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The bacteriology of Fallopian tubes removed at operation
THE
BACTERIOLOGY MARIE
’ I”rotn
thr
l)qmtmiit
s of
OF FALLOPIAN AT OPERATION I,.
Kocx,
MS..
Ikrct?rirdry!t
TUBES
BWLTIM~RE,
UI~I/ (:!/~~wolnyy,
REBIOVED
MD.
Johns
Hop7civs
3f~dicd
Nchoo7)
T
If IS invesliqition caoml)rist>s it stuci?- of ‘ig j,atients from the wards and I)t.iv:ttr scrvicc) oi’ Ihc M’0mc~11‘s (‘liilic, 01 iho Johns Iio[)kins IIospit~al. S;lcvcJn ~~~ll~~I*I*l7t~ill iII t’cction. 10 hat1 dOIlbtflll 11;itietlt.s had had ii I)t*(~vious history (rl Ilid(Jriw
:llltl
b?r
) Ililtl
ll?QXtiVC
tlistol~iw.
In 1921 Curtis isolated the gOIlOCOCCl1S from Fallopian tubes removed al ofperation in 38 01 192 cases, but gross and microscopically these tubes presented (‘~lrt is also isolated Escherichits coli, streptoa 7)ietnrc of acute inflammatioIl. CWY~, ant1 anaerobic strept.ococci from VHSASof salpingitis and perisalpingitis. (!11rd17a and Iieck in 1926, rcportetl isolating paratyphoid B bacillus from an ovarian abscess. In 1931 Iirorral repotted havin g isolated Staphylococci from infected Fallopian tubes. (-lanssade and (iiullemin, 1934, isolated the colon harillus from the tubes ui’ >L 13.year-ol(l girl. Brown, 1835, isolated Salmonelln 11crt~~?ul’t from a case 01 bilateral pyosalpins. Studdiford, Casper, and Scadron, in 1938, reported isolating gonococci from the t,ubes of 16 of 24 cases studied. The organisms mere isolated 1)~ cnlturing pieces of tissue and exudate, t7c’yer from pus, and occasionally wcrc degenerate in form but rapidly assumed t hc usual cha.racteristics upon subculture. Thirteen of the specimens yielding gonococci showed pat,hologic evidence of sllbaente inflammation, two were acute csacerbations of chronic salpingitis, and one showed evidence of chronic or l~caled salpingitis with marked structual changes in t,he walls of the tnbe. According to Cornell, unt.il 1.934 there wcrc ‘71 published cases of actinomycosis 01’ the internal feniale genitals. Americ+an literature reported seven cases, 147qlish literature six! and the remainder were in other languages. Since then c’ascs have been reported by (:ardiner and Welsh, 1935; CSte and Tudhope, 19:% ; I )e Fat*ia antI I<‘iallln. 193’i ; Austpr. 1940; and Ahnmada and Chevalier. 1942. Technique 1ltttrr~tliatcly ul,o1) rem0v:ll at oI)ct’ation the tul)es LV-;F’I’C 1)Iaced in strrilr diSilCS anti bro77~ht to tltc l~tl)O~ittC!t'J-. Tf pus or fluid was present in the tribes or ahsccsscs a small area was seared lvitli a scaring iron, a sterile glass capillary pilAte inserted, and the material aspirated for cultural study. C’iec’es of tissue \vf’r~’ tliot~o~igh1~ ground in sterile sand and 3.0 c.c. oi ])artcdrcatic digest broth. 1111 7.2, ‘for h7lrird foci of infection. All specimens u crc’ wllnrccl in the following I7lailticr: r\ t ubc of fircwer ‘s sodium thiogl?c*ollatc~ medium ww.s itiocrllatctl anal i7l~lll)i7tc~d al X0 (-!. for scvcnty-two hol7rs. Smcal’s w’er’t~ made c\-er!. I went,>--four !lonrs and examined n7icroscopically. ,\c~Iuhic~ ant1 arlarId)iC si yak plattls wt’re made on lz~ncreatic cligest blootl ( ral&it.) agat*, thta 1’ormPl itlcnbatcd Tots schrent\--two hours and examined c~vcl’~ t\vtIntr-four l10777~ and t11~ la1 tcr incrll)atetl tore forty-eight hours and the11 rsnm&cd. For isolation OF the gonococcus streak l)lates were made upon I-'c9t*i
