The Pathological Findings in Cases Clinically Diagnosed as Ureteral Stricture1

THE PATHOLOGICAL FINDINGS IN CASES CLINICALLY DIAGNOSED AS URETERAL STRICTURE 1 GUY L. RUNNER

AND

LAWRENCE R. WHARTON

From the Department of Gynecology of the Johns Hopkins Hospital and University

During the past few years we have been making a particular effort to determine by histological examination the pathological lesions present ·i n cases that had been diagnosed clinically as ureteral stricture. This paper presents the results of this study. We have included in this report every stricture case in which, either by operation or necropsy, we have been able to obtain the tissues in question. In brief, we have examined under the microscope the material from one newborn child and from 7 patients whom we had cystoscoped and in whom we had diagnosed the presence of a stricture of the ureter. On the basis of our clinical examination we suspected that in one of these cases the lesion might be a congenital valve; in another a stricture due to operative injury, while in the remainder the diagnosis of ureteral stricture was not qualified as to the etiology of the condition. Since this is purely a pathological study, whatever value it has depends solely upon the accuracy of the pathological determination. In order to eliminate error in this regard, we have submitted the complete clinical histories of these patients; the necropsy records and the pathological tissues to two recognized pathologists for independent study and diagnosis. All statements contained in this paper relating to pathology, with the exception of case 8, which was studied elsewhere, are the opinions of Dr. Arnold R. Rich and Dr. David M. Davis. Fortunately, 1 Read at the annual meeting of the American Urological Association, St. Louis, Mo ., May, 1925.

57 THE JOURNAL OF UROLOGY, VOL, XV, NO.

1

58

GUY L. RUNNER AND LAWRENCE R. WHARTON

there was complete accord in their diagnoses as far as the ureters were concerned. We hereby acknowledge our deep indebtedness to these colleagues for their valued help in these studies. When studied pathologically, the ureteral lesions that we found in these 8 patients fall into four distinct groups. They are as follows: number of cases

Congenital lesions, either stricture or valve ... . ......... . ........... . Constrictions due to the pressure of surrounding tissues .... . ... . . .. . Stricture associated with terminal general infection oi the entire urinary tract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cause of stricture not determined; Sections not through area of stricture ..... . . . . . ... .. . . ............... . .. ... ...... . . .. . . .. ..... .. ...

3 3

1 1

I. CONGE!'\ITAL LESIONS

Case 1. Baby J., newborn male infant. Delivered May, 1923, Church Home and Infirmary. The child was born at term, no obstetrical complications. The heart continued to beat for only a few minutes after delivery, efforts at resuscitation being unsuccessful. Autopsy. No pathological lesions were found except in the urinary tract. The specimen, including both kidneys, ureters and bladder, was immediately taken to Mr. Brodel, whose drawing (see fig. 1 plate 1,) describes their gross appearance. The left kidney shows marked dilatation of the calices. Both ureters are dilated, the left being particularly affected. There are two points of constriction in the left ureter, the upper one at the ureteropelvic junction, the lower in the bladder wall. Author's note. "Microscopic examination of the left kidney shows scarring, extensive destruction of the cortex and scattered white blood cells, which are chiefly of the mononuclear type. In one area, there is a wedge-shaped scar in which the mononuclears are particularly common. This resembles an infarct." The lower end of the left ureter was opened by Mr. Brodel under the dissecting microscope for the purpose of tracing its lumen into the bladder. After this dissection, he concluded that there was almost complete stricture in the bladder wall. Serial sections were therefore made of the intravesical part of the ureter. The lumen is definitely dilated until it plunges into the bladder wall. At this point the ureteral walls cease to show the normal struc-

THE JOURNAL OF UROLOGY

FIG. 1.

CASE

1.

PLATE 1

CONGENITAL STRICTURE OF 1JRETER IN NEWBORi'I BABE

Stricture situated at ureteropeivic junction and in bladder wall. ate narrowing of kidney substance.

Note moder-

URETERAL STRICTURE

FIG.

2.

CASE

1.

61

Lmv POWER PHOTO:\HCROGRAPH, SHOWI"IG URETERALLUMEN AS A FI"IE THREAD IN THE BLADDER WALL

Fw. 3. CASE 1. THE URETERO - VESICAL ORIFICE OF LEFT URETER The ureteral lumen disappears just above the vesical orifice

62

GUY L. RUNNER AND LAWRENCE R . WHARTON

tures. The longitudinal and circular layers of muscle become lost in the loose connective tissue which surrounds the extremely narrow threadlike lumen (see fig. 2) . The ureteral opening can be traced with difficulty to within about 3 mm. of the bladder mucosa, where its continuity becomes questionable. There is a pin-point slit in the bladder mucosa (see fig. 3) corresponding with the ureteral orifice. There is no evidence of inflammation in the intravesical portion of the ureter. The epithelium of the upper ureter is cuboidal in type, very thin. In the bladder mucosa itself are found occasional clumps of round cells. In the opinion of Dr. Arnold Rich, the changes are not sufficien to diagnose cystitis; Dr. D. M. Davis, however, felt that there was a low grade inflammatory reaction in the bladder. Diagnosis. Stricture of ureter, congenital; hydronephrosis; dilatation of ureter.

Case 2. A. A. P., aged twelve years, female . Admitted to Johns Hopkins Hospital September 11, 1923. Discharged October 24, 1923. Gyn. No. 28985. Complaint. Urinary incontinence. This symptom had been present since birth. It has been continual during both day and night without remission, unaccompanied by any other symptoms, and unaffected by activity, rest or position. The child also voided normally in usual amounts. During the first years of the child's life, the parents attributed the incontinence to habit formation and tried the usual measures without effect. Although physicians had examined the child many times, no abnormality had been discovered until quite recently when the family doctor found what he thought were accessory urinary openings around the external orifice of the urethra. The child had had no unusual illnesses. Physical examination. The child was well developed physically and mentally and appeared to be in perfect health. The general examination was negative, except for a rather large and red right tonsil and the left one deeply imbedded. The lower pole of the right kidney was easily felt. Gynecological examination. External genitalia normal. Urethra normal. No accessory opening visible. On getting the patient to strain, a tiny stream of urine spurted from a point on the posterior edge of the urethra and situated one to two millimeters to the left of the midline. The finest whalebone filiform failed to enter this opening. The butt

FIG. 4.

CASE

UPPER

2.

ILLUSTRATING DOUBLE KIDNEY

KIDC'/EY

OPENING

BELOW

(LEFT)

EXTERNAL

WITH URETER FROM

URETHRAL

ORIFICE

Note sudden widening of upper portion of accessory ureter above the site of the congenital valve.

