verted uterus, because, in such conditions of retroversion, there is a greater amount of congestion in the early part of pregnancy than in pregnancy with anteversion. This is believed to be due, as was noted in a previous paper (6), to the additional congestion caused by the retroversion.

With the advance of pregnancy, the congestion of the bladder mucous membrane becomes more general and uniform. The mucous membrane loses its usual pink-white appearance and becomes a cream-yellow, and also gains the appearance of greater thickness. The bladder lining appears more velvety and softer. There is apparently, an oedema and a greater increase in the lymphatic tissue of the bladder. After the congestion of the first weeks has been replaced by the thickened creamy appearance, the blood vessels of the bladder fundus are not readily seen. There is evidently a hypertrophy of both the muscular and membranous portion of the bladder wall, and the lower end of the ureter is enlarged and more easily palpated.

These facts observed cystoscopically, are borne out by the autopsies of three cases of pregnancy in which I have had the opportunity to examine the bladder wall histologically.

There was in these cases, an apparent hypertrophy of the muscle fibres and a small round-celled infiltration of the bladder wall. There were plasma cells and an apparent active proliferation of the epithelial layer. It is well known that vast numbers of epithelial cells are cast off from the bladder during pregnancy, and this proliferation is their renewal.

Mirabeau (7) has also noted cystoscopically, the curious changes in the bladder wall of the pregnant. He claims that obstruction to the urinary current is brought about

by the hypertrophy of the walls of the ureteral orifice.

While it is no doubt true that there is oedema of the bladder wall and enlargement of the lower portion of the ureter, there was never noted in my experience any obstruction at the ureteral orifice itself. The ureteral orifices are much more often rigidly patent and patulous, the so-called "golf-hole" orifice.

This condition is believed by the author to be due to the stretching of the intraureteral bladder ligament by the growing cervix of the pregnant uterus. The enlarged cervix presses upon the bladder to which it is intimately related, and causes alteration in the structure of the ureteral orifice by the pull which is caused. The orifice from being an elevated papilla becomes stretched, flattened and elongated. The base of the orifice may often be seen through the patent opening. The condition described was traced in one case of cystitis, who became pregnant while under cystoscopic observation. The elevated nipplelike ureteral orifice on the right side became flattened and patulous as pregnancy advanced.

This condition injures the valve-like action of the ureteral orifice, and allows of regurgitation of urine, with the possibility of kidney infection. If there has been a previous trigonitis this patency of the ureteral orifices is usually more marked, and is believed to be due to the loss of elasticity

The study of the female bladder in pregnancy is of great interest, and I should be grateful to those doing autopsies on the pregnant or puerperal, if they would send me pieces of the bladder, trigone, fundus and ureteral orifices for microscopic study. The specimens should be placed in Muller's fluid or formalin 10%. The cause of death and duration of pregnancy would be of use. I should be glad to send mailing bottles to any who will put me under a debt of gratitude by sending specimens to Dr. Ellice McDonald, 174 W. 58th St., New York.

Series,

of the trigone from the preceding inflammation. A similar condition of patency of the ureters is sometimes noted in the hypertrophic endocervicitis with an enlarged cervix and trigonal inflammation.

The possibility of regurgitation of urine when the valve-like action of the ureter is lost, has been proven in animals by Donati (8), Baumgarten (9), Levein (10), Goldsmith (11), Sampson (12), Garceau (13), and others.

These changes in the bladder caused by pregnancy, are of importance in the consideration of the etiology and diagnosis of pyelitis in pregnancy.

The frequency with which patency of ureteral orifices is found, makes it probable that infection may or does result from regurgitation up the ureter into the kidney pelvis. Infection is often present in the bladder, as is proved by Albeck's study, which showed that pus was discovered in the urine of 5.88 per cent., 7648 puerperae and in 14.3 per cent, of the primaparae. In a bacteriological study of 96 puerperae with pyuria, colon bacillus was found 76 times, staphylococcus 4, and a streptococcus 9 times.

Thus, we have the factors in the causation of pyelitis in pregnancy-a weakened kidney with lessened resistance, and possible dilatation of the ureter and hydronephrosis, the frequent presence of infected bladder urine and the opportunity for its regurgitation up the ureter.

The various modes of infection in pyelitis The various modes of infection in pyelitis in pregnancy are usually spoken of as, ascending, descending, blood-borne and lymphatic. The lymphatic course has been eliminated as a possibility, and the possibility of blood-borne infection in pyelitis in pregnancy, is probably not great. It no doubt does occur in pyaemia, with infected

embolic and in some cases of staphylococcic and streptococcic infection of the kidney, but the ascending form is the common or usual mode of infection.

