THREE CASES OF ACUTE PYELITIS IN INFANCY. BY L. EMMETT HOLT, M.D., Professor of Pediatrics in the New York Polyclinic. FROM ARCHIVES OF PEDIATRICS, November, 1894. THREE CASES OF ACUTE PYELITIS IN INFANCY* L. EMMETT HOLT, M. D., Acute pyelitis has been given but small space in pedi- atric literature. Cases depending upon calculi and con- genital malformations are pretty well understood. It is also known that acute pyelitis occasionally occurs as a secondary affection of perinephritis. Most writers upon pediatrics and general medicine make the statement in a general way that acute pyelitis may accompany any of the infectious diseases, the eruptive fevers, diphtheria and malaria. Very few clinical observations have, however, been recorded. I have not been able to find in medical literature anything comparable to the second and third cases whose histories are given in this report. They are of such interest that I shall give them somewhat in de- tail, and with the histories shall present the full temper- ature charts. Ca.se I.—A male infant fourteen months old, an in- mate of the New York Infant Asylum. The child had been nursed by the mother, and with the' exception of a mild attack of diarrhoea, had never been sick. On Sep- tember 15, 1892, he was taken suddenly ill with a tempe- rature of 103.50. There were no local symptoms of dis- ease excepting a slight stomatitis. On the second day the temperature ranged between 101 and 103.50. A few rales in the chest were found, and pneumonia was sus- pected. On the third day the temperature was between 100.2 and 101.80. Quinine was now ordered by the house physician, ten grains daily, the physical examination be- ing practically negative, the signs in the chest not having developed further. For the next four days a slight febrile movement con- tinued, the temperature not rising above ioi°. There Professor of Pediatrics in the New York Polyclinic. * Read at the Sixth Annual Meeting of the American Pediatric So- ciety, June, 1894. 2 HOLT : Acute Pyelitis. was now marked restlessness, pallor, the urine was no- ticed to be rather scanty and high colored. A specimen was secured for examination which after standing showed a deposit of pus nearly one inch deep, in a conical glass containing less than two ounces. There was a small amount of albumen present, and the microscope showed pus cells and epithelial cells, but no casts. The patient at this time was considerably prostrated, although he did not give the impression of being dangerously ill. There was no subsequent rise in temperature. The pus continued to diminish gradually, although it was passed in small amount for three weeks. The examina- tion of the urine two months later showed no trace of pus. At no time in this case were any casts found. Not enough urine could be collected to obtain the specific gravity. The child remained in the institution, and twenty months later Dr. Bremner, the resident physician, in response to an inquiry stated that the child had never had any sub- sequent urinary symptoms and had continued to the pres- ent time in all respects well. This case ran its course practically without treatment. Case ll.—On December 6, 1892, I saw with Drs. Mar- tin and Carman, of Harlem, a female infant eight months old who was reported to have been ill for nine days. The history given was as follows: The child had been artificially fed from birth, but had never been previously ill. While apparently in perfect health, it was taken suddenly with a chill, followed by a very high temperature, which had continued up to the time of my visit. For the first three days the temperature record had not been preserved, but it had fluctuated be- tween 103 and 1060. From the fourth to the eighth day it ranged between 102 and 105p, touching the latter point every day but one. The symptoms in other respects were almost negative. The prostration had not been great. There had been a very slight amount of indiges- tion as shown by an occasional green stool and a slight, inconstant cough. No evidence of local pain, no cere- bral symptoms, no vomiting. Pneumonia had been sus- Holt : Acute Pyelitis. 