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Pyelitis and pregnancy
722
THE AMERICAN
JOURNAL
OF’ OBSTETRICS AND GYNECOLOGY
Pyelitis and Pregnancy, DR. JAMES W. DUNCAN, Montreal, Canada. (By invitation.) (For original article, see October issue, p. 557.) DISCUSSION DR. WILLIAM C. DANFORTH, EVANSTON, ILL.-Our knowledge of this subject has been growing steadily during the last two or three years. The importance of ureteral obstruction as an etiologic factor in pyelitis of pregnancy is receiving an increasingly greater amount of attention. Last year I presented a series of thirteen cases of pyelitis of pregnancy in all of whom after delivery obstruction of urinary drainage still existed. Schreiber of New York, reporting on a series of 100 autopsies studied in Europe, was able to show that 12 per cent had a hydro-uretero-nephrosis of some degree which was dependent in every instance upon a narrowing of the ureter either at its pyeloureteral junction or at the vesieal portion. Dr. Duncan has already referred to the communication of Dr. Hofbauer in which he brings out the muscular hypertrophy which occurs in the trigone with the result that the vesical end of the ureter is narrowed. The important fact is that a definite obstrurtion of urinary drainage exists and that this during pregnancy is apt to be much exaggerated. Treatment of this condition must be based upon this fact. The essential thing is to establish urinary drainage. The possibility of focal infection elsewhere in the body, which with a urinary stasis due to obstruction may cause a hematogenous infection of the kidney and its pelvis, should not be overlooked. Eradication of focal infections is of importance. We shouId not look upon pyelitis of pregnancy as a transitory condition which requires little attention. These cases do require active treatment not only during pregnancy but some time thereafter. DR. NORRIS W. VATJX, PHILADELPHIA, PA.-Dr. Curtis, in his work done some years ago came to the conclusion that there was some definite obstruction in the lower urinary tract during the course of pregnancy. This blocking has been beautifully shown by the slides of the hydronephrosis which Dr. Duncan has so well demonstrated. In 1923, studying a series of some fifty cases which I reported before this Society, we were ab:e to determine definite edema or swelling in the trigone of the bladder. We did not have pyeloureterograms made of all cases at that time, and we were uncertain that the dilatation of the ureter was a definite factor, as well as the trigone swelling and edema. Associated with this there was a turning up of the lower ureteral orifice and in some cases a very definite residual urine was present. In a fairly extensive maternity service, both outpatient and hospital, we have found pyelitis occurring in pregnancy to be much more common than we had previously thought existed. When a case appears at our clinic that shows a great deal of sediment, particularly pus in the urine, we have that ease report for further cystoseopy and ureteral study. We have found that by taking such cases before they develop true pyelitis symptoms, and also those cases that have only a small amount of pus in the urine, and by treating them prophylactically we believe that we are able to cut down a definite percentage of cases that would develop pyelitis later in their pregnancy. We have found a dilatation of the ureter in pyelograms such as Dr. Duncan has shown in his slides in a few cases, but have not known how to account for it other than that it may have been a permanent condition present.
AMERICAN
QYNECOLOGICAL
SOCIETY
723
DR. GEORGE GELLHORN, ST. LOUIS, Mo.-Dr. Duncan ‘8 beautiful demonstrstion supplies anatomic proof of ureteral obstruction which, he says, leads in turn to urinary stasis and this again to infection. But since this obstruction is physiologic in pregnancy, if I understood him correctly, the occurrence of pyelitis should be expected in practically every pregnant woman; at any rate, it sl~oul4 occur more frequently than it actually does. IS it not possible to consider dilatation (not obstruction) of the ureter as th:? primary thing and explain it as being caused by a lowered tonus of this structure due to pregnancy changes in the vegetative nervous system1 Such an explanation would render more plausible the very marked dilatation of ureters which has been disclosed by x-ray pictures in the earliest weeks of pregnancy. I do not believe that an ascending infection of the b!adder is a frequent cause of pyelitis because there is usually no history of bladder symptoms prior to the attack. Focal infections may undoubtedly be responsible for some case3 of infection of the kidney pelvis, but this etiology is probably rather rare. It is much more likely that the chronic constipation in women which is so often aggravated in pregnancy, plays the decisive r6le. The intestines, like the ureter, have a lowered tonus in pregnancy, and this physiologic dilatation, which in extreme cases may even lead to ileus, gives the colon bacillus a chance either to wander through the intestinal wall into the ureter or, more likely, to enter the circulation whence they would have to be excreted through the kidneys. I hnvc: for some time paid particular attention to this point and noticed that pregnant as well as nonpregnant patients with pyelitis give a history of