63

64

GUY L. RUNNER AND LAWRENCE R. WHARTON

end of a fine cambric intestinal needle entered the o:pening and after feeding in four needles side by side, two of these were grasped by either hand and gentle lateral traction was made to stretch the ureteral opening. Then we had no trouble in passing a No. 5 x-ray catheter, which stopped apparently at about the pelvic brim region. Note in figure 4 that the catheter had passed beyond the valve formation. Placing the patient in the knee-breast posture and introducing the Kelly cystoscope, two ureteral openings were found in the usual position and both seemed to be functioning normaliy. The left ureter was catheterized and a urogram was taken (fig. 4). At subsequent examinations it was found that the urine from each of the three kidneys was clear and sterile to culture. An intramuscular differential phthalein test resulted as follows: R IGHT KID NEY

Appearance time .... .. . . ... . First t hirty minutes .... Second thirty minutes .. ... .

(CA'I'HETER)

LEFT KIDNEY (TRANSVESICAL)

ACCESSORY KIDNEY (CATHETER)

5 minutes 20 per cent 20 per cent

8 minutes 20 per cent 20 per cent

45 minutes, trace

Operation. Dr. Runner found the upper part of the accessory ureter dilated to a diameter of 1 cm.; the lower part appeared normal. He resected the ureter, t he specimen removed including both the dilated and normal parts. By this procedure the upper segment of the left kidney was forced to undergo atrophy. The patient made an uneventful _convalescence; the incontinence was completely relieved. Just before the patient left the hospital, at Dr. Runner's suggestion, Dr. TeLinde tested the right ureter for stricture, using a 3.3 mm. bulb. The bulb did not hang; Dr. Baetjer reported that the pyelogram showed a slight hydronephrosis, capacity 10 cc. Pathology. Gyn. Path. No. 29034. In order to preserve the operative specimen in its original form, it was immediately filled with 10 per cent formalin, ligated at each end and suspended in formalin until it had completely hardened. Mr. C. F. Ingram's drawing and the microphotograph show the appearance of the ureter (figs. 5 and 6). The specime]J is_11.5 cm. long. On its external surface is a network of veins. In the 'ffpper part, the ureter is dilated, the internal diameter being from 8 to 13 ni'1n. The lumen is widest just above the point of constriction; the dilatation ends abruptly in what appears to be a valve. In the dilated portion the ureteral wall is hardly 0.5 mm. thick.

URETERAL STRICTURE

65

Below the dilated area, the ureter measures externally 3 to 3.5 mm. in diameter; its lumen is 1 mm. wide, its walls 1 mm. in thickness.

FIG. 5.

CASE

2.

DRAWING OF CONGENITAL VALVE OF URETER IN CASE OF ACCESSORY URETER AND KIDNEY

Compare with pyeloureterogram in figure 4

Microscopic pathology. There was no evidence of inflammation in the tissues removed. In the dilated portion the ureteral wall is ex-

66

GUY L. RUNNER AND LAWRENCE R. WHARTON

tremely thin, the mucosa below the site of the valve is of the normal stratified transitional variety, showing many layers of cells. Above the valve in the dilated portion the epithelium is but 4 or 5 layers deep and shows a tendency toward flattening of most of the cells.

Case 3. M . V. W., aged three and one-half years, female. Admitted to Johns Hopkins Hospital, August 1, 1919; died October 28, 1919. Service No. 20620. Autopsy No. 6038. Clinical history. The child was first seen in the public dispensary of the hospital on March 12, 1919. Her family physician stated at that time that she had "kidney trouble." When she entered the dispensary, her most t-'I ' important symptoms were weakness, lack of appetite, inanition, convulsions, and a constant desire to void. The child weighed 5 pounds at birth, had been breast fed for eight months and her first teeth had appeared when she was one year old. She had her first convulsion at the age of eight months, and this was followed by an illness which had been called pneumonia. Her appetite had been poor continually, she was subject to respiratory infections and she Fm. 6. CASE 2. PHoTo- had been becoming progressively weaker when MICROGRAPH oF SECTION she was brought to the dispensary on March 12. oF CoNGENITAL URETEAfter having been treated in the outRAL VALVE, IN CAsE OF patient clinic without relief until August 1, ACCESSORY URETER AND she was admitted to the hospital. At that KIDNEY time her temperature was 103°, her weight only 21 pounds, although she was over three years old and she was so weak that she could not stand. Physical examination. Extreme rickets, marked pallor, great muscular weakness, abdominal distension and a large spleen. White blood cells, 13,000; red blood cells, 2,500,000; hemoglobin, 43 per cent. Report of clinical laboratory (Dr. Frank Evans): marked secondary anemia. Urine: varying amounts of albumin; casts, O; white blood cells, O; red blood cells, O; sugar, O; specific gravity always low. Culture of urine, no growth. Systolic blood pressure, 100/ 108; diastolic, 65/ 70. Marked impairment of renal function. Phthalein (two hours) 4 per cent, August 4 ; 6 per cent, August 13. Eye grounds: negative.

URETERAL STRICTURE

67

Child became stuporous and began to vomit a few days after entering hospital. On August 13, Dr. Runner was asked to cystoscope the patient. In spite of her constant bladder symptoms the mucosa was normal. The right ureter admitted a No. 9 renal for a distance of only 2 or 3 cm.; No. 6 catheter met obstruction at same point but passed up ureter. A wax bulb 2.6 mm. in diameter passed through the area of obstruction with difficulty and had firm hang on withdrawal. His diagnosis was "stricture of right ureter." On August 20, he was unable to pass a catheter up the left ureter; on August 26, he dilated the right ureter again, using a 3 mm. wax bulb and again finding the same obstruction low in the ureter. The wax bulb traversed the upper part of the right ureter without resistance. Cu1ture of right kidney negative. August 16: transfusion, 175 cc. whole blood. September 1: Hemoglobin, 70 per cent; general condition much better; weight, however, had fallen to 20 pounds. On September 8, she was discharged from the hospital, only to lose weight, become weaker and return on September 26 in worse condition than before. Hemoglobin, 28 per cent; red blood cells, 2,500,000; white blood cells, 13,900. Slight fever. Two-hour phthalein; 7 per cent. Blood pressure 102/58. Urine: as on previous examination, absolutely normal except for low specific gravity and varying amounts of albumin. The child died October 28, 1919. On only one occasion, 24 hours before death, was a positive culture obtained from the urine, when the colon bacillus was isolated. Autopsy. No. 6038. Performed three hours after death. The general pathological findings were as follows: Advanced anemia; normal lungs; advanced rickets; enlarged spleen; enlarged mesenteric lymph glands; normal stomach and duodenum; normal pancreas; large, fatty liver; normal adrenals; normal genital organs, and hypoplastic bone-marrow. The findings in the urinary tract were as follows: Left kidney: small, weight 10 grams. No fetal lobulations seen. Capsule not adherent. "Wide pelvis." Kidney architecture seems irregular and proximal edge of cortex obliterated by encroaching strands of fibrous tissue, leaving an extremely thin cortical area not more than 2 or 3 mm. thick. Tubules appear dilated. Right kidney: small, weight 7 grams. Similar in appearance to left. Fetal lobulations obliterated. Pelvis is "wide." A more diffuse infiltration with fibrous tissue is noted, very prominently in the pyramids. Cortex almost obliterated in places.

