Catheterization of the ureter itself seems to have a beneficial effect upon the patient in promoting drainage and clearing the ureteral passages. Lavage of the kidney pelvis may be of some value in the early stages, but can be of little use in pyonephrosis and pyelonephritis. It should be done very carefully, and not more than 4 c.c. of a protargol 2% solution introduced. It has been known to induce acute exacerbation of the condition. Bladder lavage, whether cystitis is present or not, should be done, as it is said to have some influence on the excretion of pus.

The bowels should be taken care of, and, if the amount of urine is not satisfactory, saline enemas or proctolysis should be given.

If the patient does not improve under the expectant treatment, and, if the amount of pus in the urine does not decrease, induction of labor should be considered.

Induction of labor is advocated because of the possibility of extension of the disease to both kidneys, and because the removal of the fetus usually has a marked beneficial effect upon the course of the disease. It should also be remembered that a considerable proportion of these babies are either stillborn (as in two cases here) or die soon after birth. So that induction, especially if the patient is at or near term, should be considered before nephrotomy.

If the patient is not near term, and there is evidence of extensive and serious infection of the kidney, nephrotomy may be possibly the choice. But it is to be remembered that, if nephrotomy is done, the infection must first be known to exist in only one kidney, and the condition of the uninfected kidney determined by ureteral catheterization.

The various writers usually range themselves into two camps; one advocating in

duction of labor, and the other protesting against induction and lauding nephrotomy. As is usual, when there is such marked divergence of opinion between good scientific observers, both are right. There is a place for both methods of treatment in different forms of the disease. If the child is near term, there is no reason why induction should not be done. And nephrotomy or nephrectomy should be reserved for those cases of unilateral severe infection with focal abscesses or pyonephritis.

It is possible that both may be required in some cases, as induction of labor may not stop the processes of infection in a kidney with advanced pyelitis and pyonephrosis. If the condition does not improve with removal of the child, as was the result in two cases here reported, nephrotomy should be considered if the infection is unilateral. But if infection is bilateral, the prospect of surgical treatment is not encouraging.

The patients, as a rule, bear surgical treatment well and without miscarriage.

There are usually no after-effects from the disease if the patient gets well under the medical treatment. One case, however, which had pyelitis in pregnancy, was referred to me for hematuria eight months after childbed, and the hemorrhage was of such a degree that nephrectomy was done. The patient recovered promptly.

One case here reported was watched through a second pregnancy, and there was no recurrence in spite of the fact that there was a chronic cystitis, with ulceration of the bladder, supposedly syphilitic.

The course of the disease is in general not severe and is easily amenable to medical measures; but it may be severe, and undoubtedly is so when the infection has advanced to invade the kidney substance itself.

Cases of Pyelitis:

Case I-Double Pyonephrosis, pyoureter; Staphylococcus pyogenes Aureus; Septicaemia.

Patient

Clinical History:-Primipara. was sent to the hospital for irrepressible vomiting when 81⁄2 months pregnant. She was much emaciated and weak. Temperature 101-102° at night and usually subnormal in the morning. The vomiting which had persisted for two weeks, was controlled by purgatives, dieting and saline enemata; but the fever persisted. The urine showed a few pus cells, but no albumen. The patient was delivered at term of a dead child. Temperature went higher after delivery, and the patient died on the same day.

Post Mortem Examination:—
Left Kidney.-Measures

IIX5.5 cm. The capsule strips readily. The surface of the kidney is pale and is dotted with purulent foci, which extend into the kidney substance. On section kidney tissue is exceed ingly pale. Occupying the pyramid in several places are small abscesses from 2 mm. to 12 mm. in diameter. These abscess cavities are surrounded by a distinct hemorrhagic zone. In some of the pyramids near the point can be seen minute pin point opaque areas extending into the tubules. The pelvis of the kidney contains a small quantity of purulent material, and the surface is somewhat hemorrhagic. The glomeruli are visible and the cortex measures 8 mm. in thickness. In numerous areas the infection can be seen extending up along the tubules. There is marked cloudy swelling. Left ureter slightly dilated.