3 pected, but up to this time no signs had been found in the chest. The case had been closely watched from the out- set, but no diagnosis made. Quinine had been given in moderately large doses, without any effect. Baths had reduced the temperature only temporarily. On examination I found a pale but fairly nourished in- fant, temperature 105°, pulse about 180°, respiration 76°, the child being at this time rather excited. There were six teeth, the gums were normal. The result of the phy- sical examination was absolutely negative, there being no evidence whatever of any disease in the ears, throat, lungs, spleen, or anywhere else in the abdomen. The child did not seem to be very ill, and excepting when the temperature was high, was usually quite bright, playful, had a fair appetite, and was taking about twenty ounces of food a day. The continued high temperature and accel- erated breathing led me to suspect pneumonia, notwith- standing the absence of all physical signs. On a second examination, on the following day, the temperature was found but a little lower, and the respira- tion 40. A very satisfactory examination of the lungs revealed absolutely no signs of disease, and excepting for the temperature the child did not seem seriously ill. Pneumonia was positively excluded. The diagnosis was still obscure. I directed that an effort be made to secure a specimen of the urine. At my third visit, on December Bth, on the eleventh day of the illness, sufficient urine was collected for the first time for examination. Only three or four drachms were obtained, but this showed a very heavy deposit of pus in the test tube and a trace of albumen. The reac- tion of the urine was strongly acid. Under the micros- cope in addition to pus there was found bladder epitheli- um, but no casts. There had been no trace of oedema, up to this time the urine had been abundant, and there had been no deposit upon the napkins. There was no tenderness over the kidneys, no evidence of a tumor, and no signs of cystitis and vaginitis. Micturition was not abnormal either in frequency or in the amount passed. 4th day* 5th day. 6th day. 7th day. 8th day. Oth day, lOthday. 11th day. 12th day, ISth day, 14th day. 15th day, 16th day, 17th day. DAY OF MO’H. Dec. 1 2 3 4 s 6 7 8 9 10 ii 12 13 14 HOUR. A.M. P.M 2 6 10 2 6 1 . A.M. P.M. A. 026 10 26 10 26 M. P.M. 4 10 2 6 10 2 l.M. P.M. 6 10 2 6 10 A.M. P.M. 2 6 10 2 6 10 A.M. P.M. 6 10 2 6 10 A.M. P.M 2 6 10 2 6 1 A.M. P.M. 0 2 6 10 2 6 10 A.M. P.M. 2 6 10 2 6 10 A.M. P.M. 2 6 10 2 6 10 A.M. P.M. 2 6 10 2 6 10 A.M. P.M. 2 6 10 2 6 10 A.M. P.M. 2 6 10 2 6 10 A.M. P.M. 2 6 10 2 6 10 107C 106° 105° 104° 103° 102c 101° 100° 99° 98° T — 1 T X ■> . 1 j 1 7 * r • • / t n if 1 M / 1 j t jj r 1 7 t t L / : 1 A i V 4 \ r 1 : , _ 1 V / I r _l \ \ / V / \ i \ t . Z / Y t... 77 _r - j< L \ . : * _r A r TMV I 1 5 ■ L : \ 1 / / "i \ r i 1 « In - -1 / \ 4- _ t v \ \ \ i Vi- f J n y 1 “P -X = h 3a Potcist bequn i \ / szoppea II i V t z 1 1 if ! n zt L i ' i~ 1 | i 1 111 1 ACUTE PYELITIS CASE II. INFANT 8 MONTHS, HOLT : Acute Pyelitis. 5 Citrate of potash was now begun in doses of gr. ii. every two hours. On December loth, two days later, the first natural fall in the temperature was seen since the beginning of the illness. The child was now taking gr. xxiv. of the citrate of potash daily, which had very much increased the quantity of urine and had neutralized the acidity. It was difficult to estimate the amount passed, but in twen- ty-four hours twenty-eight napkins were wet. About six drachms of urine were collected for examination. This, after standing in a conical glass, showed a deposit of pus % inch deep, or about 8 per cent, of the volume of the urine. On December 12th, the temperature touched normal for the first time, it having been below 102.50 for the last three days, falling gradually. The amount of pus dis- charged was still large, although diminishing. Daily mi- croscopical examinations of the urine were made, show- ing pus, a few bladder epithelial cells, and a small num- ber of renal epithelial cells, but only a few hyaline casts. The quantity still continued very abundant, the reaction very alkaline under the influence of gr. xx. of the potash daily. From this time the child improved rapidly. Recovery was interrupted on the sixteenth day by a temporary rise of temperature, apparently from constipation. The amount of pus gradually diminished, and at the end of three weeks it had practically disappeared from the urine. Sixteen months later, in April, 1894, Dr. Martin wrote that the child has been entirely free from urinary symp- toms since the last note, and its general condition had been good. CASE lII.—A female child, nine months old, under my personal observation since birth. Until ten days before the present illness, when it had what was regarded as a mild attack of influenza, the child had never been ill. Its nutrition had been excellent, leaving, in fact, nothing to be desired. 