68

GUY L. RUNNER AND LAWRENCE R. WHARTON

Left ureter: practically normal in appearance below the brim of pelvis. Above this there is a fusiform dilatation increasing the lumen to twice its natural size. As it enters the bladder the lumen is narrowed. A probe could not be passed into the bladder and the ureteral orifice was not seen. On dissecting out the ureter a small opening into the bladder is found. Right ureter: the right ureter is smaller than the left, but no difficulty is experienced in passing a probe from the bladder into the kidney pelvis. A stricture of this ureter is noticed.

FIG. 7.

CASE

3.

CONGENITAL HYDRONEPHROSIS, WITH BILATERAL STRICTURE OF URETER IN CHILD THREE YEARS OLD

The glomeruli are essentially unchanged; the renal tubules are so markedly dilated that they were clearly visible to the naked eye. Compare the size of the dilated tubules with those that are of normal size .

Bladder: mucosa pale, white, elevated into folds . Over the trigone are numerous submucous hemorrhages. Microscopic pathology (fig. 7). The most striking finding is the marked dilatation of the renal tubules. Except for a narrow strip a few millimeters wide next to the capsule, this dilatation seems to be limited to a zone including the peripheral half of the organ. In this area the tubules have assumed enormous proportions; they appear as irregularly shaped spaces lined by epithelium, cuboidal in type and

URETERAL STRICTURE

69

in a fair state of preservation. In these areas of tubular dilatation the interstitial tissue is insignificant and a picture not unlike lung tissue is the result. Most of these spaces contain coagulated fluid; a few cellular casts are seen, and a few of the tubules contain red blood cells. Signs of chronic inflammation are present throughout the entire section. Along the peripheral edge of the cortex there is marked infiltration with small round cells and fibrosis is especially prominent. This reaction is almost entirely limited to the interstitial tissues. The glomeruli have escaped any direct involvement other than thickening of their capsules. Throughout the zone of dilatation the inflammatory reaction is not particularly noticeable, but in the region of the papillae there is diffuse round cell infiltration and great interstitial fibrosis with apparent compression and diminution of the number of tubules. Some of these papillary tubules show epithelial proliferation. Both kidneys present the same picture. Bladder: Two sections, one from region of trigone, and one from the dome of the bladder, appear normal and show little or no histological evidence of cystitis. Ailthor's note. "The microscopic examination of the ureters is not recorded; there are no sections of the ureters in the collection, and the gross tissues cannot be found. Llnfortunately, we are therefore unable to elucidate a very important part of this case, the microscopic pathology of the ureters." The anatomical diagnosis as regards the urinary tract recorded the pathologist in 1919 is as follows: "Congenital cystic kidneys." After reviewing the case carefully both Dr. Rich and Dr. Davis have decided that this diagnosis is in error, and that the case should be diagnosed as congenital stricture of the ureter, bilateral; hydronephrosis, bilateral. II. CONSTRICTIONS DUE TO THE PRESSURE OF SURROUNDIKG TISSUES

Case 4- S. H., aged sixty-two, female. Gyn. No. 29646. Admitted to Johns Hopkins Hospital March 17, 1924. Operation April .5, 1924. Discharged June 2, 1924. Complaint. Pain in left side. Present illness. In 1909, at age of forty-seven, a panhysterectomy for cancer of the cervix. Following this operation the patient drained urine per vaginarn_ for seven weeks until the day before she left the hospital, when the fistula closed spontaneously and there has been no urinary leakage since.

70

GUY L. Hl-N',ER AND LAWRENCE R. WHARTON

The patient had no pain in the left side until seven years later, 1916. At first the attacks were infrequent; for three years she had at least one attack every week, the pain being so severe that morphin was required. During the past two years, the pain has not been so intense. There has been microscopic pus in the urine. No burning or pain on urination. Headaches rarely. Medical consultation. Dr. T. B. Futcher. Marked hypertension : 230 /140. Hypertrophic arthritis, fingers . Laboratory tests. White blood cells, 7690; hemoglobin, 80 per cent. Phenolsulphonephthalein: first hour, 100 cc., 5 per cent; second hour, 200 cc., 20 per cent; total, 300 cc., 25 per cent. Differential phthalein: Right kidney 23 per cent (two hours); left kidney, trace. Total non-protein nitrogen: 52.6 mgm. per 100 cc. blood. Wassermann negative. Culture right kidney: no growth. Catheterized bladder urine: specific gravity 1010, acid, no sugar, trace of albumin, occasional white blood cell, no red blood cells, no casts. X-rays of teeth and dental consultation; negative. Cystoscopic examination. On two successive trials, Dr. Runner failed to get by a dense obstruction in left ureter about 5 cm. above the bladder. Urine was seen to be spurting in apparently normal jets from the left ureteral orifice. Operation. Dr. Runner. Partial ureterectomy and nephrectomy, left. The left ureter measured 1.5 cm. in diameter at the pelvic brim, becoming "markedly constricted in broad ligament region." It was the original intention of the operator to perform a retrograde dilatation of the ureter but the smallest probes and dilators would not pass. The stricture began about 6 cm. above the bladder, continuing downward. A section of the ureter was removed from the region between the broad ligament and the pelvic brim. Culture of urine from left kidney at operation: no growth. Post-operative convalescence. Normal. During the last week in the hospital the totai non-protein nitrogen varied between 29.2 and 31.1 mgm.; the blood pressure 180/ 120 and the total phthalein increased to 50 per cent. Pathological note on operative specimen. Path. (gyn.). No. 29309. Hydronephrosis, left, with focal scars in kidney. Chronic pyelitis. Chronic pyelonephritis. The specimen of ureter measured 4.1 cm. in length. Its external diamettlr was 1.3 cm. The specimen had been hardened in formalin before examination. The ureteral wall is greatly indurated, measur-

URETERAL STRICTURE

71

ing 7 to 8 mm. in thickness. The point of occlusion was so involved in the broad ligament inflammatory tissues that it could not be removed at operation. Ureter (fig. 8). The epithelium is in some places entirely absent, in other places heaped up in many layers, usually being of the cuboidal or transitional variety. The darkly staining mass of tissue within

FIG. 8. CASE 4 K ote the marked edema of the submucosa and the edema and fibrosis of all the layers. Note the muscle hypertrophy.

the ureteral lumen consists of a pedunculated intraureteral polyp or fibroma, consisting of fibrous tissue in very dense whorls. The epithelium covering it is almost entirely missing. The blood vessels within it are engorged with erythrocytes. The ureteral wall is edematous, engorged with red blood cells, and in the tissues are a considerable number of white blood cells, chiefly plasma cells. These changes are noted chiefly in the submucosa, although the edema is general. There is also an increase in the amount of fibrous tissue throughout the ureteral wall.

