The proportion of the bacteria to the number of cellular elements is varied; the former are often present in far greater numbers, partly in pairs, partly grouped in small piles. Sometimes they are short like cocci, sometimes arranged in longer threads. They arc readily seen in the hanging drop and are still more perceptible when doffler's solu tion is added to the fresh preparation (Escherich). III order to facili• tate their identification, and to prove a mixed infection, Gram's method of double staining is to be recommended, since by this process the coli bacilli are deprived of color. The bacteria will grow upon all the usual media, but there may be some slight deviations as to the growth, mo bility or fermentation from the normal condition of the coli bacillus in the case of sugar solutions.
In addition to the strictly bacteriological demonstration, an acid reaction of the urine is also in favor of the presence of colicystitis.
This acid reaction is constantly wanting in the case of septic cystitis clue to staphylococci and streptococci. but it is present in the tubercu lous form, which is extraordinarily rare as a primary affection, Mit which does accompany tuberculosis of the kidneys, of the genitals, or a general tuberculosis, and 11 hich can be easily recognized by bacteriological exam ination. This affi•ction is said to be distinguished by sc•vere pain, cystite douloureuse (PreindlsbergeM.
We will briefly mention here the experiences of GOppert, who had the opportunity of observing, a great number of cases of cystitis in chil dren in Silesia. Ile permitted me to use a portion of his clinical experi ence for the present work, for which I wish here to express my gratitude. GOppert describes cases of cys titis which appeared sucidenly with violent general symptoms, high fever and rapid breathing during the second half of the first year in stickling babes. Conspicuous symptoms these cases were a charac teristic pallor, appearing even on the second or third day, and loud screaming when the child was held upright. Later in the progress of the disease these infants show extreme paleness of the face, large eyes, and restless, hoarse screaming, which arc symptoms reealling the aspect of severe intestinal catarrh in its later state. In older girls, Goppert saw cystitis present itself in two different forms. In one of these the child was very feverish, almost like typhoid, and there was no indication of bladder disorder. Those who suffered front the other form were brought to Goppert because of ancemia, pallor, and evening fever, i.e., with the symptomatology we are wont to see in cases of tuberculosis. Vesical disturbance was present in only a small per
centage of the cases.
Those forms of cystitis not caused by the coli bacillus, but by those bacilli mentioned above, differ in symptomatology very little from the colicystitis, only that their course is more malign, and that blood is more often found mixed with the urine. The pyocyaneus-cystitis which may be a complication of general pyocyaneus infection is characterized by hmmorrhages in the skin, and We can differentiate it only by bac teriological examination of the urine.
Pathologically, the acute bladder catarrh is characterized by red ness, infiltration and swelling of the membrane, which is covered with mucus and with numerous cells, bladder epithelium, and leucocytes. The chronic stage shows thickening and greater puffing, out of the membrane; if the process is particularly intense we see loss of substance and hiernorrhage. Except iu the cystitis due to the diphtheria bacillus, we seldom see extensive fibrinous deposits.
Pathogenesis, Character, has been much dis cussion as to the mode of entrance of the bacteria into the bladder,and as to the circumstances under which they produce inflammation of the mucous membrane. There, are three possible modes of entrance; they may enter by way of the urethra; they may reach the urinary, bladder through the circulation of the kidneys, by way of the urine, or filially they may invade the urinary tract, and settle upon its membrane by penetrating its walls from the adjoining viscera. The fact, already mentioned, that colicystitis chiefly affects the female sex, and that its presence is rare in male children, argues in favor of the first-named mode of infection. The bacterium coli almost always to be found under normal conditions upon the surface of the vulva and vagina, and its migration through the short female urethra is probably fairly fre quent, especially when the mouth of the urethra is open, as is readily possible in girls in certain positions. The penile urethra, however, from its very anatomical condition, would probably exclude this mode of infection.
Posner and Lewin proved experimentally the possibility: of a hrematogenous coli-infection of the urinary tracts. In man this method of infection must be taken absolutely for granted, but still it, occur rence may be considered rare, since a frequent invasi-ff of the blood stream by the coli bacilli is improbable, because in colicystitis the examination of the blood was almost always negative (Wunschheini, Escherich).