6 HOLT : Acute Pyelitis. On February 8, 1894, the child was taken suddenly, about noon, with a distinct chill. I saw the case a few moments later, before the chill was over. The lips and fingernails were blue, and there was a distinct chatter to the teeth, with shivering of the entire body. It was as typical a chill as one ever sees in an adult. There was considerable prostration, and the rectal temperature was 103°. Under the use of a hot bath and stimulants reac- tion was established in a few minutes, but an hour later the temperature was 104°. At SP. M. the same day the temperature had fallen to 99.50 (rectal), and all symp- toms had disappeared. At 7P. M. the temperature was normal, the child sleeping quietly, and was apparently well. A little after midnight a second chill occurred, in all respects similar to the one at noon, excepting that it was not quite so severe. Temperature 103.40. Hot baths and stimulants were repeated. At 7. A. M. on the follow- ing morning the temperature was and the child was submitted to a second thorough examination, with abso- lutely negative results. Quinine was now ordered, two grains of the bi-sulphate being given every three hours per rectum. By 1 p. m. the temperature had risen to 103.4° without any chill. It fluctuated during the even- ing, and at 10 P. M. had again risen to 105°. Up to this time, especially when temperature was high, there had been some prostration, the child was indifferent to sur- roundings and rather fretful, and had but little appetite. As soon as the temperature fell the child would laugh and play as usual, took its food well and, apparently, seemed quite normal in every respect. The movements continued good, and nearly the usual amount of food was taken. On the third day two severe chills occurred, the tem- perature rising immediately after, in one case to 105° and in the other to io4.5q. A fall occurred in the course of three or four hours with quite a profuse perspiration. The quinine by rectum was not retained, and during the day twelve grains were given by the mouth and retained. Holt ; Acute Pyelitis. 7 On the fourth day gr. xivss. of quinine were given by the mouth and retained; the temperature still fluctuating widely, but no distinct chill. During the day it was no- ticed that there was some straining and pain on micturi- tion, and that the urine was passed only in small quanti- ties. This evening for the first time a specimen was ob- tained for examination. The reaction was very strongly acid, and after standing there was a deposit of pus equal to about one-fifth of the entire volume of the urine; sp. gr. 1012, and a trace of albumen. Quinine was now discontinued and citrate ot potash gr. ii. every two hours given and hot fomentations used over the kidneys. During the following day the temperature fluctuated between ioi and io5q. The urine was still very turbid from the pus and very much increased in quantity. Re- action still acid; sp. gr. 1005. On the sixth day, February 13th, the urine was passed very freely, from sixteen to eighteen ounces in twenty- four hours; reaction still acid in spite of gr. xxiv. of the potash daily. The child’s general condition was not quite so good as previously, although she showed com- paratively little disturbance, considering how high the temperature had been. She was now taking about one- half the usual amount of food. The bowels moved regu- larly; there was no vomiting, and she slept a fair amount of time. There was no drowsiness, and the symptoms of irritation about the bladder had entirely disappeared. The temperature still fluctuated widely, rising from 98.5 to 106° in the course of two hours and falling again to 100.50 shortly afterward. The fluctuations in temperature were still irregular as to the time of their occurrence. When the rise was not preceded by a distinct chill there were nearl}' always cold hands and feet and pallor. On February 14th the general condition remained about the same. The amount of potash now taken was fifty grains daily, and with this the urine was kept neutral or faintly alkaline. The amount of pus discharged was still very large, being about five per tent, of the vol- Fch. 1 2 3 4 S 6 7 8 9 lO 11 12 13 14 IS 10 17 DAYS OF MONTH, 8th 9th tot nth 12th 13th 14th 15th 16th 17 th 18th 19th 20th 21st 22nd 23rd 24th HOUR. a.m. r.a 2 6 10 2 C I. A.M. P 10 2 6 10 2 6 M. A.M. r 10 2 6 10 2 .M. A.M. P.M. G 10 2 6 10 2 G 10 A.M. P.M. 2 G 10 2 G 10 A.M. P.M 2 6 10 2 G 1 A.M. P.M. 2 G 10 2 G 10 A.M. P.M. 2 6 10 2 C 10 a.m. p.h. 2 G 10 2 6 10 A.M. P.M. 2 G 10 2 6 10 A.M. P.M. 2 6 10 2 G 10 A.M. P.M. 2 6 10 2 6 10 A.M. P.M. 2 6 10 2 G 10 A.M. P.M. 2 6 10 2 6 10 A.M. P.M. 2 6 10 2 C 10 A.M. P.M. 2 6 10 2 6 10 A.M. P.M. 2 6 10 2 C 10 2 107 106 105 101° ■ .Vi I 1 1 | -i T“ -4- ! i | L —[ -44 441 -4 — — - - — 4 =p ±zz~ _ £ - _ - J -4 1 — — — ' -J —— f - ft T= — IZ I u . — _ - —i— - f - ft — Hi - —J—— 4- r A i i i ~t~ r J Y 103° 102 io ic 100° 99° I 7 ~ -— - j— riJJ: * -j- h- \ — - 4: -1- r J- - f | K \ - _ p — ‘ . ( .. / □ - : J_ It 1 ' 1 U: 1 u rA . - P -- 4- If z 4 — 7 = _ - - \ - r _L [~T~ -L— L - 4 -FF —Ft 1 j-J “TT" _L T 4 = 1 -j— \ E \ \ X _r :u~ . LJ : - “i ! : t n : : . . P < —r m L rec se a 98 97° rA-V-h -daihi i _ i “Mili~ r~r J _ zr: TTT 1 1 1 i 1 ACUTE PYELITIS. CASE III. INFANT 9 MONTHS. 