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FŒTAL BONES IN URINARY BLADDER UNUSUAL TERMINATION TO ECTOPIC PREGNANCY
716
Preliminary Communication
FŒTAL BONES IN URINARY BLADDER UNUSUAL TERMINATION TO ECTOPIC PREGNANCY
HUGH W. FORSHAW M.B. LATE MEDICAL
Lpool
OFFICER, H.M.
COLONIAL MEDICAL
SERVICE
IT is from a
extremely difficult to obtain an accurate history patient from the African bush. Details of past history are bound to be lacking in so far as symptoms of no importance will be remembered while others having a bearing on the case will be forgotten. Furthermore facilities for diagnosis are naturally limited, cystoscopy and radiography being unknown luxuries at an African bush hospital. A woman, aged 38, came to my outpatient clinic at the African hospital, Ijebu-ode, Nigeria, complaining that she had passed some small bones in her urine on three occasions in the last four months. She had brought two of these bones with her to show me, and on inspection they looked very like small vertebrae. These bones were sent down to Lagos for further investigation and the report came back that they were not thought to be human bones, nor was it considered likely that they had been passed in the urine, it being suggested that they had been passed per vaginam, having been placed there on some previous occasion, since it was the custom in certain tribes to insert all sorts of bones up the vagina after the delivery of a child. Pending the report I had asked her to come back to the hospital in two weeks ; but, as happens only too often out here, she did not return to my outpatients’ clinic till three months later. During this time she had passed more bones, but these she had not kept to show me. A complete history and examination now made revealed further details. On several occasions between November, 1942, and April, 1943, she had passed in her urine small bones. There was no history of any haematuria, and dysuria occurred only when the bones were passed. She had been married for fifteen years and had had dyspareunia during the last two years. She had intermittent amenorrhoea during 1942. She had not been delivered of any children. Nine years ago, she stated, she became pregnant, and at full term she was seized with severe abdominal pain accompanied by a show of blood per vaginam. These pains lasted only about half a day, and the bleeding stopped in one day. The swelling of the abdomen gradually subsided in three months. Nothing abnormal was found on abdominal examination. Examination per vaginam revealed a tender irregular hard swelling in the anterior wall of the vagina. This swelling was readily palpable bimanually, but its exact site could not be determined. A metal catheter was then inserted into the bladder, and, when this was moved round, a hard mass could be felt. The cervix was high up in the vaginal vault, and the body of the uterus was not palpable.
In view of the above history and the clinical findings tentative diagnosis of an old ruptured ectopic pregnancy which had ulcerated through into the bladder was made. Under spinalNupercaine’ 15 c.cm. a The contents of the incision was made. suprapubic pelvis were then examined, and dense adhesions between the uterus and the proximal portion of the left broad ligament and the bladder were found. The hard mass’ which had been palpable per vaginam appeared to be entirely in the bladder. The peritoneal cavity was closed, and an opening was then made into the bladder. From the bladder were removed numerous bones of various sizes, many of which could be identified, including the right half of a mandible, small ribs, and portions of the skull. After removal of all the bones the bladder and found to be apparently normal was examined a for at its posterior left angle. A depression except suprapubic catheter was inserted for a few days after the operation, and the patient made an uneventful recovery. a
EFFECT OF p-AMINO-METHYL-BENZENESULPHONAMIDE1 ON BIOSYNTHESIS OF NICOTINAMIDE Coulson2 observed that the output of nicotinamide3 as its methyl derivative in human urine was greater than its dietary intake, and concluded that there was an extradietary source of nicotinamide, " probably the intestinal flora. Using the " sterilising drugs sulphaguanidine and succinyl sulphathiazole, Ellinger, Coulson, and Benesch,4 and Ellinger, Benesch, and Kay succeeded in reducing the output of urinary nicotinamide methochloride in several persons on the average to 30% of their previous output. The bacteriological examination of the faecal flora, however, was incomplete and inconclusive. They deduced that the reduction of the output of nicotinamide methochloride was due to the bacteriostatic effect of the sulpha drugs on the intestinal bacteria normally supplying a considerable proportion of the nicotinamide required by man. The fact that nicotinamide is produced by the flora of the human intestine was confirmed by Najjar et al.1 using a different method. It had been shown by Burkholder and McVeigh 7 and Thompson 8 that certain bacteria normally inhabiting the intestinal tract can produce and release nicotinamide when grown in vitro in an entirely synthetic medium. Since Knight’s investigations 