A Case of Pyelitis of Nineteen Years’ Duration Caused by a Renal Calculus; Recovery. HY AUGUSTUS V. PARK, M.l)., OF CHICAGO. MKMfcKK OF THIS AMERICAN MKDICAL ASSOCIATION, CHICAGO MEDICO- LEGAL SOCIETY, CHICAGO MEDICAL SOCIETY, ETC. A'tad before the Chicago Medical Society, January j, isSj rlefrinteti from the Journal of the American Meiiicat Association, February J, 18S7. CHICAGO: Printku at tub Or pick of the American Medical Association. 1887 A CASE OF PYELITIS OF NINETEEN YEARS’ DURA- TION CAUSED BY A RENAL CALCULUS. RECOVERY. The case I have to present to the Society is that of William P., aged 30 years; of slight physique, medium height; temperament exceedingly nervous, disposition retiring. I saw patient first on May 12, 1885; I found him in great agony—indeed his suffer- ing was excruciating in the extreme. I found the temperature 101 F., pulse 120, respiration 20; com- plained of severe and distressing pain in the region of the left kidney, a dull aching pain in the lumbar region; sometimes the pain would be sharp and stab- bing and radiating about in different directions; there was marked gastric irritability, flatulency and indi- gestion, febrile disturbance nil, obstinate constipa- tion, and copious sweats would accompany the vio lent paroxysms of pain. Frequently the attacks would be of short duration, again they would come on instantaneously and the suffering would be intense for two days, and these sieges would be so exhausting to the system that it would require several days to regain his accustomed strength and health, which at best, was habitually deranged. I at this time secured the following interesting history of the case. The patient said the first attack of this kind oc- cured when he was but 11 years old, and it was dur- ing a convalescence from scarlet fever. The par- oxysms of pain would occasionally be of short dura- tion; usually, however, the suffering would be so great that he would be compelled to keep his bed for a day, or two, then there would be a remission of the 2 paroxysms for a week, and occasionally for a month or two, but the slightest exposure to cold in any way would precipitate an attack. One of the longest sieges, and one which was not entirely unworthy the solicitude of the thoughtful, earnest, skilful physician, was caused by a day’s fishing in the rain out at the government pier. His occupation was that of an engineer, and at times when his work was unusually labo-ious or fatiguing and he exposed himself while covered with perspiration, his old trouble would in- evitably follow. He had received treatment from several of our most successful physicians, and for the past twelve years, the family physician, who during these twelve years had called in a number of our best consulting physicians and surgeons. Microscopic examinations and urinalysis were made time and time again, medicines were given months at a time, and dozens of bottles of proprietary medicines taken without se- curing the benefit wished, or accomplishing the desired result. During the prolonged attacks, anodynes, hot packs, poultices, and hypodermic medication gave him the most relief, but not infre- quently in spite of all medication and the combined skill and associated efforts of the attending physicians, the paroxysms would continue unabated from twenty- four to forty-eight hours. He had become so ac- customed to the use of narcotics that it required the administration of almost phenomenal doses to nar- cotize or produce the constitutional or physiological effect of opium; his long and continued experience with the drug enabled him to say how large the dose and how frequently administered, and the manner it should be exhibited to secure perceptible and satis- factory results. In all these years of suffering, he had not passed any calculi with his urine. I will modify this by saying, to the best of his knowledge, for he had been in- structed by his physician what to look for, and the 3 entire amount of his urine had been saved and ex- amined day after day for weeks at a time and during his prolonged attacks but always with negative results. After securing the above history, I gave morphia Yi grain hypodermically, pill opii, i grain each every two hours if necessary. At this time I made a very careful examination, following the method advised by the late Professor GrossThe concretion, even if comparatively small, as when it does not exceed the volume of a pigeon’s egg or an almond may some times be readily detected, especially in lean subjects, after thorough evacuation of the bowels, by firmly grasping the lumbar region, immediately below the last rib, with the fingers of one hand resting upon the anterior border of the erector muscle of the spine and making counter-pressure with the thumb, while the fingers of the other hand are passed up and down over the intermediate surface in front. In this way it is very difficult for any hard substance, irregu- larity of surface or distension from fluid to escape discovery. The patient during the examination, should lie on his back with the limbs well Hexed to relax the abdominal muscles; chloroform being given if there is much pain or nervous agitation. The above plan of examining for the stone did not in this case reveal the slightest abnormality and there was but little pain experienced when quite firm pressure was applied kidney. I secured all the water he had passed during the previous twelve hours and subjected the same to an analysis, which I will here append. (Urine was of deep red color.) Specific gravity 1.028, of slight acid reaction, blood and albu- men was found in small quantities, and a large amount of phosphates and pus a trace. A thorough and careful microscopical examination was made and an abund- ance of mucus corpuscles was found: some pus, but this was slight, however, there was a large quantity of 1 Gross’ Surgery, vol. 2, pp. 709-10. 