18 19 SO SI March S3 S4 S5 SO S7 S8 SO 30 31 3S 33 34 33 I 25th 26th 27th 28th 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th nth 12th 13th '14th A.M. P.M. 2,010 2 610 A.M. P.M. 2 610 2 6 10 A.M. P.M 2010 261( A.M. P.M. 2 010 2610 A.M. P.M. 2 010 2 6 10 A.M. P.M. 2010 2610 A.M. P.M. 2 010 2 6 10 A.M. P.M. 2010 2610 A.M. P.M. 2 610 2 6 10 A.M. P.M. 2 010 2 0 10 A.M. P.M. 2 010 2 6 10 A.M. P.M. 2 610 2 6 10 A.M, P.M. 2610 2610 A.M. P.M. 2 610 2 610 A.M. P.M. 2610 2610 A.M. P.M. 2610 2610 A.M. P.M. 2 610 2.6'fO A.M. P.M. 2 610 2610 107° 106° 105° 10.4° 403° / A 102'° t i - / ✓ v i A i \ / A / A 101° -• \ y L t / _ A / F \ / 7 r A y A / - 100° 99° 98° f- , / s, 1 / S / J j J r A / \ y V 5 -t ■V t \ - -V 7 A lo / i 1 ( go; fra ri'senn e 1 11 jf a // t 1 1 1 97° ACUTE PYELITIS. CASE III. INFANT 9 MONTHS—(Concluded). 10 HOLT : Acute Pyelitis. ume of the urine. It was estimated at from two to three ounces daily. The examination of the urine showed, be- sides the immense numbers of pus cells, renal epithelium, a little bladder epithelium and a very few granular casts, these mostly in fragments; stained for tubercle bacilli, but none found. The case was seen this evening by Dr. John H. Rip- ley, who concurred in the diagnosis of acute pyelitis, but suggested, in view of the wide fluctuations of temperature and recurring chills, that another trial be made with the quinine, with the belief that there might be a malarial element in the case, although the spleen was not now en- larged, nor had it been so at any time during the attack. It was decided to give it in large doses for twenty-four hours, and then to stop it if no benefit was seen. At Dr. Ripley’s suggestion the quinine was given hypo- dermically. During the next twenty-four hours thirty-six grains of bi-sulphate of quinine were injected beneath the skin, and as no untoward symptoms were seen and the child was improved, it was continued. During the succeeding twenty-four hours twenty-four grains were given in the same way, and in the third twenty-four hours twenty grains, making in all eighty grains of the bi-sulphate hy- podermically in the seventy-two hoqrs. The injections were all given deeply into the buttocks and outer aspect of the thigh. No unpleasant local or constitutional symp- toms were seen as a result of these immense doses of qui- nine. From the time the quinine was begun, the wide fluctu- ations in the temperature ceased, and it ranged from this time between ioi and 103°. There were no more chills. In other respects there was little change in the condition of the patient. The potash was continued, twenty to twenty-four grains daily, and as much lithia water given as the child would take. Hot fomentations over the kidneys were continued. The urine ranged from sixteen to twenty-two ounces daily, the amount of pus being about four per cent, by HOLT : Acute Pyelitis. 11 volume of the urine passed. Microscopical examinations were made daily. The report of the examination of Feb- ruary 17th, by Dr. Walter Mendelson, is a good average of the urine at this time; Spec. grav. 1007; faintly alka- line; a small amountof albumen; urea 3.6 grams in twen- ty-four hours; urates, phosphates and chlorides dimin- ished; a trace of blood pigment; no indican. Microscop- ical examination: immense numbers of pus cells, a few red blood cells, a few blood and epithelial casts, bladder cells and many bacteria. From February 17th to February 22d there was a steady improvement in the general condition and in all the symptoms, the temperature gradually declining until on the 22d, for the first time, it did not rise above ioo°. Hot applications over the kidneys and potash in suffici- ent quantity to keep the urine neutral or slightly alkaline were continued. The quantity of pus slowly diminished. There was still a trace of albumen, and now and then an epithelial or granular cast would be found upon micros- copical examination. Frequent examinations of the ab- domen were made, but at no time was there tenderness or tumor in the region of the kidneys. The quinine had been gradually reduced now to six grains daily, a part of which was still given hypodermically. During the two weeks’ illness the child lost 11/,I1/, pounds in weight and cut three molar teeth. On February 23d the temperature took a sudden jump to 103.50; this was not preceded by a chill nor accompa- nied by any other general symptoms, and a careful ex- amination revealed no explanation of this increased fever. The quinine was now increased to sixteen grains daily, all given hypodermatically for twenty-four hours, and the temperature was immediately controlled. The qui- nine was then reduced to eight grains daily for three or four days, and then finally to three or four grains. On March Ist both the quinine and the potash were stopped, as the child seemed in all respects convalescent. She was now taking thirty-five ounces of food a day, had gained five ounces in weight and had a good appetite. 