[ Glll(‘I’(‘at
iC
t&St
cdtlOCW~;ltC
tlt(JOtl
( tlIIIllaI1
) iIgSals
of approximately 10 per cent carbon dioxide medium was used because it had been previously for t.hc isolat.ion of the gonococcus from cervical 1113
and
illCLlt)iItC(]
iII
;In
~bloSptlCW
for forty-eight hours. This shown to be most sat,isfactory cultares, Koch, 1946. Wrect
gcJ;rg
”
S66
BACTERIOLOGY
OF
FALLOPIAN
TUBES
1143
smears were made of all pus, exudate, and ground tissues, stained by Burke’s modification of the Gram stain and examined microsccipically. For final identification all organisms were thoroughly studied. according to their hiochemical reactions. A gonococcus complement fixation test was made upon each patient. Results For convenience the patients in this study were grouped first according to the gross pathology of the Fallopian tubes (Table I) and second according to the histologic evidence of inflammation (Table II). TABLE
I.
ORGANISMS
ISOLATED
FROM FALLOPIAN TIJBES. PATI~OLOGY OF TI-II? TUBES I
I
I
24
1: Ovarian Lumen Totals
involvement, and fimbria
tubes patent
patent
7 2”d 72
ANALYSIS
1: 62
BASED
UI,ON
GROSS
GROWTH
0
0
0 0
0 1
10
0
0o-o
1
10
i
0 1 1
0 0 1
1 1 3
0 1 1
1 0 1
0 0 1
0 0 1
:, 1
1. Twenty-four showed enlargement of the tubes with fimbria occluded. All cultures were sterile. 2. One showed atrophy of the tubes with fimhria occluded. Cultures were sterile. 3. Eighteen showed ovarian involvement with tubes occluded. Fourteen of these had sterile qltures, four yielded growt$ one an anaerobic streptococcus, one hemolytic Staphylococcus aureus, one Actanontyces muris and the other a mixed multure of Clostridium perfringnes and diphtheroids. 4. Seven showed ovarian involvement with tubes patent,. Four yielded sterile cultures and three yielded growth, one hemolytic Staphylococcus aureus, one Escherichia coli, and one an unidentified very small Gram negative rod growing only in the presence of blood. 5. Twen.ty-two showed the lumen and fimbria to be patent. Nineteen had sterile cultures and three yielded growth, one Streptococcus salit~arius, one hemolytic Staphylococcus aureus, and one Staphylococcus alhus. TABLE
II.
ORGANISMS
ISOLATED HISTOLOGIC
FROM FALLOYIAN TUBES. EVIDENCE OF INFLAMMATION
ANALYSIS
BASED
IIPON
GROWTJI
TYPESOFCASES
No evidence of inflammation Subacute inflammation Chronic inflammation Totals
TOTAL NO.
20
19
0
0
0
72
62
1
1
3
0
1
: 1
i0 1 1
‘-o-’
1
i
1
1144
\,,I. J. Obst. & Gyuer. December, 1918
liO(:H
1. Twenty showed no evidence of an inflammatory process. Nineteen cultures were sterile and one yielded a growth of Staphylococcus albw. 2. Thirty-one showed evidence of subacute inflammation. Twenty-six yielded sterile cultures and five showed growth; one Streptococcus sdivarius. one hemolytic Staphylococcus aureus, one Escherichia coli, one a mixed culture oi’ Glostridiu*n pevfringens and diphtheroids and one an unidentified very small Gram negative rod growing only in the presence of blood. Seventeen yielded 3. Twenty-one showed evidence of chronic inflammation. sterile cultures and four showed growth : one an anaerobic streptococ,cus, two hemolytic Staphylococcus CUCWUS,and one il~tinonsyce,s wwris.
