THE URINARY FINDINGS IN A SERIES OF INFANTS SUFFERING FROM INTESTINAL INFECTION.*

BY J. H. MASON KNOX, JR., M.D.,

Baltimore,

AND

J. C. MEAKINS, M.D.,

New York.

Concerning the condition of the kidneys in infants suffering from intestinal infection there has been a wide difference of opinion. In a careful review of the literature by Morse' in 1899 the conflicting views were graphically stated. Among those whose opinions are founded on large personal experience may be mentioned Kjellberg, who in 1870 found nephritis on autopsy in 67 out of 143 infants dying of acute or chronic enteritis. In 3. non-fatal and 15 fatal cases of the same kind the urine contained albumin, casts and leukocytes. Holt, writing twenty years later in Keating's Cyclopedia,3 asserts that, although cloudy swelling of the renal tubules is common in enteritis as in other febrile diseases, true nephritis is uncommon, and that albumin in large amount, renal epithelium, and casts are exceedingly rare. Nevertheless, Czerny and Moser in 1894 found nephritis in II fatal cases of gastroenteritis in infants under two weeks old. The frequency of nephritis, they admit, diminishes with age. In the same year Falsenthal and Bernhard reported a series of 15 autopsies in cases of vomiting and diarrhea in which the urinary findings had been repeatedly studied during life. Marked degeneration of the convoluted tubules was demonstrated. The collecting tubules contained many casts and often blood. In the urinary examination albumin was usually present and often necrotic cells, casts of various kinds and leukocytes were found.

Morse1 presents a series of cases all in infants attending the out-patient department ill with uncomplicated diarrheal diseases in which the urine was collected by catheterization and carefully examined. The clinical diagnosis was fermental diarrhea in 64 instances and ileocolitis in 6. Albuminuria due to renal complication was noted in but 10 cases, 14 per cent., and, except in one instance, was of small amount. Casts were found in but 6 of these cases. No mention is made in this analysis of pus cells, although

From the Laboratory of the Thomas Wilson Sanitarium.

in the table pus is recorded as present in the sediment in 4 instances, and in 8 other cases an occasional small cell is noted. No relation was made out between the urinary condition and any of the symptoms, and Morse concludes that the renal changes in the acute diarrheas are usually moderate in degree and degenerative, and not inflammatory in character. It is unfortunate that in each of the cases reported by Morse but a single examination of the urine was possible and that many of the cases passed at once out of observation.

In the same year Koplik" reported a series of 25 infants and children with acute or subacute gastroenteritis, in which albumin alone was found in 4 instances, albumin and casts in 13, albumin with casts and pus twice, and casts alone once, while the urine was normal in but 4 cases. Although Koplik thinks that these findings justify the term nephritis, he recognizes that the condition, on account of its rapid improvement without renal lesion, is different from the nephritis in adults or that after scarlet fever. It is brought about, he suggests, by the action of toxins in concentrated form upon the kidneys, because of the great loss of fluid.

Recently Chapin' found albumin in 75 out of 86 cases of disturbance of the gastrointestinal tract, in 37 of which casts were also noted. These elements were present in a somewhat larger ratio in a series of pulmonary and general diseases. The almost uniform presence of albumin, often with a few casts in many febrile affections in infancy, has been repeatedly noticed by Jacobis and others. It seems, therefore, that although renal complications play a small rôle in gastroenteric affections of mild and moderate grade, yet in the severe forms they are more serious.

The present study was undertaken with the hope that a somewhat more extended analysis of the urinary findings in a series of infants suffering from diarrheal affections, and under constant observation in hospital wards, might indicate more clearly the extent and frequency of renal complications in intestinal diseases.

INTRODUCTORY STATEMENT.