72

GUY L. RUNN ER AND LA'\VRENCE R. WHARTON

Kidney (fig. 9) . The microscopic picture of the kidney varies according to the situation of the section. In some places the epithelium of the renal tubules seems to be fairly normal, in others it is flattened out and the tubules are dilated, while elsewhere there is complete destruction by scar tissue and chronic inflammation. There is marked arteriosclerosis everywhere, involving both the larger and smaller arteries. Some of the glomeruli have been completely hyalinized. There are large numbers of white blood cells, almost exclusively

Fm. 9. CAsE 4 Note sligh t dilatation of renal t ubules, flattening and degeneration of m any of the epithelial cells, areas of round-cell infiltration.

mononuclears and plasma cells, in the tissues directly underlying the epithelium of the renal pelvis. The pelvic epithelium consists of many layers of cuboidal and transitional epithelium. Case 5. F. K., aged sixty, female. Admitted to Church Home and Infirmary July 18, 1923. Died October 17, 1923. Autopsy No. 106. Clinical history. The present illness began in 1913 with irregular uterine bleeding. The family physician states that this was due to epithelioma of the cervix. and that the cervix was cauterized. As the

URETERAL STRICTURE

73

bleeding persisted, treatment by radium was begun. In 1919 the cervix was curetted and treated both by radium and the Percy cautery. The bleeding ceased at this time and never recurred. These treatments were carried out at the Mayo Clinic. In 1919, shortly after returning to her home in Kentucky, the patient developed bladder symptoms, constant vesical irritation and frequency. These symptoms have been present ever since. During the winter of 1922 after an attack of influenza, the patient developed pain in the lower abdomen, extending up into the left flank and left back. More recently she began to have backache, situated through the sacral and lower lumbar regions, but not radiated at all. This pain gradually became intense, requiring morphin and was made much worse by irrigations of the bladder. There had never been any pain in the right flank or right renal region until two weeks before admission to the Church Home. The patient never had tonsillitis; about one year ago a bad tooth was extracted. She has had three children, the youngest being eighteen years old. Physical examination. Patient extremely obese, now weighs 227 pounds, three months ago weighed 273 pounds. Suffering continually from intense pain in the sacral region, complaining also of pain in both flanks, kidney regions and bladder symptoms. Tonsils: normal. Several gold-crowned teeth, with pyorrhea. Heart and lungs normal. Abdominal examination unsatisfactory because of extreme obesity. Some relaxation of the perineum, with moderate cystocele and rectocele. The cervix had apparently been completely destroyed; the vaginal vault was smooth, covered by normal mucosa. The cervical orifice could not be found. The adnexae and the uterus were not palpable. Catheterized urine: Albumin, O; sugar, O; white blood cells, rare; red blood cells, 0; casts, 0; bacteria, 0. Two-hour phenolphthalein, 42 per cent. Blood pressure 148/110. Cystoscopy. July 20, 1923. The urethra densely infiltrated, the mucosa red, splits on attempting to pass a Kelly cystoscope 8.5 mm. in diameter. Bladder pale, trigonum shows bullous edema. Left ureteral orifice very small, dilates to admit a wax bulb (4½ mm. diameter) with difficulty. No obstruction at any other point in ureter to bulb or catheter. On withdrawing bulb, it hangs very slightly at a point 3.5 cm. above the bladder. Content of left kidney: 7.5 cc. Urine clear.

74

GUY L. RUNNER AND LAWRENCE R. WHARTON

Subsequent examinations showed that a 4.6 mm. wax bulb hung firmly in the bladder wall area of the left ureter, a 5.6 mm. bulb hung at a point 2 cm., and a 6 mm. bulb hung at a point 2.5 cm. above the left vesical orifice. In the right ureter a wax bulb (4.6 mm.) hung in the bladder wall region, and a 6 mm. bulb hung at a point 12 cm. above the bladder and also in the bladder wall. A diagnosis was made of bilateral ureteral stricture, probably due to infiltration of the broad ligaments following carcinoma and radium. Following cystoscopic treatments the pain in the flanks and the bladder symptoms became greatly relieved; the intense sacral backache, however, was not alleviated. Dr. George E. Bennett was therefore called in consultation; it was his impression that the sacral pains were due to malignant disease, although the extreme obesity of the patient precluded the obtaining of any evidence from accurate palpation or x-ray examination. The patient gradually became weaker and developed symptoms referable to the central nervous system-generalized convulsions involving every part of the body, accompanied by extreme cyanosis, shock, rapid and thready pulse and respiratory distress. Repeated examinations of the blood never showed nitrogen retention. The patient died October 17, 1923. Autopsy. No. 106. Drs. Clark and Fried. Gross pathological diagnosis: metastatic carcinoma to lumbar glands with erosion through fourth lumbar vertebra. Chronic passive congestion of lungs with areas of bronchopneumonia at bases. Sclerosis of aorta with calcification. Ureteral stricture due to new growth. Right pyelitis. Trigonitis. Thrombosis of right iliac vein. Cloudy swelling of viscera. Left kidney: weight 260 grams, looks large and swollen. Measures 11 by 3.5 by 5 cm. Capsule strips easily, leaving a glistening surface. At lower pole is a cyst, 1.5 cm. in diameter. Pelvis seems a little larger than normal. Mucous membrane pale. Cortex averages 4 mm. thick. Striae essentially normal. Left ureter : 31.5 cm. long, filled with 10 per cent formalin and suspended in formalin. The greatest external diameter, 6 mm., is found in the abdominal portion where there is a spindle 7 cm. long, beginning 8.5 cm. below t he kidney. Above this abdominal spindle the ureter measures 4 mm. (external diameter). There is a similar shorter pelvic spindle above the broad ligament region; in this area the greatest external diameter is 6 mm. Between these spindles the external diameter of the ureter is 4 mm. The ureter measured 5 mm.

URETERAL STRICTURE

'75

(external diameter) 4.5 cm. above the vesical orifice. The lowest 4 cm. of the ureter was surrounded by the tissues of the broad ligament to which it was densely adherent (fig. 10). The left broad ligament was unusually indurated.