4 small celled epithelium, (round cells to a large ex- tent), these evidently came from the pelvis of the kidnev; no tube casts could be discovered. I there- fore hoped that the irritation had not extended into the secretory structure of the kidney proper, but was confined to the pelvis of this organ. With the knowledge gained by the analysis and the microscope came the pertinent question, What shall I do for my patient? All of the best surgical authorities agree that renal calculi are generally com- posed of uric acid or oxalate of lime, most com- monly the former; they also agree that when the concretion is an oxalate it is usually solitary. Dr. Harlan N. Orton reported2 a case of uric acid calculus which appeared to have been dissolved in the pelvis of the kidney by alkaline remedies. I had but little hope to accomplish disintegration of the calculus in this case, for he had taken alkaline reme- dies for precisely this purpose for months at a time. Professor W. T. Belfield advises3 the ingestion of large quantities of alkaline water. I quote from his admirable paper “Water under the Microscope.” In pyelitis, from whatever cause, the ingestion of such water is an absolute essential in treatment, for there is a tendency to the accumulation of catarrhal pro- ducts in the pelvis of the kidney, sometimes even causing such obstruction to the escape of the urine as to induce hydronephrosis. Another tendency to be prevented is that toward the precipitation of urinary constitutents upon the inflamed mucous membrane as well as upon the clumps of pus re- tained in the pelvis. Both of these objects of treat- ment—the removal of the products of the inflamma- tion and the prevention of the precipitation of salts in the pelvis—are attained by the administration of an abundance of pure water and in no other way. By securing these results we also secure the so-called 2 Chicago Medical Journal and Examiner, Oct., 1884. 3 Water under the Microscope. 5 “ soothing ” effect of the water, which is really sooth- ing only in a negative sense; the positive benefit consists in the removal of the irritating products. In pyelitis caused by the presence of renal calculi— a frequent form—a pure alkaline water affords the only hope of a radical cure by medical means. Cal- culi have been disintegrated and even dissolved by the copious ingestion of simple rain water, and the same effects can be achieved in less time by the use of a water which, while not loaded with mineral con stituents, contains nevertheless, a sufficient quantity of the proper ingredients to give it an alkaline reac- tion, for renal calculi are usually composed of uric acid and urates, whose solution is favored by alkalies. Agnew advises4 opiates hypodermically or by the bowel, either as enemas or as suppositories in com- bination with the extract of belladonna and when the paroxysms of pain are exceedingly severe, great re- lief may be obtained from inhalations of ether. In order that the concretion may be hurried through the ureter more rapidly than would be effected by the peristalsis of the muscular walls, it has been advised to administer largely diuretic remedies in order to excite a free secretion of urine which presses against the obstruction from behind. He says further, that it is quite proper to administer alkaline drinks as so- lutions of citrate or bicarbonate of potash, but their administration should only be to the extent of mod- erately stimulating the action of the kidneys, so that the vis a tergo should be exerted within the limit of safety; kneading has also been practised; an experi- ment, to say the least, of doubtful propriety. A fixed position of the body and limbs, by removing the tension of the ureter is favorable to the progress of the stone. May 13, 5 p.m., twenty four hours since commence- ment of attack, I was called to administer morphia hypodermically. I found the patient very weak and 4Agnew’s Surgery, vol. 2, p. 706. 6 his temperature ioo F., pulse 120, respiration 20; his suffering was very great, and he would frequently exclaim : “ Oh, father, I wish I could die ! I wish my suffering would end; how many more long years must I suffer?” f had now mapped out a line of treatment and was determined to follow it up thoroughly and faith- fully; if I failed 1 would always have the pleasant satisfaction of knowing I did my best and that too in the light of our present knowledge. All previous attempts to give permanent relief had proven singu- larly unsuccessful, and show to some extent the utter insufficiency of all human effort, no matter how earnestly or arduously the attending physician ap- plied himself to the inexplicable difficulties; in this case, at best, his efforts were only palliative. I di- rected patient to drink Waukesha water in as large quantities as he wished and as often as he could, this would quench the thirst, which was constant, ac- quainting him with the object in view and the diu- retic influence of the water. I then wrote for the following: ft. Tincture digitalis 5ss. Fluid extract hydrangea Elixir calisaya q. s. ad One teaspoonful every five hours. This was given for its direct effect upon the kidneys and would be soothing to the mucous membrane; advised a milk diet and one half drachm of Carlsbad sprudel salt in a glass of water before* each break- fast to correct constipation. In order to facilitate the washing-out process to the greatest possible degree, it occurred to me that I should relax the system as much as possible; ano- dynes were pushed to the fullest extent; hypodermic injections of morphia and atropia given every two hours; large and hot poultices were applied and made to encircle the body about the loins and fre- quently changed. This treatment, together with the 7 ingestion of large quantities of water, was continued the entire night; the patient directed to lie upon the right side as much as possible with the limbs flexed. At 7 o’clock the following morning, forty- eight hours from onset of attack, the father came to my office with message from patient, “Tell the doc- tor that I am free from all pain but so weak that I cannot pass my water.” I advised the father to have his son make patient trials, and if he failed I would relieve him immediately. 8 a.m.—Temperature 100 F., respiration 18, pulse 90, free from all pain, had passed a large quantity of urine of a dark red color, and with it a calculus which is oval in shape, with numerous little nodules, or hard beadlike elevations which are composed of uric acid. The weight of the calculus was 14 grains. An analysis was made and the calculus found to be composed principally of the oxalate of lime with a small admixture of phosphates; this was but a trace. My patient, while trying to express his gratitude for services rendered him, made this remark: “I felt a gurgling sensation in my left kidney and in the region of the greatest pain, and with this sensa- tion all my pain ceased and (like I)r. Orton’s patient said) he could distinctly feel the stone when it drop- ped into the bladder.” Patient continued with the Carlsbad sprudel salt before each breakfast, also with the digitalis, hy- drangea and calisaya four times a day before the meals; a milk diet and as much of the Arcadian mineral water as he wished; his urine soon com- menced to clear up and all kidney troubles ceased. He has had no recurrence since last attack and is now quite robust and strong, at the present time, seventeen months since last attack. No. 411 36th Street.