12 Holt : Acute Pyelitis. There was only a very faint deposit of pus seen by the naked eye, but under the microscope the pus cells were still abundant. For the next ten days the general improvement con- tinued, the temperature ranging between 99 and 100.50. On March loth a temperature of 101.50 was again reached, but was attributed to a slight sore throat. On the following day the temperature continued to rise; and a careful examination was made, but did not reveal any sufficient cause for the increased fever. The urinary con- ditions remained unchanged or slightly improved. On March 12th the throat symptoms had diminished, but the temperature had risen to 103.50, and quinine was therefore again begun, this time by the mouth and rec- tum. During the succeeding twenty-four hours twelve grains were retained, with the effect of controlling the temperature. It fell at once to ioo°, and thereafter re- mained below that point. On March 14th the child was taken to Lakewood, the urine still containing a trace of albumen, many pus cells, but no casts; reaction acid; spec. grav. 1010. Eight grains of quinine were given daily for four or five days, and six grains daily were kept up for two weeks, after which it was stopped altogether. No further rise in tem- perature occurred, and the child improved rapidly in ev- ery respect, gaining in two weeks one and a half pounds in weight. At the site of the hypodermic injections of quinine there are now over the buttocks and thighs twenty or thirty irregular lumps, of a slightly brownish color about as large as an almond. These are not tender or painful, and show no disposition to suppurate. They have only recently come to the surface. May 15th; it is now over three months since the begin- ning of the attack. The child is in splendid condition, one year old, weighing 223/4 lbs. The urine has been ex- amined at intervals of a few weeks since the last note, and has always shown a good many pus cells under the microscope, although in other respects it is normal. The Holt : Acute Pyelitis. 13 nodules upon the thigh still remain, but are slowly di- minishing in size. The child is now taken to Europe for the summer. September Ist: Reported as having been free from uri- nary symptoms since last note.* Remarks.—Case I. was a simple one, of moderate se- verity, in which the diagnosis seems quite clear, and in which there is no reason to suspect any complication. There was a sudden onset, with a temperature of 103.50, and an unexplained fever for a week, ranging most of the time between 100 and io2q. The urine was at first no- ticed to be scanty and high-colored, but no examination was made until the end of a week, when pus was found in large amount. The constitutional symptoms were only moderately severe. There was no evidence of any im- plication of the kidney, and the case made a prompt and complete recovery. There was nothing in this case to suggest a local cause, such as traumatism or calculus, balanitis or urethritis. In Case 11. the condition is a much more complicated one. The striking features of this case were a sudden on- set with a chill, in a child who had been previously in perfect health and from birth under the close observation of one of the physicians, in fact living in the same house with him. For twelve days the temperature was steadily high, touching 105° almost every day, and on several oc- casions above this point, only temporary reduction being effected by baths. The early administration of quinine in doses of eight to ten grains daily had no effect what- ever upon the symptoms. There was no evidence of local disease until the urine was examined on the eleventh day and found to contain a large amount of pus. With the administration of alkaline diuretics, and a great increase in the quantity of urine and the discharge of pus the tem- perature gradually fell, and after four days remained at the normal point. There seems to be no suspicion of malaria. The early administration of quinine had no ef- * Note.—Specimen of urine Sept. 15th showed a considerable number of pus cells, but was otherwise normal. 