Discussion l’us producing organisms other than the gonococcus were isolated in 13.S ~CI* c.ent or ten cases of the 72 patients studied; from 16.1 per cent of the tubes showing histologic evidence of subacute inflammation, and from 19.0 pci cent of the t~ubes showing histologic evidence of chronic inflammation. That the gonococcus was not isolat,ed was not surprising, since it is a known fact that the organism soon disappears from t,he bubal mucosa, and the Fallopian tuhes studied in this survey showed no evidence of acute inflammation. The four strains of hemolyt,ic Staph~$ococcus aurem isolated? three from tubes and one from the pus aspirated from bilateral ovarian abscesses, were probably toxin producing strains, since all produced b&a hemolysis on blood agar plates, fermented mannitol. liquefied gelatin, and were coagulase positivct. The patient yielding the Gram-ncgativc unidentified rod from tubal cultures viehled HemoyMu.s infIupnzue from cultures of the pus from bilateral ovarian abscesses. Brucclla agglut,ination tests were negative. Two paCents had positive gonococcus complement fixation tests. One patient had a recent history of gonorrhea; the other denied ever having been infected.
Conclusions 1. In this study it was not possible to isolate the gonococcus from Fallopian tubes showing histologic evidence of subacute and chronic inflammation. 2. The Fallopian tube is not, the focus of chronic gonorrhea1 infection. 3. The gonococcus is short lived in the tubal mncosa and apparentl> l~otlucrs a low level of demonstrable antihodies, since only one patient, in the series of seven having histories of a previous gonorrhea1 infection, and one 1~11icnt in the 40 having doubtful histories had positive gonococcus complement fixation tests. 1. To my knowledge no other casr has heen reported in the literature of the isolation of Actinowtyc.es )rt~l~-i.s (sometimes called Streptobacillus moniliformis and Haverhillia multiformis) from bilat,eral tuho-ovarian abscesses or of the isolation of Henzoph&cs i?~flurnzrro from bilateral ovarian abscesses. If such vases have been reported, 1 have not been able to find them. The author wishes t,o acknowledge t,hr valuable assiatnncc of Dr. J)r. Richard IV. Te Linde during this ~WLIIX of investigation. Reports on the gross and histologic pathology of the sperimens from the Pathology Laboratory of the Department of Gynecology.
J. How:rrd studied
Brown were
ant1
obtained
Volume Number
56 6
BACTERIOLOGY
OF
FALLOPIAN
TUBES
1145
References 1. 2. 3. tr
Curtis, A. H.: Surg., Gynee. & Obst. 33: 621, 1921. Cordua, R., and Keck, F. A.: Zentralbl. f. Gynlk. 50: 2747, 1926. Worral, R.: M. J. Australia 1: 146, 1931. CBau;sndeD and * Lane& Giullemin,2: A. : 1935. Bull. Sot. d’obst. et de gynee. 23: 659, 1934.
6: Studdifor’d, B. S., Casper,1173, W. A., and Scadron, E. N.: Surg., Gynec. & Obst. 67: 176, 1938. 7. Cornell, V. D. : Am. J. Path. 10: 519, 1934. 8. Gardiner, S. S., and Welsh, D. A.: Australian & New Zealand J. Surg. 41: 279, 1935. 9. Cote, F. H., and Tudhope, G. R.: J. Path. & Bact. 42: 679, 1936. 10. De Faria, G., and Fiablo, A.: Ann. brasil de gynec. 3: 1, 1937. 11. Au&r, L. S.: Am. J. Clin. Path. 10: 688, 1940. 12. Ahumada, J. C., Chevalier, R. M., and Sammertino, R.: Bol. Sot. de Obst. y ginec. de Buenos Aires 22: 362, 1943. 13. Koch, M. L.: TeLinde. Operative Gynecology, ed. 1, Philadelphia, 1946, J. B. Lippincott co. 14. Burke, V. : J. Bact. 7: 159, 1922.