9 on the nutritional requirements of bacteria it has been known that bacteria consumed nicotinamide, and Koser and Baird 10 and Benesch 11 have shown that bacteria can destroy nicotinamide. Benesch 11 showed that a suspension of bacteria from a human caecum produced nicotinamide under aerobic and destroyed it under anaerobic conditions. He suggested that the nicotinamide available for absorption from the gut was determined by the bacterial production and destruction of the compound and therefore depended on the relative numbers of bacteria producing and consuming or destroying nicotinamide. An extensive investigation is being carried out on the constitution of the fecal flora in man under various conditions, and an attempt is made to correlate it qualitatively and quantitatively with the extent of the urinary elimination of nicotinamide methochloride. We decided to examine the effect of’Ambamide’
Ellinger
and
(p-amino-methyl-benzene-sulphonamide, H2NCH2.C6H4. S02NH2) on the intestinal flora and on the urinary output of nicotinamide methochloride. According to Domagk 12 this drug is mainly active against anaerobes. If Benesch’s
assumption
that the bacterial nicotinamide
uptake was the result of the production by aerobes and the consumption by anaerobes is correct, a drug with a bacteriostatic action predominantly against anaerobes should increase the output of nicotinamide methochloride. EXPERIMENTAL RESULTS IN MAN
Experiments with ambamide were carried out on two physically fit patients of West Park Hospital, Epsom, who volunteered for the experiment and were
female
1. This compound, previously known as ’ Marfanil,’ is now called ’ Arobamide’ in this country. 2. Ellinger, P., Coulson, R. A. Biochem. J. 1944, 38, 265. 3. The word "nicotinamide" is used here indiscriminately for both nicotinamide and nicotinic acid. 4. Ellinger, P., Coulson, R. A., Benesch, R. Nature, Lond. 1944, 154, 270. 5. Ellinger, P., Benesch, R., Kay, W. W. Lancet, 1944, i, 432. 6. Najjar, V. A., Holt, L. E. jun., Johns, J. A., Medairy, G. C., Fleischmann, G. Proc. Soc. exp. Biol., N.Y. 1946, 61, 371. 7. Burkholder, P. R., Meveigh, I. Proc. nat. Acad. Sci., Wash. 1942, 28, 285. Univ. Texas Publ. 1942, 4237, p. 87. 8. Thompson, C. 9. Knight, B. C. J. G. Nature, Lond. 1937, 139, 628. 10. Koser, S. A., Baird, G. R. J. infect. Dis. 1944, 75, 250. 11. Benesch, R. Lancet, 1945, i, 718. 12. Domagk, G. Klin. Wschr. 1942, 21, 448.
Preliminary Communication
FŒTAL BONES IN URINARY BLADDER UNUSUAL TERMINATION TO ECTOPIC PREGNANCY
HUGH W. FORSHAW M.B. LATE MEDICAL
Lpool
OFFICER, H.M.
COLONIAL MEDICAL
SERVICE
IT is from a
extremely difficult to obtain an accurate history patient from the African bush. Details of past history are bound to be lacking in so far as symptoms of no importance will be remembered while others having a bearing on the case will be forgotten. Furthermore facilities for diagnosis are naturally limited, cystoscopy and radiography being unknown luxuries at an African bush hospital. A woman, aged 38, came to my outpatient clinic at the African hospital, Ijebu-ode, Nigeria, complaining that she had passed some small bones in her urine on three occasions in the last four months. She had brought two of these bones with her to show me, and on inspection they looked very like small vertebrae. These bones were sent down to Lagos for further investigation and the report came back that they were not thought to be human bones, nor was it considered likely that they had been passed in the urine, it being suggested that they had been passed per vaginam, having been placed there on some previous occasion, since it was the custom in certain tribes to insert all sorts of bones up the vagina after the delivery of a child. Pending the report I had asked her to come back to the hospital in two weeks ; but, as happens only too often out here, she did not return to my outpatients’ clinic till three months later. During this time she had passed more bones, but these she had not kept to show me. A complete history and examination now made revealed further details. On several occasions between November, 1942, and April, 1943, she had passed in her urine small bones. There was no history of any haematuria, and dysuria occurred only when the bones were passed. She had been married for fifteen years and had had dyspareunia during the last two years. She had intermittent amenorrhoea during 1942. She had not been delivered of any children. Nine years ago, she stated, she became pregnant, and at full term she was seized with severe abdominal pain accompanied by a show of blood per vaginam. These pains lasted only about half a day, and the bleeding stopped in one day. The swelling of the abdomen gradually subsided in three months. Nothing abnormal was found on abdominal examination. Examination per vaginam revealed a tender irregular hard swelling in the anterior wall of the vagina. This swelling was readily palpable bimanually, but its exact site could not be determined. A metal catheter was then inserted into the bladder, and, when this was moved round, a hard mass could be felt. The cervix was high up in the vaginal vault, and the body of the uterus was not palpable.
