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The Treatment of Pyelitis1
THE TREATMENT OF PYELITIS 1 C.H. CHETWOOD New York City
Received for publication August 10, 1922
To undertake to answer the question- what is the treatment of pyelitis?-is like attempting to name the treatment of cystitis. The answer in either case would resolve itself into an investigation of etiology and bacteriology. There is, however, no intention on the part of the speaker to inflict upon this seasoned assembly such unnecessary detail. The purpose is rather to speak of a single method of treatment, to report the experience therewith of those who have contributed to the subject, to give the result of a limited personal observation and to defer pending more extended observation, a qualified judgment as to jts relative value. I refer to the method introduced by Gross of Vienna involving the treatment of pyelitis by intravenous injections of neosalvarsan, with apparent strikingly successful effect. Naturally, the question arises as to what particular type of renal infection lends itself favorably to this procedure. Its value has been compared with the treatment by pelvic lavage of the same condition, the merits of which are variously estimated. The latter method has been used by some as a routine practice, often unjustified if not harmful, in any case, from one revealing a few leukocytes to that of a frankly purulent pyelitis. I garnered the opinion from some of the European clinics that lavage with the silver nitrate was applicable to colon bacillus pyelitis but not to streptococcus or staphylococcus. Be this as it may, it is interesting to note the experience of different observers with the treatment by intravenous injection of neosalvarsan. It is stated that Porges (Necker (1)), first observed the clearing up of a urinary infection after the injection of neosalvarsan. The case was one of cystitis and pyelitis in a tabetic patient. The 1 Read at the meeting of the American Association of Genito-Urinary Surgeons, Waehington, May, 1922 .
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bacterial coefficient in this instance is not stated but according to the same observer the treatment is without.effect in gonorrheal cases. A brief abstract of what may be gleaned from the literature is as follows: The "rationale" of the controlling influence upon bacterial invasion of the renal pelvis by intravenous injections of neosalvarsan is kindred to that of hexamethylenatetramin although intravenous injections of the latter do not exercise the same effect. Old salvarsan does not work. The therapeutic effect is not sufficiently explained athough it is thought in some way to be due to the spliting off of formaldehyde in the blood. Gross' theory assumed that the freeing of the formaldehyde took place in the kidney itself and his tests proved the presence of formaldehyde in the urine. Favorable results are reported in both acute and chronic cases, although in the former group the urine does not clear so quickly as in the latter. Kall of Freiburg (2) who is attached to Professor Rost's Genito Urinary clinic, has used this method of treating pyelitis for three years. Most of the cases were post-gonorrheal but did not reveal a gonococcus infection of the pelvis. The organisms comprised B. coli and staphylococcus. The author contrasts this treatment favorably with older methods especially that of urotropin, as the former is not dependent for its success upon an acid medium. The results obtained were favorable in a high percentage of cases. In a few cases relapses occurred but improved upon return to treatment. A small percentage proved refractory to this method. Necker (1) reports observations covering a four years' period. In summarizing his observation he states that neosalvarsan injections show beneficial effect in all cases where inflammation is limited to the mucosa of the renal pelvis and fail where the parenchyma of the kidney is notably affected. The effect is also checked if there is retention of urine either in the pelvis or the bladder. Nathan and Reinecke reported extraordinarily favorable results and tested the remedy especially in pyelitis complicating female gonorrhea (non-gonococcus infection). Of especial interest
TREAnrnNT OF PYELITIS
89
is this treatment in the case of solitary kidney of the nephrectomized patient. Rencker of Herzheimer's Dermatological Clinic,- Frankfurt am M. (3) embodies in his report those of Gross, Nathan and Reinecke, and Kall. He furnishes the history of 12 personal cases. Most of these were former gonorrheal subjects who had had inadequate treatment. Save for 1 case the results bore out the claims of Gross and other authors reported. There was no recurrence. The technic is the usual method employed, namely, freshly prepared solution in recently boiled and distilled water. The average dose is 0.15 gram of the drug. Subsequent dosage according to effect and response, as low as 0.05 gram and up to 0.3 gram. Total number of doses usually four. Intervals from three to five days. As to personal experience, I employ a 5-cc. record syringe with an unusually fine platinum, iridium needle and dissolve the dose of neosalvarsan, whether it be the minimum or maximum quantity, in that amount of water. Case 1. November, 1921; female; age twenty-three. General health, good. Frequency of urination commenced two years ago when B. coli bacilluria was detected. Present condition: urination every two hours, day and night, painful at times but not always. Cystoscopic examination reveals general cystitis of mild degree. Both ureters catheterized. Right side specimen: Frequent pus cells; caudate and cuboidal epithelial cells; scattered red blood cells; microorganisms, many bacilli in chains; negative for tuberculosis. Left side specimen: Frequent pus cells; caudate and cuboidal epithelial cells; many red blood cells; microorganisms, bacilli in chains and cocci; negative for tuberculosis. Cultures from throat and left kidney urine yield Staphylococcus aureus and albus. Autogenous vaccine from culture administered without improvement. First intravenous injection, neosalvarsan 0.15 gram in 5 cc. distilled water. Second injection three days later. Soon afterwards blood appeared in the urine and when this subsided some improvement followed, revealed in elongation of urinary intervals from t wo to four hours and some clearing up of the urine. One week after second
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C. H. CHETWOOD
injection a third was given of 0.1 gram. Six days after the third a fourth dose of 0.15 gram was given. The improvement in this case was maintained for three weeks after stopping injections, then a relapsing tendency was revealed which quickly yielded to renewed treatment in a much milder dosage. At present report, three days after last treatment, intervals are about one-half as frequent as formerly and the urine in gross appearance is notably clearer. The right catheterized specimen is normally clear and the left only moderately turbid.