constipation prior to their attacks. The practical application is self-evident. Stoeckel and others have demonstrated the beneficial effect of thorough mechanical cleansing of the intestinal canal; and with me, copious colonic flushings form an integral part of the treatment of pyelitis. Another reason why the obstruction theory of pyelitis does not fully sntisf? me, is the observation that a simple ureteral catheterism often suffices to relieve the syndrome for the rest of the pregnancy. Yet, as the obstruction remains or forms again soon after the catheter is withdrawn, one would logically expect a return of the symptoms. In closing, may I be permitted to point to the danger of puerperal sepsis from a neglected pyelitis. It is quite conceivable that in such a case urine con taminated with colon bacilli or other bacteria, may run into the vulva during labor and give rise to childbed fever. This possibility alone demands most enobservation ergetic treatment of the pyelitis during pregnancy, and long-continued after the confinement so as to forestall a recurrence in the next pregnancy. DR. DUNCAN (closing).-In regard to Dr. Danforth’s remarks I might say, ~VF have endeavored to work out the question of focal infections. We have attempted in a series of rabbits to create focal infection8 in various parts of the body as close to the kidney, ns in the hepatic flexnre of the colon, and have not been able to recover. uniformly, in the tied side or the untied side of the ureters, direct cultures of eoii. The possibility that a focal infection in the tonsils or sinuses or teeth might lower the woman’s powers of resistance, plus an obstruction, might very well exp!oin thnt woman falling an easy prey to pyelitis. In regard to drainage, I would simply point to our postpartum cases in answer to Dr. Danforth ‘8 query; no doubt, with drainage established in these postpartum case8 the danger of developing an infected condition will be much lessened
724
THE AMERICAN
JOURNAL
OF OBSTETRICS AND GPNECOLOGi
In answer to Dr. Vanx’s question as to constipation, we have fully realized the extreme danger of constipation. After tying the transverse colon of rabbits with a loose ligature, bringing about an incomplete stasis, we have actually been able to recover from the ureter the bacillus coli in the tied side, also a positive culture in the urine on the tied side under the most rigid technic. In the untied side we have not been successful in recovering coli from the bladder in large quantities, whereas in the undisturbed, undamaged the Bacillus coli, so that we have concluded from this if we go on further it may be possible to demonstrate very large factor in the development of pyelitis. In effect for the no way
reply upon
to Dr. Gellhorn, I would point out the ureter and upon the parametrium,
production preceding
of obstruction and the slight dilatation
glomerulus we have found series of experiments that that constipation plays a
that congestion has a tremendous which is one of our main claims
that occurs as early as the such as we have shown.
sixth
week,
in
The distortion of the trigone which begins in multiparae at the sixth week and in primiparae at the tenth week, associating itself with a mild degree of dilatation, is physiologic and does not become pathologic until the twenty-fourth week, when stasis makes its appearance. I am in sympathy with Dr. Gellhorn’s remarks about the parasympathetic nervous system. There is no doubt that it plays a part in the ease with which the ureter gives way. I quite agree that the patient should be treated clinically along the lines which he suggested. I would point to the fact that this stasis has a very grave effect but it begins to disappear
about
the
ninth
day
postpartum.
A Comparative Study of Certain Gynecologic and Obstetric Conditions a.s Exhibited in the Colored and Whit&z Races, DR. C. JEFF MILLER, New Orleans, La. (For original article, see p. 662.) DISCUSSION DR. WILLIAM T. PRIDE, MEE~~PHIS, TENN.-one feature of Dr. Miller’s paper is especially interesting to me and that is the abnormal deliveries. Some years ago I left Philadelphia and entered practice in Memphis and was very much surprised at the measurements that we obtained in pelvimetry. In Philadelphia we had not assumed any difference between the colored and the white, but in the South we always found the difference. I tabulated over a period of years about 1500 cases, part of them taken from the South and part from the North, and we found that the difference existed not only in the negro, but in the Northern and Southern negro. Dr. Williams reported about all of his data from Baltimore. demonstrated that the Northern the Southern; that the Northern
4000 cases some years ago but naturally he took Mine taken from the North and from the South negro is larger in pelvic measurements than white woman is larger than the Southern.
Our deliveries are not operative as often in the colored as in the white. I have always attributed that to the fact that they are stronger, they stand pain better, and our statistics prove that they will labor very much longer without any assistance than the white woman will. There are many other features of this subject that are interesting, for instance eclampsia. We see eolampsia more frequently in the colored race according to Since we have been running our statistics. I think that is due to neglect.