An evidence of the slight possibility of blood-borne infection in pyelitis in pregnancy, is the fact that the great majority of such cases are of colon infection. The colon bacillus occurs seldom in the blood, so seldom that cases are reported as of great rarity. At the same time, colon is the most frequent form of bladder infecting organism. Also streptococcus infection of the kidney pelvis is rare, while it is the most common blood-borne organism in pregnancy; staphylococcus infection of the kidney is also rare, although more common than streptococcus. Yet staphylococcus infection of the kidney may result without abscesses elsewhere, (Case 1) which renders it unlikely that it was blood-borne or hematoge nous infection. The gonococcus is also found as an infecting organism and it is but seldom blood-borne.

The facts render it probable, although impossible of proof, that the great majority of kidney infections in pregancy occur through a scent of infection from the bladder through the ureter.

The infection of the pelvis of the kidney or ureter is the first step in disease which may continue to become a pyonephrosis or pus kidney with focal abscess, as is reported in cases I and 2.

Diagnosis: The diagnosis of pyelitis in tion of the signs and symptoms of an infecpregnancy depends first, upon the recognition as shown by the fever, increase in pulse rate, headache, backache, flush and general malaise. Second, upon the evidence of urinary infection, as shown by the presence of pus in the urine and localization of the kidney as the site of the origin of the pus by means of ureteral catheterization,

The condition is not usually marked by sudden onset or rapid course in the beginning. The first symptoms may only be general depression.

There is usually dull pain upon the right side and back, under the ribs in the kidney region. This pain is often of the renal colic type, and may radiate down the ureter toward the pelvis. This type of pain is fairly constantly found. The kidney is sometimes enlarged and not infrequently tender, although the presence of the pain is more constant than either enlargement or tenderness.

There is frequently a tender spot in the abdomen upon the right side and about two fingers' breadth above the ramus of the pubic bone. This corresponds to the point of crossing of the ureter over the pelvic brim, and its proximity to McBurney's point makes the mistaken diagnosis of appendicitis possible.

Pain in the bladder is usually present, and may be from previous cystitis or be the result of cystalgia from reflex irritation. It is much more frequently, however, caused by cystitis. There is usually frequency of urination or irritation from the cystitis, and this is worse at night, being of the type called "nocturnal pollakuria."

One patient of mine showed a kidneybladder reflex of pain in the kidney on making efforts to urinate.

Fever is almost constantly present, being of the remittent type, high in the evening and down in the morning. The fever is usually 101 deg. and the amount of its rise

is a fair indicator of the amount of toxaemia from infection. Chills are quite commonly present. Vomiting is not infrequent, and there may be associated with the infection considerable toxemia of pregnancy, as was noted in Case I.

The pain is usually referred to the right side in the beginning, and in my two cases of bilateral pyelitis, the pain was always referred to the right side alone.

The diagnosis must depend after all upon examination of the urine, as does the diagnosis of pyelitis in the non-pregnant. The presence of pus in the urine, with fever, is sufficient to warrant a suspicion of pyelitis. The amount of pus varies greatly, and depends in a great measure as to whether there is a coincident cystitis.

Cystitis of Pregnancy:- Cystitis in pregnancy on account of the changes in the bladder wall, above described, is often of a character peculiar to itself and worthy of the name "cystitis of pregnancy.' nancy." The softening and thickening of the bladder wall cause the inflammation to

be more widely distributed and penetrating to the bladder tissues than commonly. Greater quantities of pus and epithelial cells are, as a rule, excreted than in cystitis and in the non-pregnant. The bladder is very much inflamed, with marked oedema and hyperaemia. There is considerable desquamation and exfoliation of the epithelium and pus. The exfoliated shreds and cells cling to the bladder wall like small tags. The mucosa is markedly softened, swollen and boggy. The picture is that of a generally acute cystitis, with congestion and much oedema. It is sometimes associated with fever, as in cases Nos. 5 and 6 of cystitis simulating pyelitis in pregnancy.

The occurrence of this form of cystitis with its large amount of pus and the possibility of referred pain and fever, makes it of importance that the diagnosis of pyelitis should be made by cystoscopic examination of the bladder and direct examination of the kidney urine, obtained by ureteral catheterization.

The necessity of this course is obvious. It is the only way to decide the locality and

origin of pus in the urine. If, in purulent kidney disease in the non-pregnant, it is necessary to catheterize the ureters in order to make an exact diagnosis of the condition, how much more so must it be required in purulent kidney disease of the pregnant, where the diagnosis is complicated by the presence of the fetal tumor, and the possibility of the various forms of infection of

pregnancy.

In the three cases, Nos. 5, 6 and 7, simulating pyelitis, here reported, the diagnosis, if uncorrected by ureteral catheterization, would have been that of pyelitis in pregnancy. In one case operation was considered, and, if ureteral catheterization and cystoscopic examination had not eliminated pyelitis, an exploratory kidney operation would have been done. The two cases of cystitis of pregnancy simulating pyelitis, had the evidences of an infection of the urinary tract, as shown by the fever, pain, and pus in the urine, and in one case there was marked right-sided pain. These cases cleared up promptly upon bladder treatment and the therapeutic test bore out the diagnosis.