FIG. 10. CASE 5. SECTION OF uRE'rER (Ur.) IN LEFT BROAD LIGAMENT Note the marked thickening of the ureteral walls, and the dense infiltrntion surrounding the ureter and replacing the loose aerolar tissue. Note phlebolith (Ph.) in vein.

Right kidney weighs 280 grams, measures 11 by 5 to 4.5 cm, Pelvis well formed, normal in size and shape, not injected. Cortex seems narrowed in places, averages 4 mm. in thickness. Right ureter: 31.5 cm. long. It is surrounded by a hard inflammatory mass which is intimately attached to it 5 cm. below the kidney. This mass extends 3 cm. along the ureter. Above this mass the ureter measures 8 mm., external diameter. Below this mass for a THE JOURNAL OF UROLOGY 1 VOL. X\r, XO~

1

76

GUY L. RUNNER AND LAWRENCE R. WHARTON

distance of 10 cm. the right ureter is uniformly dilated, its external diameter being 11 mm. (fig. 11). At a point 12 cm. above the bladder it becomes narrower (fig. 12). Between this point and the bladder, its greatest external diameter is 3.5 mm. As on the left side, the right ureter is intimately adherent to the tissues of the broad ligament and the pelvic floor for 3.5 cm. above the bladder. The broad ligament is densely scarred and indurated.

FIG.

11.

CASE

5.

THE DILATED RIGHT URETER, IN THE ABDOMINAL PORTION,

AT A POINT BELOW THE CARCINOMATOUS LUMBAR GLANDS, BUT ABOVE THE STRICTURE AREA I N THE PELVIS

Compare the thinness of the ureteral wall with the size of the lumen. External diameter of ureter at this point 11 mm.

Trigonum: injected diffusely. The internal urethral orifice granular and red. Bladder normal. Uterus : small. Uterine cavity practically obliterated. Uterine wall very fibrous. Blood vessels thick-walled. Cervix missing. Tubes and ovaries: senile. There is no cancer in the uterus, tubes, ovaries, broad ligaments or at any point along the course of the lower ureter. Lumbar glands. Surrounding aorta at level of third, fourth and

Fm.

12.

CAsE

5.

URETERAL WALL AT A PornT

12

cM. ABOVE THE BLADDER

Compare with figure 11, and compare both figures 11 and 12 with figure 13 representing a normal ureter.

FIG.

13.

CROSS-SECTION OF AN ORMAL URETER, TAKEN

4 CM.

ABOVE THE BLADDER,

FOR COMPARISON WITH PATHOLOGICAL SPECIMENS

Note the proportion between the diameter of the lumen and the thickness of the wall. 77

78

GUY L. RUNNER AND LAWRENCE R. WHARTON

fifth lumbar vertebrae is a hard mass, 10 cm. long, constricting the aorta. In one place softening anci necrosis have occurred. This mass has invaded the fourth lumbar vertebra, penetrating the medullary cavity and forming an abscess. Brain: marked edema. No cancer. Case 6. C. B., aged fifty-two female. Admitted to Johns Hopkin8 Hospital March 23, 1921. Operation April 2, 1921. Died April 3, 1921.

FIG. 14.

NORMAL URETER,

HIGHER MAGNIFICATION,

FOR

COMPARISO N

WITH

p ATHOLOGICAL SPECIMENS Photomicrograph of segment A, taken from figure 13, representing a normal ureter. Note the comparatively thin submucosa, and the loose aureolar tissue of the periureteral sheath.

Complaint. Pain in left side, starting in back and radiating to grom. Present illness. Onset three years before with sharp pain in left lumbar region radiated to groin. No nausea. No vomiting. No fever. Pain required morphin. This first attack lasted for a day or two and blood and pus were present in the urine for three or four. days longer. The next attack occurred one year later. The last attack

URETERAL STRICTURE

79

was six weeks before admission to the hospital. Frequency and burning on urinating have been present for three years. Twelve years ago the patient underwent a gynecological operation, the indications and nature of which she does not remember. A few months later a hernia appeared in the incision. This caused no acute symptoms until one year ago when there were signs of incarceration with pain, nausea and vomiting. The patient has had several such attacks smce. Past history. General health poor since age of twenty-three. Measles at thirty-five, no rheumatic fever. Tonsillitis twice. Not subject to sore throat. Frontal headaches frequently during past fifteen years. Some swelling of feet on standing. Digestion good until fifteen years ago, since then much flatulence, with "heartburn" after meals. Married thirty years, one normal child, one miscarriage at three months. Menses always painless and normal; menopause (surgical) following operation at age of forty. Physical examination. Temperature, 99.2°. Patient very obese, in great discomfort, iohe pain being typical of renal colic. Marked dental caries. Tonsils normal. Heart and lungs normal. The midline abdominal incision shows three distinct points of rupture, with herniae as large as lemons. Easily reducible. Neither kidney palpable. Distinct tenderness in both renal fossae. Phenolphthalein: 40 per cent (one hour). Cystoscopic examination. March 24, 1921. Urethra infiltrated, takes 8½ Kelly cystoscope with pain. Bladder normal. Region around left ureter injected, left orifice pin-point, will not take No. 7 rena,l catheter. Right orifice normal. Catheterized bladder urine: no albumin, sugar, red or white blood cells, casts or organisms. On March 28, after dilating the ureteral orifice a No. 8 catheter was passed up the left ureter, meeting but passing beyond a dense obstruction low in the ureter. A wax bulb 4 mm. in diameter engaged the obstruction but would not pass through it. The capacity of the left ureter and kidney pelvis was 13 cc. On withdrawing the bulb, it hung densely from a point 6.5 cm. to a point 2.5 cm. above the vesical ori-fice of the ureter. The bladder urine was again clear; the left kidney urine contained a few red blood cells, because of the trauma inflicted by the catheter. There was a superficial scratch both on the wax tip and on the distal shoulder of the bulb. No stones could be seen in the x-ray plate.

