others there is pure sarcoma with absence of any carcinoma. In still other parts are found areas where there is well-defined carcinoma and a rather cellular and suspicious looking stroma; the stroma, however, not showing the typical picture of sarcoma seen else- where. In those sections showing the combined processes, the

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carcinomatous one is marked by large islands of glands (Fig. 3), the glands in most instances being irregular in size and shape and presenting a distinctly atypical appearance (Fig. 4). The individual cells vary in size, shape, and staining qualities, and many nuclear figures are visible. Immediately adjacent to these islands of glands, the stroma shows a distinctly malignant ap- pearance. The predominating cells are spindle-shaped and round, but there are many large irregular, deeply staining cells scattered throughout (Figs. 3 and 4, d). Some parts of the tumor show a greater number of these large cells than do others. The individual stroma cells vary in size and shape. The nuclei are as a rule large, stain rather deeply, and assume an oval or round contour. The protoplasm of the cells takes a fairly uniform stain. The large (atypical giant) cells assume different sizes and shapes. (Figs. 3 and 4, d.) The nuclei are irregular in outline, multiple, very deeply stained, and are surrounded by a considerable quantity of protoplasm. A number of nuclear figures are visible. The carcinomatous and sarcomatous proc- esses are entirely distinct and independent and this point is especially well emphasized by the fact that the glands of the carcinoma have retracted from the stroma and there is a dis- tinct area of separation between the two. The cells which line the narrow spaces that separate the carcinomatous from the sarcomatous processes are in the main uniform in appearance and seem to form a distinct membrane. In some portions of the tumor there is marked degeneration. Here the tissue has under- gone extensive hyaline change and merely shadows of cells are present. Sections taken through the periphery show a well- defined capsule, which has undergone partial hyaline degenera- tion, and considerable infiltration with round cells. At no point was there evidence of penetration by either malignant process. The vascularity of the tumor, while not especially prominent, is in greater evidence where the sarcomatous process is most active.

The right ovary on microscopic examination shows no evi- dence of malignancy. Both tubes show some chronic inflamma- tion, but there is no involvement by the malignant process. Sec- tions from the body of the uterus show an early diffuse adeno- myoma. The cervix is quite normal.

From the tumor it is impossible to determine whether one process preceded the other or whether the development was simultaneous. It is significant, however, that in those areas where the carcinomatous elements show the greatest disin- tegration the sarcomatous process presents a wilder and a more rapidly growing appearance. Degeneration seems to play some rôle in the early development of sarcoma in certain instances. This point has been emphasized by Kelly and Cullen & in their examination of myomata which have under- gone sarcomatous transformation. In many instances the sar- comatous tissue was adjacent to hyaline degeneration on the one side, and fairly typical looking myomatous tissue on the other. Bashford (loc. cit.) states: " In all the latter stages of sarcoma development we find the first changes beginning in the center of the carcinomatous tumor where sclerotic changes are present."

RECURRENCE OF TUMOR IN PELVIS.

Within a few weeks after leaving the hospital, there were signs of a recurrence of the tumor in the pelvis and the patient died on October 27, 1910, eleven months after the operation.

Autopsy Report .- (The body had been embalmed with a weak formalin solution about ten hours before the post mortem ex-

Cullen. Myomata of the Uterus. W. B. Saunders Co.,

amination.) The body is markedly emaciated and the i. shows a diffuse yellowish tinge. There is some abdominal . tension, due partially to fluid, but no edema of the ertrer: is present. On opening the abdominal cavity, there is foc be some distension of the bowel and about one liter ds. fluid, with a distinctly formalin odor. The viscera hares- partially hardened. Occupying the pelvis is a large semker. mass which is intimately adherent to the sigmold, mor= bladder and pelvic wall. Scattered everywhere over the !z_ of the large and small bowel are numerous firm whitish tice varying in diameter from 1 mm. to large confluent patches a proximately 7 cm. in diameter. Sections through the'aler: portion of the bowel show the process to be limited to the c: coat. The omentum is markedly thickened and is studded v. numerous large and small firm white nodules, similar to :- on the bowel surface. The liver, spleen and kidneys are sig: enlarged, but show no evidence of metastases. Both lung : edematous and a few scattered areas of broncho-pneumccas present. Careful examination showed no evidence of menrx- outside of the peritoneal cavity, no enlarged retroperitet. glands were found.

Anatomical Diagnosis .- Pelvic tumor, general peritona. - astases, broncho-pneumonia.

GYN. PATH. No. 15613. Pathological Report .- The tumor : measures approximately 15 x 12 x 12 cm. It is cystic in = acter and is covered by many old adhesions. On sectic: :: found numerous cystic spaces, the largest of which is apr". mately 8 cm. in diameter. These contain some light sn colored fluid and are lined by a shaggy tissue which Is me. peeled off. The walls, which vary in thickness from 0. 5 to : : consist of a moderately soft homogeneous tissue, pinkist -: in color, closely simulating sarcoma.

Histological Examination .- As in the original tumor the ; processes are combined, but the sarcomatous elements pret .: nate. Scattered throughout a bed of sarcomatous tisser E groups of glands presenting the typical picture of adent." noma (Fig. 5). The sarcoma belongs to the mixed-cell type. ": spindle cells predominating. Numerous large, so-called ( cells, are present. These are well seen in Fig. 6. In some : tions the picture was one of pure sarcoma, no glands : visible (Fig. 6). The metastases on the bowel wall and in : omentum show a picture of adenocarcinoma (Fig. 1). .. stroma shows no evidence whatever of sarcoma.

Study of the original tumor shows a combination ! two malignant processes, the carcinomatous element: dominating. In the recurrent tumor, however, the pr .. " is mainly sarcomatous in character.

It is interesting to note that metastases were purely cinomatous. They were limited to the peritoneal surfa: the bowel and the omentum, simulating in great measure : picture observed in malignant papillocystomata of the with general peritoneal implantations.

I am indebted to my brother, Dr. Thomas S. Cullen. the privilege of reporting this case and to Dr. J. S. Blok .: and Mr. Schapiro for the protomicrographs.

The patient was referred to Dr. Cullen by Dr. Clara E: of Hagerstown, Md.

DESCRIPTION OF FIGURES.

FIG. 1. - Gyn. Path. No. 14414 (natural size). This pictor- resents the appearance of the ovarian tumor which bas ? hardened in 10 per cent formalin.

FIG. 2 .- Gyn. Path. No. 14414 (natural size). On ser ... the tumor various stages of cystic and hyaline degenerate !: visible. b represents a large central cavity lined by a su;

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3 .- Gyn. Path. No. 14414 (80 diameters). The two proc- are well represented here. At a are seen the large gland a partially filled with coagulated fluid. The glands present pical picture of adenocarcinoma. The stroma c shows a dly active and malignant picture. The majority of the are spindle shaped, but numerous large irregular cells, d, und scattered throughout. The stroma is rich in blood 3 e.

4 .- Gyn. Path. No. 14414 (380 diameters). This illustra- hows a magnification of the picture seen at Fig. 3, b. Note rge atypical cells lining the glands a. At b the glands are less well defined. The stroma c consists of cells irregular

and sarcomatous processes, showing a tendency on the part of the carcinoma to retract from the sarcoma.

FIG. 5 .- Gyn. Path. No. 15613. The section here pictured is taken from the recurrent tumor. The combined malignant proc- esses are well marked. The sarcoma predominates and appears much more active than the process in the original tumor (Fig. 3).

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 157

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

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