Right Kidney.-Measures 11x6x4 cm. Capsule strips readily; surface pale and is studded with numerous small abscesses. There is one retention cyst, I cm. in diameter, on the surface. On section, the tissue of the kidney is very pale and is thickly studded with small abscesses which appear to extend up along the tubules and in places show large areas of necrosis. As in the other kidney the abscesses are surrounded by a hemorrhagic area. The cortex measures 6 mm. The pelvis of the kidney is much dilated, contains a small

quantity of purulent material and its mucosa is markedly hemorrhagic.

Bladder:-Contains

about 60 CC. of turbid straw colored urine; beyond some congestion, its. mucous membrane is of normal appearance. The right ureter, just where it passes over the pelvic brim, becomes markedly dilated and at a point near the kidney measures 2.75 cm. in diameter. Throughout the dilated portion the mucous membrane is dotted with hemorrhages, and in some places clots have formed. On the left side, 12 cm. above the ureteral orifice, the ureter is dilated and measures .75 cm. in diameter, while near the kidney it measures 1.75 cm. in diameter. The mucous membrane is hemorrhagic in places. Both ureters in the region of their entrance into the bladder are of normal appearance.

Uterus:-Measures 16.5x11x8 cm. There are lateral lacerations of the cervix most marked upon the right side. The fundus of the uterus contains a considerable amount of clotted blood. The interior is much regular. Uterine muscle is of normal aproughened and the surface is exceedingly irpearance. The vagina is much dilated and the mucous membrane shows numerous normal. Placenta is normal. small hemorrhages. Ovaries and tubes are

Microscopic Examination.-Kidneys:The greater portion of the substance shows marked cloudy swelling. Scattered here and there through the organ, usually along the group of tubules, are areas in which the kidney substance is densely infiltrated with cells, both polynuclear and small round cells. Some of these cells are in the lumen of the tubules, others are between the tubules. Associated with these lesions is a certain amount of hemorrhage between the tubules and a considerable degree of necrosis of the kidney cells. In some places there has been an extensive breaking down of the kidney. substance with the formation of abscesses.

The vessels are in places plugged with bac

teria.

Bacteriological Examination:-Cultures were taken from heart's blood, liver, spleen, both kidneys, pericardium and mesenteric gland.

Cultures from heart's blood, liver, spleen and both kidneys showed a coccus in pure

culture which liquefied gelatin, coagulated and produced acid reaction in milk and produced a marked yellowish growth on potato, corresponding in all particulars to the staphylococcus pyogenes aureus. Pathological Diagnosis:-Infection of both kidneys with cloudy swelling. Dilatation of both ureters with pyo-ureter. Slight pyonephrosis. Acute splenic tumor. Cloudy swelling of liver. Swelling of mesenteric glands. Slight arteriosclerosis. Persistent Meckel's diverticulum. Enlarged uterus just after labor. Infection of kidneys with staphylococcus pyogenes, aureus, associated with general infection of blood and organs with the same organism.

liver. On section, kidney is pale, soft, and there is moderate dilatation of the pelvis. Cut section is mottled in appearance and in the kidney substance are multiple abscesses of creamy-white pus, varying in size from a pin point to the size of a pea. There is moderate cloudy swelling and right ureter is not dilated.

Left Kidney:-Shows a similar condition, but less marked. There are not so many abscesses, nor are they of as great size

largest measures 5 cm. Pelvis of kidney is not dilated, and left ureter is not visibly dilated.

Bladder contains a small amount of straw colored turbid urine. There is

tion.

Clinical History:-Para ii, age 32. Well formed, well nourished woman, was admitted to the hospital 72 months pregnant and in labor. No fetal heart was heard. She complained of having had chills and fever for two days and pain upon the right fever for two days and pain upon the right side. Temperature 101.4°, pulse 120. Delivered 8 hours after admission of a dead fetus. Temperature next night 100.2°, pulse 100. Second day temperature rose to 102.4°, and pulse 104. Large quantity of pus was found in the urine. Pain on right side continued and was referred down along the ureteral course.

Ureters were catheterized and pus found in both kidney urines. Colon bacillus was recovered from kidney urine. Bladder showed a chronic trigonitis. Patient was put on medical treatment with excess of liquids, hexamethylenamine, sodium benzoate and buchu, and did consistently well for 9 days. The pulse and temperature came to normal and the amount of pus steadily decreased in the urine. On the tenth day the temperature shot up to 101°, pulse to 96, and the patient went into shock and died on the 13th day, never recovering from the shock, and passing into coma in spite of intravenous saline and stimulants of many kinds.