THE AMERICAN
JOURNAL
OF’ OBSTETRICS AND GYNECOLOGY
Pyelitis and Pregnancy, DR. JAMES W. DUNCAN, Montreal, Canada. (By invitation.) (For original article, see October issue, p. 557.) DISCUSSION DR. WILLIAM C. DANFORTH, EVANSTON, ILL.-Our knowledge of this subject has been growing steadily during the last two or three years. The importance of ureteral obstruction as an etiologic factor in pyelitis of pregnancy is receiving an increasingly greater amount of attention. Last year I presented a series of thirteen cases of pyelitis of pregnancy in all of whom after delivery obstruction of urinary drainage still existed. Schreiber of New York, reporting on a series of 100 autopsies studied in Europe, was able to show that 12 per cent had a hydro-uretero-nephrosis of some degree which was dependent in every instance upon a narrowing of the ureter either at its pyeloureteral junction or at the vesieal portion. Dr. Duncan has already referred to the communication of Dr. Hofbauer in which he brings out the muscular hypertrophy which occurs in the trigone with the result that the vesical end of the ureter is narrowed. The important fact is that a definite obstrurtion of urinary drainage exists and that this during pregnancy is apt to be much exaggerated. Treatment of this condition must be based upon this fact. The essential thing is to establish urinary drainage. The possibility of focal infection elsewhere in the body, which with a urinary stasis due to obstruction may cause a hematogenous infection of the kidney and its pelvis, should not be overlooked. Eradication of focal infections is of importance. We shouId not look upon pyelitis of pregnancy as a transitory condition which requires little attention. These cases do require active treatment not only during pregnancy but some time thereafter. DR. NORRIS W. VATJX, PHILADELPHIA, PA.-Dr. Curtis, in his work done some years ago came to the conclusion that there was some definite obstruction in the lower urinary tract during the course of pregnancy. This blocking has been beautifully shown by the slides of the hydronephrosis which Dr. Duncan has so well demonstrated. In 1923, studying a series of some fifty cases which I reported before this Society, we were ab:e to determine definite edema or swelling in the trigone of the bladder. We did not have pyeloureterograms made of all cases at that time, and we were uncertain that the dilatation of the ureter was a definite factor, as well as the trigone swelling and edema. Associated with this there was a turning up of the lower ureteral orifice and in some cases a very definite residual urine was present. In a fairly extensive maternity service, both outpatient and hospital, we have found pyelitis occurring in pregnancy to be much more common than we had previously thought existed. When a case appears at our clinic that shows a great deal of sediment, particularly pus in the urine, we have that ease report for further cystoseopy and ureteral study. We have found that by taking such cases before they develop true pyelitis symptoms, and also those cases that have only a small amount of pus in the urine, and by treating them prophylactically we believe that we are able to cut down a definite percentage of cases that would develop pyelitis later in their pregnancy. We have found a dilatation of the ureter in pyelograms such as Dr. Duncan has shown in his slides in a few cases, but have not known how to account for it other than that it may have been a permanent condition present.
AMERICAN
QYNECOLOGICAL
SOCIETY
723
DR. GEORGE GELLHORN, ST. LOUIS, Mo.-Dr. Duncan ‘8 beautiful demonstrstion supplies anatomic proof of ureteral obstruction which, he says, leads in turn to urinary stasis and this again to infection. But since this obstruction is physiologic in pregnancy, if I understood him correctly, the occurrence of pyelitis should be expected in practically every pregnant woman; at any rate, it sl~oul4 occur more frequently than it actually does. IS it not possible to consider dilatation (not obstruction) of the ureter as th:? primary thing and explain it as being caused by a lowered tonus of this structure due to pregnancy changes in the vegetative nervous system1 Such an explanation would render more plausible the very marked dilatation of ureters which has been disclosed by x-ray pictures in the earliest weeks of pregnancy. I do not believe that an ascending infection of the b!adder is a frequent cause of pyelitis because there is usually no history of bladder symptoms prior to the attack. Focal infections may undoubtedly be responsible for some case3 of infection of the kidney pelvis, but this etiology is probably rather rare. It is much more likely that the chronic constipation in women which is so often aggravated in pregnancy, plays the decisive r6le. The intestines, like the ureter, have a lowered tonus in pregnancy, and this physiologic dilatation, which in extreme cases may even lead to ileus, gives the colon bacillus a chance either to wander through the intestinal wall into the ureter or, more likely, to enter the circulation whence they would have to be excreted through the kidneys. I hnvc: for some time paid particular attention to this point and noticed that pregnant as well as nonpregnant patients with pyelitis give a history of constipation prior to their attacks. The