The cases studied were those of 72 infants admitted to the wards of the Thomas Wilson Sanitarium.* They may be divided for our purposes into two groups-those with intestinal infection and those without. The urine was collected in specially ar

Hospital for children suffering from intestinal disorders, situated in the country ten miles from Baltimore.

ranged flasks or test tubes, or, in the case of girls, directly in a vessel or obtained by catheterization. In many instances a number of specimens were obtained from the same case.

The first group, the diarrheal cases, consisted of 53 infants; of these 33 had dyspeptic or fundamental diarrhea of varying degrees of severity, and 20 ileocolitis, as determined chiefly by the character of the discharges. In many of the latter cases there was evidence of intestinal ulceration.

GENERAL CHARACTER OF THE URINE.

In 31 of these 53 cases no pathologic elements were found in the urine; in 22 instances the urine contained albumin, casts, pus, red blood corpuscles, or several of these elements together, as will be specifically stated later on.

AGE PERIOD.

The infants studied fell into the following age periods:

Thus more than half were in the middle half of the first year.

SEX.

But little interest attaches in this preliminary analysis to the sex of the cases studied. They were: Boys, 34; girls, 19. Total, 53.

DURATION OF ILLNESS.

The duration of illness at time of urinary examination may be briefly stated as follows in periods of weeks:

As the urine was usually examined shortly after admission, this date indicates that the babies when received were suffering from more than light transitory intestinal derangement. This is also shown by the result of treatment.

This table indicates that the cases studied were of somewhat severer character than those of the sanitarium as a whole.

Passing from the more general consideration to a study of the cases in which the urine was abnormal, a further analysis should consider the extent and nature of the urinary alterations and the renal changes, if any, indicated thereby. Twenty-two cases were found. It has long been known that in any febrile or toxic disease, a certain amount of albumin and some casts may be found in the urine, not because of an inflammatory lesion in the kidneys, but due rather to a parenchymatous degenerative process or "cloudy swelling" which the kidneys show in common with the other organs of the body and which may be of mere transitory character.

CLOUDY SWELLING.

Of the 22 cases, in 2 the presence of albumin was the only abnormality, while in 5 other albumin and hyalin casts were noted together. The albumin was never present in large amount, and the condition of the patients not particularly serious, with the exception of one infant who died of ileocolitis, in whom the renal condition was comparatively unimportant. All these patients had more or less fever; one had convulsions.

PYELITIS.

We regarded the presence of pus, polymorphonuclear leukocytes, in fairly large numbers in the urine as significant of a definite inflammatory process in the urinary tract. There was no evidence in the whole series of any urethritis or cystitis. The region. of the bladder was repeatedly palpated in all our cases, and in no instance was any tenderness elicited. No frequency of micturi

tion was noted. Pyuria alone or with moderate albuminuria without other change suggests pyelitis, although the exact extent of the renal involvement is difficult to determine. Cases belonging to this group were as follows: With pus alone, 2; with pus and albumin, 5, making 7 in all.

NEPHRITIS OR PYELONEPHRITIS.

When pus cells, together with albumin and casts, were found, the diagnosis of nephritis was made, especially when red blood cells or many bacteria were also present. This group of cases is as follows:

Pus with albumin and casts.

Pus with albumin and casts and many bacteria....
Pus with albumin and casts and red blood cells..

The casts were for the most part hyalin in character, though pus casts and granular casts were frequently found, but never in large numbers.

In regard to the character of the intestinal condition, these cases are divided as follows:

Dyspeptic or fermental diarrhea.
Ileocolitis

ΙΟ

12

Dividing the cases with urinary changes into three groups, as above indicated: (a) albuminuria with or without casts; (b) pyelitis (pus cells without casts); (c) nephritis or pyelonephritis (pus cells with albumin and casts), the relation of each of these to the intestinal condition may be indicated thus:—

This table suggests the conclusion that urinary findings may be altered by the toxins or fever in dyspeptic diarrhea, as well as during an ileocolitis. This may be because in many of these cases the two conditions are not to be sharply distinguished. A further analysis of the cases in respect to the intensity of the renal