Post Mortem Examination:—

Right Kidney:-Measures 10x5x4.5. Capsule strips with difficulty. A moderate number of fibrinous placques between the peri-renal tissue and the under surface of the

there are hemorrhagic spots in places. The orifices of the ureters are large, patent, and moderately congested.

Uterus: The uterus is large and measures 15x12x7. The fundus contains clotted blood, with an irregular and rough mucosa. Vagina is much dilated and shows small

hemorrhages.

Microscopic Appearance:-

Kidney:-Cloudy swelling. Dense in

filtration in areas of small round cells and polymorphonuclears. There is moderate necrosis of kidney cells and formation of abscesses.

Pathological Diagnosis:-Infection of both kidneys. Pyonephrosis. Enlarged uterus after labor. Acute splenic tumor.

Case III-Cystitis-Pyelitis in Pregnancy:

Patient was referred for sudden colicky pain in the right side, with temp. 101.4, pulse 120. Para i, 72 months pregnant. Pain and tenderness was marked, and had been present with increasing severity, for a week. There was marked frequency of urination, more pronounced at night, and when she made efforts to urinate, it caused a pain in her right side.

Temperature had been remittent 100°103°, for one week, and pus was present in the urine. Patient gave a history of bladder and cervical infection following marriage and before pregnancy, had been under treatment for syphilis contracted from her husband.

, 1910

Series, Vol. V.,

Cystoscopic examination showed a marked hypertrophic cystitis, with considerable oedema and hyperaemia. There was marked exfoliation of pus and shreds. At the fundus of the bladder showed a granulating ulcer, 2x2 cm., with a whole false membrane. The right ureteral orifice was markedly patent, while the left was slightly so. Ureters were catheterized, and the right kidney urine sp. gr. 1016, alkaline, contained pus cells, and bacteriological examination showed a mixed culture of colon and staphylococcus albus.

Left Kidney: Urine sp. gr. 1018, acid, contained no pus and was sterile. Patient was treated expectantly and improved. The bladder was washed out and treated by protargol 5%. The patient was also given mercurial treatment. The urine cleared up but not completely, and the patient was delivered of a live child at term.

The bladder condition did not improve markedly, but became somewhat better. One year after the delivery the patient became pregnant for a second time, and, apart from her chronic cystitis, had an uneventful pregnancy, until 8 months when she was delivered of a macerated syphilitic fetus.

Case IV-Cystitis Pyelitis:

Para ii, 6 months pregnant, complained of pain in right side and back for several days. There was tenderness in right iliac region and down toward the right thigh. Temperature had been 102° for two days, with headache and nausea. There was pus in the urine, but no complaint of frequency or pain on urination. Cystoscopic examination showed a bladder with a very moderate trigonitis and a patulous right ureteral orifice. Right kidney urine obtained by urine obtained by ureteral catheter, showed pus in moderate quantity, while in the left were a few blood cells alone, thought to be due to the manip

ulation.

Patient was in eighth month of pregnancy and referred with a presumptive diagnosis of pyelitis of pregnancy. There was pain on the right side; temperature 100° to 103°, remittent and pus in the urine.

Cystoscopic examination showed a marked hypertrophic cystitis with oedema and congestion. There was much exfoliation and desquamation of epithelium and pus. The mucus was boggy and oedematous. The ureteral orifices were swollen and congested.

The bladder was washed out with quinine bisulphate 1-1000 and the ureters were catheterized. The kidney urine was found clear and contained no pus cells. Patient was put upon bladder irrigations and protargol 5%. Temperature was normal second day and continued so.

Diagnosis:-Cystitis in pregnancy.

Case VI:-Cystitis in Pregnancy with Fever:

Para ii, 72 months pregnant, referred because of pus in urine and abdominal pain. Temperature for five days has been for°102° remittent. Pain on right side was not marked. Cystoscopic examination showed a moderate cystitis and ureteral catheterization showed clear kidney urine.