practical application is self-evident. Stoeckel and others have demonstrated the beneficial effect of thorough mechanical cleansing of the intestinal canal; and with me, copious colonic flushings form an integral part of the treatment of pyelitis. Another reason why the obstruction theory of pyelitis does not fully sntisf? me, is the observation that a simple ureteral catheterism often suffices to relieve the syndrome for the rest of the pregnancy. Yet, as the obstruction remains or forms again soon after the catheter is withdrawn, one would logically expect a return of the symptoms. In closing, may I be permitted to point to the danger of puerperal sepsis from a neglected pyelitis. It is quite conceivable that in such a case urine con taminated with colon bacilli or other bacteria, may run into the vulva during labor and give rise to childbed fever. This possibility alone demands most enobservation ergetic treatment of the pyelitis during pregnancy, and long-continued after the confinement so as to forestall a recurrence in the next pregnancy. DR. DUNCAN (closing).-In regard to Dr. Danforth’s remarks I might say, ~VF have endeavored to work out the question of focal infections. We have attempted in a series of rabbits to create focal infection8 in various parts of the body as close to the kidney, ns in the hepatic flexnre of the colon, and have not been able to recover. uniformly, in the tied side or the untied side of the ureters, direct cultures of eoii. The possibility that a focal infection in the tonsils or sinuses or teeth might lower the woman’s powers of resistance, plus an obstruction, might very well exp!oin thnt woman falling an easy prey to pyelitis. In regard to drainage, I would simply point to our postpartum cases in answer to Dr. Danforth ‘8 query; no doubt, with drainage established in these postpartum case8 the danger of developing an infected condition will be much lessened
724
THE AMERICAN
JOURNAL
OF OBSTETRICS AND GPNECOLOGi
In answer to Dr. Vanx’s question as to constipation, we have fully realized the extreme danger of constipation. After tying the transverse colon of rabbits with a loose ligature, bringing about an incomplete stasis, we have actually been able to recover from the ureter the bacillus coli in the tied side, also a positive culture in the urine on the tied side under the most rigid technic. In the untied side we have not been successful in recovering coli from the bladder in large quantities, whereas in the undisturbed, undamaged the Bacillus coli, so that we have concluded from this if we go on further it may be possible to demonstrate very large factor in the development of pyelitis. In effect for the no way
reply upon
to Dr. Gellhorn, I would point out the ureter and upon the parametrium,
production preceding
of obstruction and the slight dilatation
glomerulus we have found series of experiments that that constipation plays a
that congestion has a tremendous which is one of our main claims
that occurs as early as the such as we have shown.
sixth
week,
in
The distortion of the trigone which begins in multiparae at the sixth week and in primiparae at the tenth week, associating itself with a mild degree of dilatation, is physiologic and does not become pathologic until the twenty-fourth week, when stasis makes its appearance. I am in sympathy with Dr. Gellhorn’s remarks about the parasympathetic nervous system. There is no doubt that it plays a part in the ease with which the ureter gives way. I quite agree that the patient should be treated clinically along the lines which he suggested. I would point to the fact that this stasis has a very grave effect but it begins to disappear
about
the
ninth
day
postpartum.
A Comparative Study of Certain Gynecologic and Obstetric Conditions a.s Exhibited in the Colored and Whit&z Races, DR. C. JEFF MILLER, New Orleans, La. (For original article, see p. 662.) DISCUSSION DR. WILLIAM T. PRIDE, MEE~~PHIS, TENN.-one feature of Dr. Miller’s paper is especially interesting to me and that is the abnormal deliveries. Some years ago I left Philadelphia and entered practice in Memphis and was very much surprised at the measurements that we obtained in pelvimetry. In Philadelphia we had not assumed any difference between the colored and the white, but in the South we always found the difference. I tabulated over a period of years about 1500 cases, part of them taken from the South and part from the North, and we found that the difference existed not only in the negro, but in the Northern and Southern negro. Dr. Williams reported about all of his data from Baltimore. demonstrated that the Northern the Southern; that the Northern
4000 cases some years ago but naturally he took Mine taken from the North and from the South negro is larger in pelvic measurements than white woman is larger than the Southern.
Our deliveries are not operative as often in the colored as in the white. I have always attributed that to the fact that they are stronger, they stand pain better, and our statistics prove that they will labor very much longer without any assistance than the white woman will. There are many other features of this subject that are interesting, for instance eclampsia. We see eolampsia more frequently in the colored race according to Since we have been running our statistics. I think that is due to neglect.