Case 2. March, 1922; male; aged nineteen. No venereal history. Two years ago entered hospital for alleged appendicitis. No operation. At that time blood and pus found in the urine and since then dysuria with increasing intensity. At present urination every one and one-half to two hours, day and night, with much pain before and during urination. The urine is freely purulent. Capacity of bladder reduced to between 3 and 4 ounces. Cystoscopy: marked cystitis in vicinity of trigone rendering it difficult to detect ureteral openings. Both ureters are catheterized. Right side specimen diffusely turbid; numerous pus cells, pelvic cells. Left side normal specimen of clear urine obtained. First treatment, 0.15 grams neosalvarsan injected intravenously, following which within twenty-four hours there is abatement of symptoms. Second treatment, seven days later, 0.15 grams neosalvarsan. Following second treatment, for the first time in many months patient passes the night through without the necessity of rising but once to urinate. The urine is somewhat clearer but still cloudy and purulent. Third treatment, seven days after second, same dosage. Last report now about two weeks after third dose: bladder capacity increased to 7 ounces. Urine much clearer. Pain entirely absent Intervals about every four hours. General health noticeably improved·
This communication is only a brief note and not a paper as it purports to be. But the subject seemed to me to be of sufficient moment to become a part of these proceedings and I hope you agree with me. REFERENCES (1) NECKER: Rothschildspital reports, Vienna, vi, Nr. 1-2, 1921. (2) KALL: Munch. Med. Woch., May, 1920. (3) RENCKER: Archiv. f. Dermatol. u. Syph., 1921.
Received for publication August 10, 1922
To undertake to answer the question- what is the treatment of pyelitis?-is like attempting to name the treatment of cystitis. The answer in either case would resolve itself into an investigation of etiology and bacteriology. There is, however, no intention on the part of the speaker to inflict upon this seasoned assembly such unnecessary detail. The purpose is rather to speak of a single method of treatment, to report the experience therewith of those who have contributed to the subject, to give the result of a limited personal observation and to defer pending more extended observation, a qualified judgment as to jts relative value. I refer to the method introduced by Gross of Vienna involving the treatment of pyelitis by intravenous injections of neosalvarsan, with apparent strikingly successful effect. Naturally, the question arises as to what particular type of renal infection lends itself favorably to this procedure. Its value has been compared with the treatment by pelvic lavage of the same condition, the merits of which are variously estimated. The latter method has been used by some as a routine practice, often unjustified if not harmful, in any case, from one revealing a few leukocytes to that of a frankly purulent pyelitis. I garnered the opinion from some of the European clinics that lavage with the silver nitrate was applicable to colon bacillus pyelitis but not to streptococcus or staphylococcus. Be this as it may, it is interesting to note the experience of different observers with the treatment by intravenous injection of neosalvarsan. It is stated that Porges (Necker (1)), first observed the clearing up of a urinary infection after the injection of neosalvarsan. The case was one of cystitis and pyelitis in a tabetic patient. The 1 Read at the meeting of the American Association of Genito-Urinary Surgeons, Waehington, May, 1922 .