Case VII:-Cystitis in Pregnancy. Septic Endocarditis-Fever:

Patient was seen when 7 months pregnant in consultation on account of her heart and kidney condition. She had mitral stenosis and chronic nephritis. Expectant treatment with rest in bed was advised for a few days, but, as no improvement resulted, induction was advised. Induction was done by her physician and afterwards she showed evidences of infectious endocarditis. Ten days after delivery pus appeared in the catheterized urine, and she complained of pain on the right side. The right kidney was enthe right side. larged and easily palpable. Temperature was remittent 101°-104°. Pulse 110-140.

Patient was sent to the hospital for further investigation with a tentative diagnosis of septic endocarditis and pyelitis of pregnancy.

Cystoscopic examination showed a moderate cystitis with no pus in either kidney urine or ureteral catheterization. Patient was put upon bladder treatment and anti-streptococcic vaccine. She remained

six weeks in the hospital, but eventually recovered.

Diagnosis: Septic endocarditis-cystitis in pregnancy.

BIBLIOGRAPHY.

1. Olshausen, Samml. Klin. Vort. f. Gyn., 1892, xxxix, 15.

2. Pollack, Kritisch

experimentalle Studien zur Klinik der puerperalen Eklampsie.Leipsig, 1904.

3. Cathala, L'obstetrique, 1905.

4.

5.

Sippel, Centr. f. Gyn., 1905, xxix, 37.
McDonald, Cystitis in Women, Med.
Record, 1909, Feb. 23.

6. McDonald, Diagnosis of Early Pregnancy, Am. Jour. Obst., 1900, LVII. 3.

7. Mirabeau, Munch. Med. Woch., 1907, 1 iv, 345.

8. Donati, Arch. per ii Sci. Med., 1907, p. 203. 9. Baumgarten, Berl. Klin. Woch., 1905, Oct. 23.

10. Levein, Goldsmith, Virchow's Arch., 1893, CXXX, 10.

11. Sampson, Johns Hopkins Hosp. Bull. 1903, XIV, Dec.

12. Garceau, Am. Jour. Obst., 1909, Jan.
13. Barth, Centralb, f. Chir. 1907, 524.
14. Beardsley, Therap. Gaz., 1901, Jan. 15.
174 W. 58th St., New York.

SOME CLINICAL OBSERVATIONS ON BLOOD PRESSURE WITH SPECIAL REFERENCE TO THE EFFECT OF PROSTATIC MASSAGE.1

BY

DAVID MURRAY COWIE, M. D.,

Clinical Prof. Pediatrics and Internal Medicine, Univ. Mich.

Ann Arbor, Mich.

In discussing the subject of blood pressure from clinical standpoints I do so not with the intent of adding anything especially new to our general knowledge of this very important subject, unless it be the effect of prostatic massage. Altered blood pressure must be considered a symptom or state and not a disease. It is dependent upon such a variety of conditions that its clinical interpretation is often difficult and

'Read by invitation, Kalamazoo (Mich.) Academy of Medicine.

sometimes misleading. Several years ago in a discussion on this subject I heard it stated that nitroglycerine and nitrites in general have only a transitory effect in lowering blood pressure due to arterial disease or other causes. My experience at least seemed to me to be different. I had repeatedly noted what I thought permanent or prolonged changes in the character of the pulse under the use of the nitrites. At the time of the discussion I had no definite data at hand with which to substantiate my opinion and since that time I have not been so active in keeping records as perhaps I should.

There are many recorded observations of the changes which occur in blood pressure after the administration of a dose of

nitroglycerine. There is always a quick and marked fall and a gradual return to the normal point, the whole phase lasting not longer than fifteen or twenty minutes. Accordingly this drug has been employed chiefly for its transient effect, as for instance in attacks of angina pectoris, asthma, or apoplexy. In looking over my cases I have picked out a few that will serve to illustrate the points I wish to consider this afternoon.

I think the majority of observers are of the opinion that the sense of touch is not trustworthy for comparative blood pressure records, although no less an authority than authority than Sir William Broadbent emphatically stated at the Toronto meeting of the British Medical Association, that the educated finger is better than any instrument. By this method we make a note today of a blood vessel being straight or tortuous; its tension high, good, fair, or low; its quality full, small, quick, rapid or thready; its bulk plainly felt after compression, and tomorrow, or more fre