80

GUY L. HUNNER AND LAWREN CE R. WHARTON

Clinical impression. Ureter stone, left; ureteral stricture, left; hydronephrosis and hydroureter, left. The patient had a very severe reaction following this examination. Although the urine was observed with every care, no stone was discovered. Operation. Dr. Runner. April 2, 1921. Cure of hernia. Release of adhesions. Exploration and retrograde dilatation of left ureter. Omentum was adherent in hernia. Sigmoid redundant, adherent deep in pelvis over ureter. Considerable bleeding on releasing it. The floor of pelvis densely scarred, board-like, an immense amount of indurated fat. At former operation, supravaginal hysterectomy and bilateral salpingo-oophorectomy had been done. Many dense adhesions all through pelvis. Left ureter difficult to isolate. Much bleeding. Small incision made into ureter at brim of pelvis. External diameter of ureter at that point 6 mm. A ureteral catheter with a wax tip was passed into bladder, finding no stone. A wax bulb hung just above the bladder. The ureter was then dilated by means of Hegar dilators. No stone was found. The ureter was drained extraperitoneally, the abdomen closed with drainage through the cul de sac of Douglas. The patient left the operating room in shock and died twenty-six hours later. Au.topsy. No. 6538. Anatomical diagnosis. Drainage fistula of left ureter, stricture left ureter, hydroureter, hydronephrosis, left; multiple cysts of left kidney; extensive necrosis of renal epithelium, bilateral; abdominal and pleural adhesions; thrombosis of left common iliac artery. Cleft formation in adrenals. Autopsy performed eight hours after death. The stump of cervix, the bladder, a portion of the left ureter and · left common iliac artery are firmly bound down to the pelvis by dense adhesions abundantly infiltrated with fat. Kidneys : Left kidney weighs 110 grams. Numerous small cysts. Cortex is slightly thinner than usual. Slight hydronephrosis. Vessels of pelvic wall injected. Right kidney weighs 180 grams. Capsule strips easily. Cortex and medulla of normal relative thickness. Cortical vessels deeply injected. Right ureter of normal size, being smaller in the broad ligament than in the abdomen. Ureters : The left ureter is markedly dilated above the operative site,

URETERAL STRICTURE

81

being 7 mm. in diameter through the abdominal portion. At points 5 and 4 cm. above the vesical orifice it measures scant 3 mm. in diameter, being markedly constricted, and its walls greatly thickened. Where the common iliac artery branches it is firmly adherent. Microscopically the left ureter shows fibrous thickening of the wall, edema and infiltration with round cells and leucocytes, many of which are eosinophiles. Kidneys: Right kidney shows extensive destruction of tubular epithelium. The cells have lost their nuclei and are greatly swollen. Many have gone to pieces. The glomeruli are swollen and there is apparently a little old blood within the capsule of some. The capsules are slightly thickened in several. Blood vessels are congested, but no blood is seen within the tubules. Left kidney shows the same thing as the right with the addition of considerable infiltration of the meduila with round celis and leucocytes, many of which are eosinophiles. The destruction of renal epithelium apparently was not a post mortem change, as autolysis was not found in any other organ. The cause of this extensive renal necrosis is unexplained. It does not affect the glomeruli nearly as much as the tubules. III. STRICTURE ASSOCIATED WITH GENERAL INFECTION OF THE ENTIRE URINARY TRACT

Case 7. E. S., aged forty, female, admitted to Johns Hopkins Hospital January 6, 1923. Operation January 13, 1923. Died February 8, 1923. Gyn. No. 28365. Autopsy No. 7344. Complaint. "Frequency of urination and paroxysms of pain in right side." Previous operations. Tonsillectomy April, 1922. Present illness. Of two years' duration. Onset in January, 1921, with frequency, chiefly nocturia, accompanied by no other symptom and preceded by no acute illness or infection. Frequency was always aggravated by fatigue or exertion and continued untreated until April, 1922, when the tonsils were removed. This gave no relief from the urinary symptoms. In June, 1922, bladder irrigations and jnstillations of AgNO 3 (0.1 per cent solution) were instituted, and during July and August, 1922, because of pain in the right side and back, the right ureter was catheterized five times without relief. Frequency and pain in the right lower abdomen and right back became progres-

82

GUY L . RUNNER AND LAWREN CE R . WHARTON

sively worse. During the past four months patient has had on an average one attack daily, duration of the painful paroxysms being from a few moments to six hours. Before the onset of menstrual periods the pain is radiated down the right leg. Past history. Patient never enjoyed rugged health. Never had much endurance. Best weight 154 pounds in 1907. Average weight 132 pounds. Present weight 125 pounds. Has had a good deal of dentistry, with two extractions, but never any noteworthy trouble with her teeth. Not susceptible to colds. No serious illness or infections. Married fifteen years, no pregnancies. Menses: onset at age of fourteen, regular every four weeks, profuse, lasting 3 days; occasionally a little intermenstrual bleeding if patient exerts herself. General health fair. Physical examination. General examination negative except for moderate grade of anemia. White blood cells, 7800 ; hemoglobin, 60 per cent ; blood pressure, 110 / 80. Temperature, 98°; pulse, 80; respiration, 20. The teeth were well kept. The thyroid not enlarged. The heart and lungs normal. No arteriosclerosis. Patient generally very hypersensitive. "Left kidney not palpable, not tender. Somewhat tender over left ureter at pelvic brim. Right kidney not palpable, not tender. Somewhat tender in appendix region, not tender over right ureter at pelvic brim. "Pelvic outlet : narrow and extremely tender. Cervix : far back in vagina. Fundus: apparently enlarged, seems impacted in pelvis. . . . . Extremely tender over both ureters in broad ligament region with desire to void." Urine examination (catheterized): Specific gravity 1010-1014. Albumin: faint trace, alkaline; sugar, 0; few white blood cells ; no red blood cells; no casts; no bacteria. January 13, 1924, culture urine : no growth. Further peivic and cystoscopic examinations were performed by Dr. Runner January 13, 1923, under ether anesthesia. Pelvic examination. Myomata 6 to 8 cm. in diameter in the anterior uterine wall. Uterus freely movable. Ureters not felt . Cystoscopic : Urethra everywhere infiltrated, dilated to admit No. 11 Kelly cystoscope. Bladder everywhere normal except in extreme right vertex where there is a brilliant red area 2 cm. long, 1 cm. wide, with a linear split in center oozing blood. The region around the right ureteral orifice is pale white, of normal color. Right ureter catheterized, using No. 9 renal with 5 mm. wax bulb. Catheter obstructs completely

