PYELITIS TERMINATING IN SUPPURATIVE NEPHRITIS-CASE AND SPECIMENS. BY J. PARK WEST, M.D., The child from whom these kidneys were taken was a female ten months old when taken sick; her death occurred twenty-four days later. She had always been a healthy child, and had just been weaned on account of the mother's health. Her illness can be divided pretty definitely into three periods: the first represented by a lobar pneumonia, the second by pyelitis and the third by pyelonephritis. I saw the child two days after the beginning of her sickness. A croupous pneumonia was suspected, but, owing to the late appearance of the physical signs, a positive diagnosis was not made until twenty-four hours before the crisis, which took place early in the morning of the sixth day of her sickness. The second period of about ten days began on the evening of the day of the crisis by the temperature going up to 103° F., without symptoms on the part of any other organs. It is believed the pyelitis began at this time and was a direct result of the pneumonia. There was not now, nor had there been, any evidence of vulvovaginitis; it was only during the last period that a vulvovaginitis developed. While during the pneumonia the urine had been quite free, of a strong odor and stained the napkin deeply, it was now not so free, had but little odor and caused but little staining. On this first day of the second period, after three days' trial, a sample of one teaspoonful of highly acid albuminous urine was secured; it also contained a number of small cells and a few epithelial cells. The urine the next day was the color of milk and water, and for the next eight days was of a clean milky color. It was acid for the first few days; then became neutral, being slightly alkaline twice. The sp. gr. of but three specimens could be taken it was 1014, 1012 and 1014. It always contained pus, albumen, pus cells in abundance, a great many epithelial cells of different kinds, and not a few blood cells. Altogether, about a half-dozen hyalin casts were seen. At times, the secretion was fairly free-at others scanty. On the second day of this period the temperature was 1043° and 104°, after which it went down. gradually, until the eighth day it had almost subsided. There were never any marked excursions of the temperature, nor any chills or sweats. For three days there was marked soreness over the entire body, and at all times there appeared to be soreness over the left kidney only. After the third day there was swelling of the face, hands and feet, which later extended up the arms and to the thighs, and pitted over the tibia. The child was very pale and depressed, but not wasted. At times she was very restless and at others took prolonged sleeps, and was usually dazed for some time after waking. During the first period she had vomited three or four times and the bowels were rather constipated; there was no vomiting during the second period, but on two or three days the bowels were loose. The urine gradually increased in amount and was usually passed more frequently, but was seldom free, and while the amount of albumen and pus diminished, they were never absent, and the milky color persisted. For three days now (thirteenth to fifteenth days) the general condition improved slightly and the temperature ranged from 99.4° to 100.2° F. On the sixteenth day of her sickness, after three days of slight and gradual improvement, the third period began suddenly with severe gastrointestinal and uremic symptoms and continued until her death, eight days later. During this period there was never any fever and once the temperature was 98° F. per rectum. The vomiting was very severe and from twelve to twenty-four times in the twenty-four hours, while in the same time there were from four to twelve stools. Soon after the oncoming of these symptoms a vulvovaginitis developed. The urine was lessened again, although frequent small quantities were passed, excepting on two days (eighteenth and twentieth) it was fairly free. There was none passed for thirty hours before her death and about a half ounce was found in the bladder at the post mortem. The urine remained milky, but did not look so clean. There was less pus and a little more albumen. The cells-pus, blood and epithelial-were more numerous. An occasional hyalin and epithelial cast was seen, but infrequently. A sufficient quantity to get the sp. gr. was not secured. Every specimen tested for reaction was neutral. Most of these last eight days she was never fully conscious, and for two days (Wednesday and Thursday, or twentieth and twenty-first) she was semicomatose. On the third to the fifth days the right kidney could be easily felt through the anterior abdominal wall; after the fifth day it could no longer be felt. For the last three or four days she suffered so greatly that considerable doses of codeine had to be given her to control the screaming and restlessness. The postmortem was limited to the abdomen. The pelvis of each kidney was thick and rough, and on the surface of each were a few small spots of distended capillaries. The left kidney weighed 80 grams and the right 72. This should be contrasted with 30.1 grams, the average weight for children of this age, as given by Bovaird and Nicoll in their tables in "The Weights of the