14 Holt ; Acute Pyelitis. feet whatever on the symptoms, and the temperature re- mained throughout steadily high, and not of remittent type. There were no evidences of vaginitis or cystitis. It is of interest to note that this case occurred at a time when grippe was prevalent in New York City, and it seemed not improbable that this may have been the etio- logical factor in the case. The occasional casts which were found, and renal epithelium, indicated that the kid- ney participated in the inflammatory process, but only to a very slight degree, as the rapid and permanent recov- ery of the case showed better than anything else. A sur- prising thing in this child was the absence of very marked prostration in spite of the prolonged high temperature. In fact, without the thermometer one would hardly have deemed the child seriously ill. Case 111. is in all respects a remarkable one. It re- sembles Case 11. very closely in many particulars, in the age of the patient, the previous good health, the sudden onset with a chill, and in the excessively high tempera- ture. What the exact etiology of this case was lam un- able to say. The family history was a gouty one, and a grandmother of the patient has diabetes. An older child has been repeatedly under observation, with attacks of genital irritation accompanied by an excessively acid urine and the discharge of crystalline uric acid. Were the recurring chills due to malarial poisoning, or were they septic? It should be remembered that this child had what would be considered very large doses of quinine during the first three days of the illness, but with- out any effect whatever upon the symptoms, and also that there was no enlargement of the spleen at any time dur- ing the attack. Furthermore that the child had never been exposed to any malarial poisoning, excepting such as may exist in the best residential portion of New York City. I regret that the blood was not examined. When the quinine was given hypodermically in the immense doses mentioned, viz. eighty grains of the bi-sulphate within three days, although the chills ceased, and the wide fluctuations in temperature were at once checked, Holt : Acute Pyelitis. 15 still a very decided fever continued and the disease itself did not seem to be affected. The effect of the quinine, it seems to me, admits of two explanations, the first that there was a malarial element in the case, and the second that the drug eliminated in such a large amount by the kidney had a marked antiseptic effect in the urinary tract. In view of all the facts I regard this explanation as more probable than the malarial theory. In this case there was more evidence of implication of the kidney than in either of the foregoing, but even here the renal disease was evidently of very secondary importance. The amount of albumen was not more than would be expected from the quantity of pus present. The casts were few; and at many examinations none whatever could be found. A number of epithelial cells present was very much more distinctly of the bladder type, and others distinctly renal, with many intermediate forms between. It is now pretty well agreed that there is no peculiar epi- thelium in the pelvis, the form present being generally of the transitional variety. In none of the cases reported was there any evidence of a local cause of the disease, either of traumatism or of calculus. In no one were there any previous or subse- quent symptoms pointing to disease of the kidney, and in no one were there any minute calculi discovered at any of the examinations, although they were carefully looked for. In no case was there evidence of disease of the lower part of the urinary tract. It seems difficult in view of the histories given to make any other diagnosis than that of acute pyelitis, arising probably from some infection carried to the kidney through the blood vessels. What the primary source of infection was it is impossible to say. That the pelvis of the kidney rather than the kidney itself should be affected also seems surprising, although the clinical course leaves no doubt in my mind that such was the case. In conclusion I should like to call attention to the ne- cessity of the examination of the urine in infancy in all acute diseases with doubtful symptoms. In a previous 16 Holt ; Acute Pyelitis. communication to this Society I have reported a series of cases in which prolonged high temperature in infants de- pended upon an acute nephritis, apparently of primary origin. We must now add acute pyelitis to the causes which may give a very high temperature of a prolonged character. Archives of Pediatrics EDITED BY DILLON BROWN, M. D., Adjunct Professor of Pediatrics in the New York Polyclinic, etc. This is the only English publication devoted exclusively to diseases of infants and children. 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