URETERAL STRICTURE

83

was withdrawn, and after two trials a 4¾ mm. bulb was passed up ureter. On withdrawal the bulb hung firmly at points 3.5 cm. and 6.5 cm. above the ureteral orifice. Clinical diagnosis: "multiple ureteral stricture, right. . . . . Fibroid of uterus, medium size. Elusive ulcer of bladder." Operation. (Performed immediately after cystoscopic examination.) January 13, 1923. Dr. Runner. Supravaginal hysterectomy. Resection of bladder for elusive ulcer. Tubes and ovaries normal. Appendix atrophic. Multiple myomata. Right ureter slightly enlarged at region of pelvic brim. Bladder was opened in vertex, and an area 10 cm. by 5 cm. was excised from the right lateral wall and vertex. The dissection was carried down to within 1 cm. of urethral and right ureteral orifices. The bladder was closed completely and drained through the urethra by a mushroom catheter. Three cigarette drains were placed in the space of Retzius. Operation performed without accident or complication. Post-operative course. The convalescence following operation was perfectly normal until the seventh day when the temperature rose to 101 ° due to an infection of the space of Retzius. The urine was practically clear until this complication arose. The wound was irrigated through Dakin's tubes, and within three or four days the infection was apparently well controlled. The bladder sutures had broken down and all the urine was coming out through the suprapubic opening. On the nineteenth day she began to void per urethram in small amounts; the urine was very purulent as there was an open connection between the infected operative wound and the bladder. On the nineteenth day, the patient developed the symptoms of pyelitis, the temperature 103°, white blood cells, 18,400. On the twenty-third day Dr. Thomas R. Boggs diagnosed diffuse bronchopneumonia. She then developed femoral phlebitis and had several minor attacks of pulmonary embolism. Dr. Glen Craig, the interne, recognized the presence of fluid in the chest. On the twenty-fifth day, blood cultures yielded a heavy growth of hemolytic streptococci. On the twentysixth day she died. Autopsy. Dr. H. P. Smith. Performed ten hours after death. Anatomical diagnosis. "Partially healed laparotomy wound. Acute cystitis. Acute pyelitis and ureteritis. Acute splenic tumor. Thrombi in femoral vessels and in smaller pulmonary arteries (pulmonary embolism). Serofibrinous pleurisy. Cloudy swelling of liver with focal necroses."

84

GUY L. RUNNER AND LAWRENCE R. WHARTON

Laparotomy wound leads into bladder. Left pleural cavity contained 1200 cc. yellowish fluid. Patchy fibrinous pleural exudate. Left lung collapsed. Right lung normal. In left lung beneath pleura surfaces are several cherry red petechial hemorrhages. Kidneys: Left kidney 200 grams. Capsule normaliy thin, strips normally. Remains of fetal lobulations are made out. Cortex 6 mm. wide. Pelvis itself is seen to be of "normal size," contains a small amount of thin yellow turbid fluid, pelvic mucosa reddened, bright petechial hemorrhages. No focal abscesses in kidney. In the right kidney, the pyelitis was more marked. Ureters appear normal (in gross). Tubes and ovaries normal. Enlarged lymph glands anterior to lower part of aorta. No very great amount of arteriosclerosis. Femoral veins are filled with grayish red masses of thrombotic material. None of veins in pelvis are thrombosed. 111icroscopic. Lungs : no definite infarcts seen. No actual pneumonic consolidation seen. Thrombi in arteries. Liver: focal necroses. Kidneys: "A few inconspicuous scars are found and in association with these scars a few old hyalinized glomeruli. Otherwise the kidney appears normal. There is almost no arteriosclerosis. No inflammation is made out about t he pelvis of the kidney." "Bladder: Several blocks of tissue are obtained from the piece of bladder removed at operation. The most characteristic feature is the great edema which involves especially the submucosa but also rather strikingly the muscularis as far out as the peritoneal surface. The mucosa is gone in places but there is no diphtheritic membrane over the surface. The submucosa is rather extensively infiltrated with cells. There are almost no polymorphs. There are a few small lymphoid cells but by far the greater part of them are of the plasma cell type. There is some tendency for the exudate to be grouped about the biood vessels, but this tendency is not at all striking. There are a · number of compact clumps of cells in the submucosa. They resemble small lymphoid nodules. No necrosis is found in association with them. In places, the remaining epithelial lining seems to have proliferated slightly and in one place a small clump of cells is found beneath the epithelial lining and is derived from it. It has something of a syncytial character but does not resemble a tubercle giant cell at all closely. The blood vessels in the section are numerous and are somewhat dilated but otherwise not rtmarkable. No thrombi are found in any of them. Bacterial stains show no microorganisms."

URETERAL STRICTURE

85

"A section taken from the bladder at time of autopsy shows less edema but more strikingly cellular infiltration. "A section taken from the left ureter shows considerable . round cell infiltration of its wall and the mucosa is entirely gone but there is no great amount of cellular exudate on the inner surface of the ureter."

FIG. 15.

CASE

7.

SECTION OF URETERAL WALL THROUGH STRICTURE OF RIGHT

URETER 4 CM. ABOVE BLADDER Ureteral wall measured 7 mm. thick at this point, two or three times the normal thickness of the ureter in this area. Compare the thickness of this half segment of ureteral wall with the total cross-section, figure 13, of a normal ureter taken at the same level above the bladder. Note the thickening and fusion of the periureteral sheath as compared with the same structure in figure 13. Same magnification as figure 13.

Dr. McCallum's note. "From the point of view of the clinician this is an example of the so-called interstitial cystitis which is said to be characterized by a great irritability of the bladder and inability to contain any considerable quantity of urine, and marked pain. The section taken at the time of the operation shows great edema, rather widespread erosion of the epithelium and infiltration with scattered wandering cells, chiefly mononuclear in character. There are seen in the section no definite ulcers. Following the operation there appears to have been a generalized infection with streptococci, etc."

86

GUY L. RUNNER AND LAWRENCE R. WHARTON

"On microscopic examination, the kidney shows moderate autolysis, a few very inconspicuous scars are found and in association with these scars a few old hyalinized glomeruli. There is almost no arteriosclerosis." The secreting and collecting tubules vary but little from the normal diameter, there being occasional slight dilatation. There are numerous areas of small round-cell infiltration. (See figures 15

FIG.

16.

CASE

7.

HIGHER POWER MAGNIFICATION OF BLOCK OUTLINED IN FIGURE

12

THROUGH STRICTURE OF RIGHT URETER

Note the unmistakable signs of chronic inflammat ion, with great hypertrophy of the muscle bundles. Compare with normal ureter, figure 14, of same magnification.

and 16 for a microscopic study of an area in the right ureter iocated about 4 cm. above the bladder where the wax-bulb located stricture in 11ivo. This ureter was pronounced normal at autopsy.) I V. CAUSE OF STRICTURE NOT DETERMINED ; SECTIONS NOT THROUGH AREA OF STRICTURE

Case 8. G. M., aged twenty-six, female, seen in Asheville, N. C., by Dr. Runner, May,_1923.