Cystoscopic examination and ureteral catheterization is necessary not only for diagnosis of pyelitis, but, as a means of prognosis it is invaluable. If operation upon an infected kidney is considered, it should be known that one kidney alone is involved, and that the disease is not bilateral. There is no means of doing this in this affection except by collection of the kidney urine by ureteral catheterization or other methods.

Catheterization of the ureter and cystoscopic examination are not difficult procedures, even in pregnancy, and cause but little discomfort. They can be done without anaesthesia, and I have for three years done

them without cocaine or other local anaesthetic. The danger of the procedure is slight as regards possible infection of a healthy kidney, and only one case of premature labor as a result has been reported by Bath (13).

The catheterization of the ureter is facilitated by having the patient in the raised lithotomy position or lithotomy Trendelenberg position, so that the weight of the fetal tumor is removed from the bladder and allowed to rise in the abdomen.

It should also be remembered that the dilated bladder is usually distorted in pregnancy by a marked transverse dilatation and a hollow in the bladder fundus in which the uterus lies. This frequently alters the position of the ureteral orifices, so that the orifice must be pressed up toward the catheter by the fingers or a tampon in the vagina.

The examination of the resultant urine should be for specific gravity, pus cells, casts, urea, chlorides, etc., and it should, if possible be compared with the mixed bladder urine and the urine of the opposite kidney, obtained by ureteral catheter.

The ureteral orifice, as a rule, does not show the marked changes about its opening. as occurs in chronic pyelitis and tuberculosis of the kidney in the non-pregnant.

If there is marked cystitis, it is well to wash the bladder out with an antiseptic solution and catheterize the ureter through such a solution. I use for this purpose, quinine bisulphate, 1-1000.

The presence of pus cells in the kidney urine with the constitutional evidences of an infection in pregnancy, is taken as evidence of a diagnosis of pyelitis.

The examination of the mixed bladder urine can give no evidence of a pyelitis from examination of the various forms of its epithelia. There are so many epithelia cast

off from the bladder and "kidney of pregnancy" that it is useless to attempt to base a diagnosis of pyelitis upon the bladder specimen.

The diagnosis of pyelitis in pregnancy cannot be differentiated from cystitis with fever without ureteral catheterization. No doubt, many cases have been reported, before methods of ureteral catheterization were simplified, in which this mistake has been made.

Appendicitis is another disease which may be mistaken for pyelitis, on account of the right-sided pain and vomiting which may accompany it, as in case 1.

Septic endocarditis with cystitis, as in case No. 7 is also a possibility of the differential diagnosis. In this case, ureteral catheterization alone, prevented the operation, as there was an enlarged and palpable right kidney, with fever and pus in the urine.

Gall-bladder disease from its right-sided position, must also be eliminated in the diagnosis.

The course of the disease varies very much, but the onset is seldom sudden and the condition has usually progressed some time before its recognition.

It is believed that the usual course is an extension from the pelvis of the kidney to the parenchyma to cause a pyonephrosis. When the disease is a simple pyelitis, there is seldom any enlargement of the kidney, but this sometimes may occur with pyonephrosis and focal abscesses.

Those cases of staphylococcus infection are usually more severe than those of colon infection, and this has a bearing on the prognosis and treatment and may be noted by bacteriological examination of the kidney urine.

The treatment of the disease is usually expectant. If the patient is put to bed and kept quiet, in such position as to remove the weight of the fetus from the affected side, recovery is the rule. Thus, the patient should be upon the left side in right-sided pyelitis.

Large quantities of water should be given, amounting to 6-8 glasses daily apart from meals. Some writers advocate restriction of liquids, but this is not advisable.

Diet should be soft or liquid, and contain no meat in order to make it as unirritating as possible to the kidney. Salt should be restricted in order to relieve the kidney, and the patient should abstain from all articles which contain salt in the raw state or require much salt to make them palatable. The diet should be mainly sweetened, unsalted butter, rice cooked in milk, sago, baked potatoes, puddings, gruels, vegetables without salt, fruit, weak tea, lemonade, milk, but no coffee. This diet allows of sufficient

variety and sustains the patient.

The use of a urinary antiseptic and diuretic is of value. Hexamethylenamine, gr. 5, three times daily, is useful, but it should be given with care, and not in excessive doses. In large doses, it is a direct kidney irritant, and hemorrhagic urine has been noted in five cases in the writer's experience. Beardsley (14) has collected many additional cases of its tonic effect. It is, however, of value, and should be used carefully. Combined with sodium benzoate, it is much less irritating and a useful prescription is the following: Hexamethylenamine Sod. Benzoate

Sod. citrate

Elixir Buchu ad

.gr. v

gr. x

gr. v

.3ii

Dose: 3 three times daily in a full glass of water.