1907 BMJ (Clinical Research Edition)  
1907) describes a fatal case of the so-called Kahler's disease, and discusses at some length the name that should be given to it and its etiology. The patient, a man of 54, of simple and regular habits of life, gave a negative family and past medical history; syphilis was-denied and he had never taken much alcohol or tobacco. In the winter of 1904 he had transient attacks of violent pain in his ribs and femurs, not in the joints ; he was treated with salicylate and quinine. Some relief was
more » ... ome relief was obtained, but soon the pains returned, with general debility, palpitations, loss of appetite, constipation, and other symptoms. Various treatments were tried without success; the pains and gastro-intestinal troubles increased and the patient came into hospital early in 1906. He was thin, pale, troubled with frontal headache, unable to stand up without much pain, and forced to lie curled up on his side in bed. The eyes and fundi were normal, and no evidence of visceral disease could be found. The upper ribs and the upper dorsal vertebrae were very painful at times, and were very tender on palpation, as was the manubrium. Little tumours the size of a lentil or of half a pea,D ot so hard as spongy bone, tender, and the seat of constant pain, could be felt on these bones. The skull was normal. The superficial and deep reflexes of the legs were increaFed; the glands were normal. The blood showed 3} million red cells, 9,000 white, and 80 per cent. of haemoglobin; the leucocytes were normal in percentage and type. The urine varied from 1± to 2 litres a day, specific gravity 1028 to 1020. It always contained 0.7 to 0.8 per cent. of albumose ; when acidified with acetic acid and boiled, itgave no precipitate; but if it were thus acidified and treated with a few drops of strong potassium ferrocyanide solution, a copious white precipitate appeared, dissolving on heating, and reappearing when the mixture was cooled. The urine gave a marked biuret reaction; nitric acid brought doNwn a precipitate soluble on heating, but saturation with MgSO4, cr with NaCl caused no precipitation. The amount of urinary albumose was increased when the pains were very severe. The urinary sediment showed no abnormality. Treatment, except with morphine, gave no relief. The patient suffered terribly from pains aggravated by any movement, was prone to bedsores, took his food ill, and died of exhaustion and heart failure in two months. At the necropsy the viscera in general were normal; no enlargement of the lymphatic glands could be found. The bones showed a number of small rounded tumours, covered with thinned periosteum on Eection, it appeared as if the medulla were growing out through the bony wall at these points. Under the microscope, these tumours appeared to be plasmomas, or plasmacell tumours, composed of small rounded cells 5 to 12 ,u in diameter, and arranged in cords or concentric rods, with scanty connective tissue. The small rounded celIs had finely granular protoplasm, a single excentric nucleus, and various staining reactions; the larger cells were oval, and had two, or even three, distinct nuclei. This newlyformed tissue entirely replaced the bony medulla where it occurred. 189. Aeute and Chronic Pyelitis. BELIEVING that certain points in connexion with pyelitis are but little recognized, H. Lenhartz (Muench. med. Woch., April 16tb, 1907) considers that a short description of the clinical picture of the cases which he has studied will be of interest. He only deals with primary pyelitis, and does not include any of the cases which depend on such primary causes as pregnancy, prostatic hypertropby, etc. The majority of the observations were carried out on adults, and he particularly emphasizes that the fever curve appears to him to be extremely characteristic in his cases. He believes that the majority of infections attack the pelvis of the kidney by spreading upwards; it is possible that the infection may spread occasionally from the blood -vessels, but he does not think that it ever is derived from the intestine. Females are much more frequently attacked than are males, and the infection appears to be derived in them from local infections of the genital organs in connexion with the menses, pregnancy, ad parturition. In 66 out of his 80cases .the Bacterium coli communis was the sole infective agent. The fact that males are but rarely affected shows that the infection with the colon bacterium does not take place directly. Th;e bacteria, passing from the bowel, give rise to an infection through the external genitals. Bacllus lactie and proteus were found twice each, Friedlaender's pneumobacillus once, and the paratyphoid bacillus three times. On one occasion there was a mixed infection of coli and proteus. The soil suitable for the propagation of the bacteria appears to be produced by pregnancy, parturition, and also by the menses. As a rule the bladder does not become affected by the passage of the bacteria on their way to the kidney. The right kidney is much more frequently affected than the left. In 75 per cent. of the cases of acute and chronic pyelitis the temperature is raised. This fever is mostly characterized by a sudden and severe pyrexia lasting for from eight to fourteen daye, or by recurrent attacks of pyrexia at irregular or regular intervals. Only in about 25 per cent. is the temperature either only slightly raised or subnormal. Accompanying the fever, there are symptoms of general illness of a more or less severe type, and pains in the head, back, and limbs. Only about one-half of the patients refer' the pain to the seat of the trouble, but on careful bimanual examination it can be found that the kidney affected is very tender from the first. In a number of his cases he was able to make out a marked swelling of the renal pelvis, which attained the size of a fetal head in one or two cases. The urine is turbid, and in severe cases contains sufficient pus in it to be recognizable to the naked eye. It often contains blood. The reaction is acid, and albumen is always present. Microscopically, it contains pus cells, red blood; corpuscles, and rodlets, mostly agglutinated in clumps or arranged in threads. Threads of fiorin can also be seen in stained preparations. The nature of the rodlets or other bacteria can only be deteimined by bacteriologieal examination. The differential diagnosis must be made from appendicitis, influenza, pneumonia, etc. The diagnosis can mostly be made from the type of the fever curve. In most cases there is an initial rigor, and this can be repeated if the attack recur. Many cases present a curve which is practically identical with a pneumonia fever curve, but the low pulse and respiration-rate offer a marked contrast to this disease. When the crisis occurs between the sixth and tenth days there is little likelihood of confusion with enteric fever, but at times the type is more remittent, and ends by lysis. When the leucocyte count is low the diagnosis may be very difficult between? these diseases, but as a rule the leucocytes are increased in number. The author gives the charts of a number of patients to illustrate, first, the short severe fever with critical fall at the end of the first week; secondly, high fever with lytic fall during the second week; thirdly, cases in which a succession of attacks gives a typical curve. The intervals are represented by periods of normal or subnormal temperature, and the fresh attack generally sets in with a sudden rise of temperature. In the recurrent cases he has noticed that the onset of the menstruation is often in direct connexion with the renewed manifestation of the local infection. With regard to the prognosis, he says that of his 80 patients, 5 died; but of these 5, 1 must be excluded, as she was suffering 'from carcinoma, and the same applies to a seconcd, who died of a tuberculous affection. It therefore appears that 3 of his patients died as a direct result of the pyelitis. Of the remaining 75, 54 were clinically cured, 14 considerably' improved, and 7 still had symptoms. Bacteriologically speaking, only 16 we]re actually cured, 20 improved, and 3 were not cured. He does not think that drugs do much to help the patients to get better. He usually gets good results by washing the kidneys out with waters, such as. Wildunger, or by giving hot tea made of the blossoms of the lime tree. Urotropin is the best of the so-called bactericidal drugs, but he says that this preparation does not cure the disease, and that the bacteria continue to have their own way after one has given urotropin for some time. He only deals separately with the bladder when there is evidence of cystitis. The pain can be treated without narcotics as a rule, either by heat or by cold, according to the individuality of the patient. He concludes by saying that when the swelling of the renal pelvis is marked one can puncture the tumour, or even make an incision into the organ; bdt the majority of the patients do not consent to any surgical procedure. ISIPTS'21t lgqil,
doi:10.1136/bmj.2.2438.e41 fatcat:6hlfzi6j3vc7hpyabvoalxt54i