URETERAL STRICTURE

87

Complaint. Burning in bhdder and pain in left back. Clinical history. Bladder symptoms had been present about two years. Within two or three months after onset of these symptoms the uterus was suspended "to relieve the bladder pressure," but the symptoms were not altered. Pain in left back came on about six months ago. Exam;nation of urine at that time showed heavy pyuria. In January, 1923, Dr. Webb Griffith found the bladder severely inflamed. Right kidney was catheterized in March, 1923, and found to be normal. By the beginning of May the urine had cleared up appreciably, the bladder looked much better, but the left ureter could not be catheterized. Dr. Runner examined the patient on May 23, 1923, at the request of Dr. Griffith. Both kidneys were easily felt; the right kidney could be moved down as far as the brim of the pelvis. The left kidney was not tender. There was some tenderness over the right ureter at the pelvic brim, none over the appendix area. Pelvic examination was negative except for thickening of the left ureter as felt per vaginam and tenderness over both ureters in the broad ligament region. Cystoscopic. The bladder in general looks normal, pale white. In the right wall and extending down the right lateral wall is an area of petechial hemorrhagic points. A typical picture of elusive ulcer. This entire area is about 4 cm. long and 2 to 3 mm. wide. It is of a distinctly iinear character and the easy bleeding makes one think of the possibility of tuberculosis as contrasted with elusive ulcer. The trigonum shows a general red congestion and two or three slight pale white elevations, either tubercles or vesicles. Both ureteral orifices are very small, pin-point. There is considerable scar tissue about the trigonum and the trigonum in general seems considerably narrowed. The left ureter is entered with the curved metal searcher for about 1 cm. Then the No. 7 renal catheter with spiral wax tip enters about 3 cm. and stops completely. Impression. With the former history of much pus and albumin and a generalized cystitis, with the gross thickening of the lower end of the left ureter, with the rather free bleeding of the linear bladder ulcer, and with the scar tissue and contraction of the trigonum, Dr. Runner was inclined to favor the diagnosis of tuberculosis over that of elusive ulcer. Dr. Griffith removed the left kidney and upper three or four inches of the ureter under the impression that it was tuberculous. He states

88

GUY L. RUNNER AND LAWREN CE R. WHARTON

that the visible portion of the ureter below the operative site was "decidedly dilated- possibly to half again its normal size. It was thickened but was not adherent to the surrounding structures." Dr. Griffith sent the removed tissues to a prominent pathologist apparently

F m.

17.

CASE

8.

MrcRO PHOTO GRAPH OF URET E R AL WALL A FEW CENTI METE RS BELOW THE KIDNEY

Note marked hypertrophy of the en tire wall. The changes in the epithelial layer described in the text are probably partially due to the post-operative contraction of the specimen, for the ureter was not distended with fluid before fixation. Note widening and edema of the submucosa layer, also the slight roundcell and plasma-cell infiltration. The moderate leucocyte invasion mentioned in the text was probably due to operation trauma. N ote hypertrophy of t he muscle_bundles, and increase in fibrous tissue.

without a report on the clinical findings, and he received the following preliminary report: "I have been more interested than I can tell you in the sections of the specimen (Mrs. M. J . M ., aged twenty-six) which you forwarded on June 9, 1923. What I have to say now can hardly

URETERAL STRICTURE

89

be considered in the light of a complete report, for experience indicates that this is the type of lesion with which one is likely to play for a long time before coming to any absolute conclusion, but rather than delay I am sending you a tentative report, of course, with the understanding that if subsequent study allows further conclusions to be drawn, these will be communicated to you. "The kidney looks quite normal grossly, but our attention was attracted to the ureter which is undoubtedly enlarged and very thick wailed (fig. 17). When cross section of the ureter was made, this became quite obvious. Indeed, the wall of the ureter as well as the wall of the pelvis was many millimeters thickened and lined here and there by brownish material, probably blood. Microscopic sections were, therefore, made of the ureter and of the kidney including its pelvis, and these show essentially the same changes. There is great thickening of the wall of the ureter and of the pelvis of the kidney. This thickening is not confined to any one layer. The submucosa is very much wider than normal, infiltrated here and there with mononuclear cells and occasional polynurlear cells. The blood vessels are rather prominent and the lymphatics are enlarged. The epithelium in places is denuded; in other places it is very much thickened, many layers projecting papillomatous-wise into the lumen. These papillae may be solid epitheliai core or they may be hollow epithelial masses with the connective tissue core extending into them. In many places there are cyst-like masses in the wall of the ureter which indicate that the process is chronic and of the nature of the so-called cystitis cystica which you know in the bladder. Nowhere in the submucosa of the ureter or its pelvis is there any foreign body reaction indicating tubercles. Nowhere is there caseation or necrosis. As one ascends into the pelvis of the kidney the changes in the epithelium and in the underlying connective tissue are similar to those described for the ureter. There are also changes in the kidney itself, but these are too indefinite at the moment for a more complete description (fig. 18). The changes involve the epithelium of the uriniferous tubules and involve them in a way similar to that in which the epithelium of the ureter and pelvis is involved. The cells seem to be foamy much more like the rhinoscleroma cell or the leprous cell. "As yet I have been unable to find any outspoken etiology. One naturally thinks of schistosoma or bilharziasis, but I have not been able to find any eggs, and it would be unusual indeed for such a condition to be found in the United States.

90

GUY L. RUNNER AND LAWREN CE R. WHARTON

"I am quite convinced this is some form of parasitic infection; it may be bacterial, if it is, it is an unusual form of bacterial infection, and I am more inclined to think that it belongs to some higher type of fungus or protozoa, but as to just what it is, I am still in the dark. I shall have some special stains made and try to find out what we can. In the meantime, of course, it would be very interesting to know about the patient's history, as to whether there was any eosinophilia or whether there was any general reactions such as are associated with bilharziasis, etc."

FIG. 18. CASE 8 Note degenerative changes in the tubular epithelium although this is an operation specimen placed in hardening solution at once. Note absence of inflammatory tissue. Other areas of this microscopic section showed more clearly a dilatation of many of the tubules. CONCLUSIONS

V,.Te have presented the clinical and pathological records of 8 cases of ureteral obstruction. Seven of these patients had been cystoscoped, and in all but case 2 (the one with congenital valve the strictures had been diagnosed clinically. These cases throw but little light on the problem with which

URETERAL STRICTURE

91

we were chiefly concerned and which prompted us to conduct this investigation, namely, the pathology of the focal infection stricture. This was the clinical diagnosis in 2 of these 8 patients, and in only 1 of these 2 was there opportunity to study the actual site of the stricture, and the pathological picture in this case was complicated by a general urinary tract infection of seven days' duration. In all the other cases, the strictures were due to other conditions which have long been recognized as causes of ureteral obstruction. This series is too small to form the basis of any sweeping generalizations or definite conclusions. It is, however, the first effort that has been made to correlate the clinical and pathological findings in cases in which focal infection stricture has been clinically diagnosed. It is to be hoped that further studies of this sort will eventually enable us to determine the pathology of this clinical syndrome.

THE JOURNAL OF UROLOGY, VOL.

XV,

NO.

1

,J