BACTERIOLOGY MARIE
’ I”rotn
thr
l)qmtmiit
s of
OF FALLOPIAN AT OPERATION I,.
Kocx,
MS..
Ikrct?rirdry!t
TUBES
BWLTIM~RE,
UI~I/ (:!/~~wolnyy,
REBIOVED
MD.
Johns
Hop7civs
3f~dicd
Nchoo7)
T
If IS invesliqition caoml)rist>s it stuci?- of ‘ig j,atients from the wards and I)t.iv:ttr scrvicc) oi’ Ihc M’0mc~11‘s (‘liilic, 01 iho Johns Iio[)kins IIospit~al. S;lcvcJn ~~~ll~~I*I*l7t~ill iII t’cction. 10 hat1 dOIlbtflll 11;itietlt.s had had ii I)t*(~vious history (rl Ilid(Jriw
:llltl
b?r
) Ililtl
ll?QXtiVC
tlistol~iw.
In 1921 Curtis isolated the gOIlOCOCCl1S from Fallopian tubes removed al ofperation in 38 01 192 cases, but gross and microscopically these tubes presented (‘~lrt is also isolated Escherichits coli, streptoa 7)ietnrc of acute inflammatioIl. CWY~, ant1 anaerobic strept.ococci from VHSASof salpingitis and perisalpingitis. (!11rd17a and Iieck in 1926, rcportetl isolating paratyphoid B bacillus from an ovarian abscess. In 1931 Iirorral repotted havin g isolated Staphylococci from infected Fallopian tubes. (-lanssade and (iiullemin, 1934, isolated the colon harillus from the tubes ui’ >L 13.year-ol(l girl. Brown, 1835, isolated Salmonelln 11crt~~?ul’t from a case 01 bilateral pyosalpins. Studdiford, Casper, and Scadron, in 1938, reported isolating gonococci from the t,ubes of 16 of 24 cases studied. The organisms mere isolated 1)~ cnlturing pieces of tissue and exudate, t7c’yer from pus, and occasionally wcrc degenerate in form but rapidly assumed t hc usual cha.racteristics upon subculture. Thirteen of the specimens yielding gonococci showed pat,hologic evidence of sllbaente inflammation, two were acute csacerbations of chronic salpingitis, and one showed evidence of chronic or l~caled salpingitis with marked structual changes in t,he walls of the tnbe. According to Cornell, unt.il 1.934 there wcrc ‘71 published cases of actinomycosis 01’ the internal feniale genitals. Americ+an literature reported seven cases, 147qlish literature six! and the remainder were in other languages. Since then c’ascs have been reported by (:ardiner and Welsh, 1935; CSte and Tudhope, 19:% ; I )e Fat*ia antI I<‘iallln. 193’i ; Austpr. 1940; and Ahnmada and Chevalier. 1942. Technique 1ltttrr~tliatcly ul,o1) rem0v:ll at oI)ct’ation the tul)es LV-;F’I’C 1)Iaced in strrilr diSilCS anti bro77~ht to tltc l~tl)O~ittC!t'J-. Tf pus or fluid was present in the tribes or ahsccsscs a small area was seared lvitli a scaring iron, a sterile glass capillary pilAte inserted, and the material aspirated for cultural study. C’iec’es of tissue \vf’r~’ tliot~o~igh1~ ground in sterile sand and 3.0 c.c. oi ])artcdrcatic digest broth. 1111 7.2, ‘for h7lrird foci of infection. All specimens u crc’ wllnrccl in the following I7lailticr: r\ t ubc of fircwer ‘s sodium thiogl?c*ollatc~ medium ww.s itiocrllatctl anal i7l~lll)i7tc~d al X0 (-!. for scvcnty-two hol7rs. Smcal’s w’er’t~ made c\-er!. I went,>--four !lonrs and examined n7icroscopically. ,\c~Iuhic~ ant1 arlarId)iC si yak plattls wt’re made on lz~ncreatic cligest blootl ( ral&it.) agat*, thta 1’ormPl itlcnbatcd Tots schrent\--two hours and examined c~vcl’~ t\vtIntr-four l10777~ and t11~ la1 tcr incrll)atetl tore forty-eight hours and the11 rsnm&cd. For isolation OF the gonococcus streak l)lates were made upon I-'c9t*i