Viscera in Infancy and Childhood" (ARCHIVES OF PEDIATRICS, September, 1906). Vierordt's. table (quoted in the same paper) gives practically the same weight. Dr. W. G. MacCallum, who kindly made the microscopical examination, sends the following report: "The section of the child's kidney shows a remarkable suppurative nephritis. The capsule is unaffected. The blood vessels are in general normal in appearance, although the smaller ones are distended with blood and there are occasional hemorrhages. "Scattered through the tissues, sometimes in connection with disintegrated tubules, sometimes inside the tubules, there are clumps of bacteria. These do not appear to be in the blood vessels at all. They are bacilli somewhat larger than the typhoid bacillus. The tubules are very generally distended, with great quantities of leukocytes and desquamated cells. There are no definite abscesses, but relatively few of the tubules escape. The glomeruli wherever seen seem fairly well preserved. The remaining tubules show a most extreme fatty degeneration of the epithelium. The tubules of the medulla are uniformly filled with the débris of cells and leukocytes. "The absence of glomerular changes and the presence of bacteria in the tubules and not in the blood vessels seems to argue in favor of an ascending, rather than a hematogenous, infection." DISCUSSION. ISAAC A. ABT. M.D., Chicago.-It would be well to cystoscope the bladder and learn something as to the nature of the bladder wall and also as to the orifices of the ureters, particularly in female children. The expert cystoscopist can occasionally throw important light upon these cases and render material aid, es pecially in cases where relief by operative procedure is contemplated but not clearly indicated. A. JACOBI, M.D., New York.-Were gonococci found? DR. WEST.-No examination was made for them. There was no history of former vulvovaginitis. DR. JACOBI.-Undoubtedly the two belong together-the pyelitis and the vulvovaginitis. Was the uterus examined? DR. WEST.-No. DR. JACOBI.—It is a very common experience not to find a vulvovaginitis when it has existed for weeks and months perhaps. That is a result of the fact that the process is very frequently limited at that time to the uterus. The gonococci are stored away in the uterus. Up to the seventh to ninth year the mucous membrane of the uterus is not a smooth surface, but is in folds so that the gonococci may easily be buried in these folds and not come to the surface at all for weeks and months. That is the explanation of why we frequently think we have cured a case, when all at once it breaks out again-the gonococci could not be reached at all. There may be a gonococcal metritis a long time. before it makes its appearance. CHARLES G. KERLEY, M.D., New York.-Dr. West's case reminds me of one that I was called upon to autopsy. The child was supposed to have had malaria. There was a typical malaria. chart, but autopsy showed extensive cystitis and multiple nephritic abscesses. AN UNUSUAL TYPE OF ACUTE NEPHRITIS IN CHILDHOOD. BY JOHN LOVETT MORSE, A.M., M.D., Assistant Professor of Pediatrics, Harvard Medical School; Assistant Physician at the Children's Hospital and at the Infants' Hospital; Visiting Physician at the Floating Hospital, Boston. I have recently seen a number of cases of acute nephritis in childhood in which the characteristics of the urine have been materially different from those of the ordinary form, the chief differences being the complete, or almost complete, absence of blood and blood elements and the presence of a large number of small, round mononuclear cells, often associated with a considerable number of polynuclear leukocytes. There can be no doubt that these cases were acute and not chronic. The course was essentially the same as in other forms of acute nephritis, with the exceptions that the duration was usually shorter and the prognosis somewhat better. The following histories illustrate this type very well. A boy, eleven years old, had had scarlet fever and measles when four, and diphtheria when four and one-half, years old without any complications. Since then he had been perfectly well, except for adenoids, which had been removed two years before. He went to the country about the first of August, 1907, and while there had no illness. August 17th he complained of a slight headache, and it was noticed that his eyelids and face were puffy. There were no other symptoms. He entered the Children's Hospital August 20th. The physical examination was negative, except for a little puffiness of the eyelids, which disappeared in forty-eight hours. There was no accentuation of the second aortic sound, and no enlargement of the left heart. The urine was yellow, acid, 1.030, and contained 0.2 per cent. of albumin. The sediment showed numerous short hyalin and fine granular casts, many leukocytes and a moderate number of small, round cells. The urine of the 26th was acid, 1.023, and contained no albumin. The sediment showed a few hyalin and fine granular casts, a moderate number of leukocytes and a few small, round cells. On the 29th albumin was still absent, but the sediment showed a few coarse, granular casts, a moderate number of leukocytes and a few round cells. He was discharged September 4th, having had no symptoms what |