In view of the above history and the clinical findings tentative diagnosis of an old ruptured ectopic pregnancy which had ulcerated through into the bladder was made. Under spinalNupercaine’ 15 c.cm. a The contents of the incision was made. suprapubic pelvis were then examined, and dense adhesions between the uterus and the proximal portion of the left broad ligament and the bladder were found. The hard mass’ which had been palpable per vaginam appeared to be entirely in the bladder. The peritoneal cavity was closed, and an opening was then made into the bladder. From the bladder were removed numerous bones of various sizes, many of which could be identified, including the right half of a mandible, small ribs, and portions of the skull. After removal of all the bones the bladder and found to be apparently normal was examined a for at its posterior left angle. A depression except suprapubic catheter was inserted for a few days after the operation, and the patient made an uneventful recovery. a
EFFECT OF p-AMINO-METHYL-BENZENESULPHONAMIDE1 ON BIOSYNTHESIS OF NICOTINAMIDE Coulson2 observed that the output of nicotinamide3 as its methyl derivative in human urine was greater than its dietary intake, and concluded that there was an extradietary source of nicotinamide, " probably the intestinal flora. Using the " sterilising drugs sulphaguanidine and succinyl sulphathiazole, Ellinger, Coulson, and Benesch,4 and Ellinger, Benesch, and Kay succeeded in reducing the output of urinary nicotinamide methochloride in several persons on the average to 30% of their previous output. The bacteriological examination of the faecal flora, however, was incomplete and inconclusive. They deduced that the reduction of the output of nicotinamide methochloride was due to the bacteriostatic effect of the sulpha drugs on the intestinal bacteria normally supplying a considerable proportion of the nicotinamide required by man. The fact that nicotinamide is produced by the flora of the human intestine was confirmed by Najjar et al.1 using a different method. It had been shown by Burkholder and McVeigh 7 and Thompson 8 that certain bacteria normally inhabiting the intestinal tract can produce and release nicotinamide when grown in vitro in an entirely synthetic medium. Since Knight’s investigations 9 on the nutritional requirements of bacteria it has been known that bacteria consumed nicotinamide, and Koser and Baird 10 and Benesch 11 have shown that bacteria can destroy nicotinamide. Benesch 11 showed that a suspension of bacteria from a human caecum produced nicotinamide under aerobic and destroyed it under anaerobic conditions. He suggested that the nicotinamide available for absorption from the gut was determined by the bacterial production and destruction of the compound and therefore depended on the relative numbers of bacteria producing and consuming or destroying nicotinamide. An extensive investigation is being carried out on the constitution of the fecal flora in man under various conditions, and an attempt is made to correlate it qualitatively and quantitatively with the extent of the urinary elimination of nicotinamide methochloride. We decided to examine the effect of’Ambamide’
Ellinger
and
(p-amino-methyl-benzene-sulphonamide, H2NCH2.C6H4. S02NH2) on the intestinal flora and on the urinary output of nicotinamide methochloride. According to Domagk 12 this drug is mainly active against anaerobes. If Benesch’s
assumption
that the bacterial nicotinamide
uptake was the result of the production by aerobes and the consumption by anaerobes is correct, a drug with a bacteriostatic action predominantly against anaerobes should increase the output of nicotinamide methochloride. EXPERIMENTAL RESULTS IN MAN
Experiments with ambamide were carried out on two physically fit patients of West Park Hospital, Epsom, who volunteered for the experiment and were
female
1. This compound, previously known as ’ Marfanil,’ is now called ’ Arobamide’ in this country. 2. Ellinger, P., Coulson, R. A. Biochem. J. 1944, 38, 265. 3. The word "nicotinamide" is used here indiscriminately for both nicotinamide and nicotinic acid. 4. Ellinger, P., Coulson, R. A., Benesch, R. Nature, Lond. 1944, 154, 270. 5. Ellinger, P., Benesch, R., Kay, W. W. Lancet, 1944, i, 432. 6. Najjar, V. A., Holt, L. E. jun., Johns, J. A., Medairy, G. C., Fleischmann, G. Proc. Soc. exp. Biol., N.Y. 1946, 61, 371. 7. Burkholder, P. R., Meveigh, I. Proc. nat. Acad. Sci., Wash. 1942, 28, 285. Univ. Texas Publ. 1942, 4237, p. 87. 8. Thompson, C. 9. Knight, B. C. J. G. Nature, Lond. 1937, 139, 628. 10. Koser, S. A., Baird, G. R. J. infect. Dis. 1944, 75, 250. 11. Benesch, R. Lancet, 1945, i, 718. 12. Domagk, G. Klin. Wschr. 1942, 21, 448.