[ Glll(‘I’(‘at
iC
t&St
cdtlOCW~;ltC
tlt(JOtl
( tlIIIllaI1
) iIgSals
of approximately 10 per cent carbon dioxide medium was used because it had been previously for t.hc isolat.ion of the gonococcus from cervical 1113
and
illCLlt)iItC(]
iII
;In
~bloSptlCW
for forty-eight hours. This shown to be most sat,isfactory cultares, Koch, 1946. Wrect
gcJ;rg
”
S66
BACTERIOLOGY
OF
FALLOPIAN
TUBES
1143
smears were made of all pus, exudate, and ground tissues, stained by Burke’s modification of the Gram stain and examined microsccipically. For final identification all organisms were thoroughly studied. according to their hiochemical reactions. A gonococcus complement fixation test was made upon each patient. Results For convenience the patients in this study were grouped first according to the gross pathology of the Fallopian tubes (Table I) and second according to the histologic evidence of inflammation (Table II). TABLE
I.
ORGANISMS
ISOLATED
FROM FALLOPIAN TIJBES. PATI~OLOGY OF TI-II? TUBES I
I
I
24
1: Ovarian Lumen Totals
involvement, and fimbria
tubes patent
patent
7 2”d 72
ANALYSIS
1: 62
BASED
UI,ON
GROSS
GROWTH
0
0
0 0
0 1
10
0
0o-o
1
10
i
0 1 1
0 0 1
1 1 3
0 1 1
1 0 1
0 0 1
0 0 1
:, 1
1. Twenty-four showed enlargement of the tubes with fimbria occluded. All cultures were sterile. 2. One showed atrophy of the tubes with fimhria occluded. Cultures were sterile. 3. Eighteen showed ovarian involvement with tubes occluded. Fourteen of these had sterile qltures, four yielded growt$ one an anaerobic streptococcus, one hemolytic Staphylococcus aureus, one Actanontyces muris and the other a mixed multure of Clostridium perfringnes and diphtheroids. 4. Seven showed ovarian involvement with tubes patent,. Four yielded sterile cultures and three yielded growth, one hemolytic Staphylococcus aureus, one Escherichia coli, and one an unidentified very small Gram negative rod growing only in the presence of blood. 5. Twen.ty-two showed the lumen and fimbria to be patent. Nineteen had sterile cultures and three yielded growth, one Streptococcus salit~arius, one hemolytic Staphylococcus aureus, and one Staphylococcus alhus. TABLE
II.
ORGANISMS
ISOLATED HISTOLOGIC
FROM FALLOYIAN TUBES. EVIDENCE OF INFLAMMATION
ANALYSIS
BASED
IIPON
GROWTJI
TYPESOFCASES
No evidence of inflammation Subacute inflammation Chronic inflammation Totals
TOTAL NO.
20
19
0
0
0
72
62
1
1
3
0
1
: 1
i0 1 1
‘-o-’
1
i
1
1144
\,,I. J. Obst. & Gyuer. December, 1918
liO(:H
1. Twenty showed no evidence of an inflammatory process. Nineteen cultures were sterile and one yielded a growth of Staphylococcus albw. 2. Thirty-one showed evidence of subacute inflammation. Twenty-six yielded sterile cultures and five showed growth; one Streptococcus sdivarius. one hemolytic Staphylococcus aureus, one Escherichia coli, one a mixed culture oi’ Glostridiu*n pevfringens and diphtheroids and one an unidentified very small Gram negative rod growing only in the presence of blood. Seventeen yielded 3. Twenty-one showed evidence of chronic inflammation. sterile cultures and four showed growth : one an anaerobic streptococ,cus, two hemolytic Staphylococcus CUCWUS,and one il~tinonsyce,s wwris.
