The gradual extension of the infection through the ureter into the renal pelvis and further into the kidneys renders the course of the disorder prolonged and chronie. Symptoms indicating a secondary pyelitis resulting from cystitis, are:—sensitiveness to pressure over the renal region, radiating colicky pains in the neighborhood of the kidneys, elevation of tempertaure, which is intermittent, and ''of which the IV-7 type reminds its of malarial fever," with a feeling of perfect well-being during the intervals. The spread of the inflammation to the membrane of the renal pelvis is, according to Rosenfeld, recorded in the urine by an increase in the percentage of albumin, by the appearance of distorted white blood corpuscles, crenated red blood corpuseles, and the small cubical epithelium of the upper urinary tracts. The primary pyelitis which is observed espeeially in older girls, may present clinically the same appearances RS the secondary, but. s.ometinies not. a single symp tom indicates the seat of the disease, except the irritability of the child, oceasional febrile reaction, an extreme pallor, and a lack of appetite, whiela look more like the symptoms of a general disease than of a local infection. The diagnosis can only be established by an examination of the urine, whiell bs supposed to have, according to Graf, a smaller percentage of bacteria, a greater percentage of albumin, and a. more decided aeid reaction, than cystopyelitis.
If the kidney becomes involved in the inflammation, it will be shown, as in the ease of an infant whose eystitis followed upon an in testinal disease, by exacerbation of the gastro-intestinal symptoms, by the appearance of vomiting and diarrhota, which do not depend upon the character of the nourishment., and which alone point to the nature of the disturbance. The percentage of albumin in the diminished urine is increased, and easts and renal elements appear. Convulsions, opisthotonos, and coma may be added to the picture and the patient may die with high remittent or intermittent fever, with symptoms due partly to the urinary intoxication, and partly to the septic infection.
If we bear in mind what was said of the symplomatology of the nephritis complicating the gastro-intestinal diseases of infancy, it is apparent that where a cystitis has come on rapidly in the course of an intestinal disease, it is hardly possible to establish the differential diagnosis between cystitis associated with a simulanteous hiernatog enous nephritis, due to the fundamental disease, and a pyclonephritis. Only the postmortem will certainly clear up our doubts in many of these cases.
proper treatment the prognosis of cystitis, except in the forms resulting from diphtheria and the tubercle bacillus may be considered in general to be favorable. Without. medical treat ment some of the cases, especially in infancy, terminate in death with septie symptoms. Even involvement of the renal pelvis does not greatly inerease the seriousness of the prognosis, but where the infec tion spreads to the kidney the danger of the outlook is greatly increased.
Prophylaxis and of the genitals is of the utmost importance in prophylaxis. Those who have the nursing of children should be directed to bathe the anal and the genital regions only from the front towards the back, since otherwise the bacteria about the anus may readily be introduced into the urethra. Therapeutic measures are directed to the cause. In the presence of conditions which excite or maintain a cystitis, of anomalies of the urinary tract, of ex traneous bodies or calculi, we must, in the first place, treat or remove these causes. Only after they have been gotten rid of can medicinal and dietetic therapeutics be effective.
The sovereign remedy for eystitis and pyelitis is urotropin (hexa methylenetetramin) introdueed by Nicolaier, which, when taken by the mouth counteracts the influence of the exciters of the infection by splitting off' formaldehyde during its excretion through the kidneys. For infants 10 c.c. (21 dr.) of a solution of 13 Gm. (31 dr.), of urotropin in 100 Gm. (31 oz.), of water should be given three times daily in milk. To older children larger doses up to 1.5 Gm. (25 grains) per day can be given. Instead of urotropin, helmithol has been recommended, lynt it possesses no superiority, and children dislike it because of its disagreeable taste.
Another remedy which is fairly- popular, and quite effective, is salol. The doses should not be too small if we are to obtain good re sults. For infants we should use 0.1 to 0.3 Gm. (11-41 grains); for older children 0.5 Gin. 17 grains) four times a day. Recovery will be hastened by simultaneous irrigation of the bladder, which is to be effected in babies by introducing a small metal catheter, which is fastened by a short piece of rubber tubing to a syringe hokling 10 c.c. At first a 3 per cent. solution of boraeie acid is used, 3 to 5 injections arc given, after each of which the boracic solution is allowed to e.scape again and then in the same way three injections of a solution of nitrate of silver (1 to 2000 to 1 to 1000) are introduced, and finally the remnants of the solution of silver arc precipitated by the introduction of 3 to 5 syringefuls of a 1 per cent. solution of common salt. Violent pain may necessitate the symptomatic use of poultices and of narcotics; nausea and vomit ing are effectively eombated by craeked icc.
The nourishment of the infant during this affection is indicated by the condition of the child. Food rich in salts is to be avoided, and liquids are to be supplied in abundance. Older children should be given a diet free from spices and consisting of milk and vegetable dishes. Drinks which may be given are: whey, fruit lemonade, almond milk, or alkaline waters. The children must be kept in bed until the acute symptoms, fever and pains, have disappeared. They- need careful nursing, and must be guarded against any bodily exertion or catching cold.