87
88
C. H. CHETWOOD
bacterial coefficient in this instance is not stated but according to the same observer the treatment is without.effect in gonorrheal cases. A brief abstract of what may be gleaned from the literature is as follows: The "rationale" of the controlling influence upon bacterial invasion of the renal pelvis by intravenous injections of neosalvarsan is kindred to that of hexamethylenatetramin although intravenous injections of the latter do not exercise the same effect. Old salvarsan does not work. The therapeutic effect is not sufficiently explained athough it is thought in some way to be due to the spliting off of formaldehyde in the blood. Gross' theory assumed that the freeing of the formaldehyde took place in the kidney itself and his tests proved the presence of formaldehyde in the urine. Favorable results are reported in both acute and chronic cases, although in the former group the urine does not clear so quickly as in the latter. Kall of Freiburg (2) who is attached to Professor Rost's Genito Urinary clinic, has used this method of treating pyelitis for three years. Most of the cases were post-gonorrheal but did not reveal a gonococcus infection of the pelvis. The organisms comprised B. coli and staphylococcus. The author contrasts this treatment favorably with older methods especially that of urotropin, as the former is not dependent for its success upon an acid medium. The results obtained were favorable in a high percentage of cases. In a few cases relapses occurred but improved upon return to treatment. A small percentage proved refractory to this method. Necker (1) reports observations covering a four years' period. In summarizing his observation he states that neosalvarsan injections show beneficial effect in all cases where inflammation is limited to the mucosa of the renal pelvis and fail where the parenchyma of the kidney is notably affected. The effect is also checked if there is retention of urine either in the pelvis or the bladder. Nathan and Reinecke reported extraordinarily favorable results and tested the remedy especially in pyelitis complicating female gonorrhea (non-gonococcus infection). Of especial interest
TREAnrnNT OF PYELITIS
89
is this treatment in the case of solitary kidney of the nephrectomized patient. Rencker of Herzheimer's Dermatological Clinic,- Frankfurt am M. (3) embodies in his report those of Gross, Nathan and Reinecke, and Kall. He furnishes the history of 12 personal cases. Most of these were former gonorrheal subjects who had had inadequate treatment. Save for 1 case the results bore out the claims of Gross and other authors reported. There was no recurrence. The technic is the usual method employed, namely, freshly prepared solution in recently boiled and distilled water. The average dose is 0.15 gram of the drug. Subsequent dosage according to effect and response, as low as 0.05 gram and up to 0.3 gram. Total number of doses usually four. Intervals from three to five days. As to personal experience, I employ a 5-cc. record syringe with an unusually fine platinum, iridium needle and dissolve the dose of neosalvarsan, whether it be the minimum or maximum quantity, in that amount of water. Case 1. November, 1921; female; age twenty-three. General health, good. Frequency of urination commenced two years ago when B. coli bacilluria was detected. Present condition: urination every two hours, day and night, painful at times but not always. Cystoscopic examination reveals general cystitis of mild degree. Both ureters catheterized. Right side specimen: Frequent pus cells; caudate and cuboidal epithelial cells; scattered red blood cells; microorganisms, many bacilli in chains; negative for tuberculosis. Left side specimen: Frequent pus cells; caudate and cuboidal epithelial cells; many red blood cells; microorganisms, bacilli in chains and cocci; negative for tuberculosis. Cultures from throat and left kidney urine yield Staphylococcus aureus and albus. Autogenous vaccine from culture administered without improvement. First intravenous injection, neosalvarsan 0.15 gram in 5 cc. distilled water. Second injection three days later. Soon afterwards blood appeared in the urine and when this subsided some improvement followed, revealed in elongation of urinary intervals from t wo to four hours and some clearing up of the urine. One week after second
00
C. H. CHETWOOD
injection a third was given of 0.1 gram. Six days after the third a fourth dose of 0.15 gram was given. The improvement in this case was maintained for three weeks after stopping injections, then a relapsing tendency was revealed which quickly yielded to renewed treatment in a much milder dosage. At present report, three days after last treatment, intervals are about one-half as frequent as formerly and the urine in gross appearance is notably clearer. The right catheterized specimen is normally clear and the left only moderately turbid.
Case 2. March, 1922; male; aged nineteen. No venereal history. Two years ago entered hospital for alleged appendicitis. No operation. At that time blood and pus found in the urine and since then dysuria with increasing intensity. At present urination every one and one-half to two hours, day and night, with much pain before and during urination. The urine is freely purulent. Capacity of bladder reduced to between 3 and 4 ounces. Cystoscopy: marked cystitis in vicinity of trigone rendering it difficult to detect ureteral openings. Both ureters are catheterized. Right side specimen diffusely turbid; numerous pus cells, pelvic cells. Left side normal specimen of clear urine obtained. First treatment, 0.15 grams neosalvarsan injected intravenously, following which within twenty-four hours there is abatement of symptoms. Second treatment, seven days later, 0.15 grams neosalvarsan. Following second treatment, for the first time in many months patient passes the night through without the necessity of rising but once to urinate. The urine is somewhat clearer but still cloudy and purulent. Third treatment, seven days after second, same dosage. Last report now about two weeks after third dose: bladder capacity increased to 7 ounces. Urine much clearer. Pain entirely absent Intervals about every four hours. General health noticeably improved·
This communication is only a brief note and not a paper as it purports to be. But the subject seemed to me to be of sufficient moment to become a part of these proceedings and I hope you agree with me. REFERENCES (1) NECKER: Rothschildspital reports, Vienna, vi, Nr. 1-2, 1921. (2) KALL: Munch. Med. Woch., May, 1920. (3) RENCKER: Archiv. f. Dermatol. u. Syph., 1921.