Discussion l’us producing organisms other than the gonococcus were isolated in 13.S ~CI* c.ent or ten cases of the 72 patients studied; from 16.1 per cent of the tubes showing histologic evidence of subacute inflammation, and from 19.0 pci cent of the t~ubes showing histologic evidence of chronic inflammation. That the gonococcus was not isolat,ed was not surprising, since it is a known fact that the organism soon disappears from t,he bubal mucosa, and the Fallopian tuhes studied in this survey showed no evidence of acute inflammation. The four strains of hemolyt,ic Staph~$ococcus aurem isolated? three from tubes and one from the pus aspirated from bilateral ovarian abscesses, were probably toxin producing strains, since all produced b&a hemolysis on blood agar plates, fermented mannitol. liquefied gelatin, and were coagulase positivct. The patient yielding the Gram-ncgativc unidentified rod from tubal cultures viehled HemoyMu.s infIupnzue from cultures of the pus from bilateral ovarian abscesses. Brucclla agglut,ination tests were negative. Two paCents had positive gonococcus complement fixation tests. One patient had a recent history of gonorrhea; the other denied ever having been infected.
Conclusions 1. In this study it was not possible to isolate the gonococcus from Fallopian tubes showing histologic evidence of subacute and chronic inflammation. 2. The Fallopian tube is not, the focus of chronic gonorrhea1 infection. 3. The gonococcus is short lived in the tubal mncosa and apparentl> l~otlucrs a low level of demonstrable antihodies, since only one patient, in the series of seven having histories of a previous gonorrhea1 infection, and one 1~11icnt in the 40 having doubtful histories had positive gonococcus complement fixation tests. 1. To my knowledge no other casr has heen reported in the literature of the isolation of Actinowtyc.es )rt~l~-i.s (sometimes called Streptobacillus moniliformis and Haverhillia multiformis) from bilat,eral tuho-ovarian abscesses or of the isolation of Henzoph&cs i?~flurnzrro from bilateral ovarian abscesses. If such vases have been reported, 1 have not been able to find them. The author wishes t,o acknowledge t,hr valuable assiatnncc of Dr. J)r. Richard IV. Te Linde during this ~WLIIX of investigation. Reports on the gross and histologic pathology of the sperimens from the Pathology Laboratory of the Department of Gynecology.
J. How:rrd studied
Brown were
ant1
obtained
Volume Number
56 6
BACTERIOLOGY
OF
FALLOPIAN
TUBES
1145
References 1. 2. 3. tr
Curtis, A. H.: Surg., Gynee. & Obst. 33: 621, 1921. Cordua, R., and Keck, F. A.: Zentralbl. f. Gynlk. 50: 2747, 1926. Worral, R.: M. J. Australia 1: 146, 1931. CBau;sndeD and * Lane& Giullemin,2: A. : 1935. Bull. Sot. d’obst. et de gynee. 23: 659, 1934.
6: Studdifor’d, B. S., Casper,1173, W. A., and Scadron, E. N.: Surg., Gynec. & Obst. 67: 176, 1938. 7. Cornell, V. D. : Am. J. Path. 10: 519, 1934. 8. Gardiner, S. S., and Welsh, D. A.: Australian & New Zealand J. Surg. 41: 279, 1935. 9. Cote, F. H., and Tudhope, G. R.: J. Path. & Bact. 42: 679, 1936. 10. De Faria, G., and Fiablo, A.: Ann. brasil de gynec. 3: 1, 1937. 11. Au&r, L. S.: Am. J. Clin. Path. 10: 688, 1940. 12. Ahumada, J. C., Chevalier, R. M., and Sammertino, R.: Bol. Sot. de Obst. y ginec. de Buenos Aires 22: 362, 1943. 13. Koch, M. L.: TeLinde. Operative Gynecology, ed. 1, Philadelphia, 1946, J. B. Lippincott co. 14. Burke, V. : J. Bact. 7: 159, 1922.