The third possible manner of infection, the wandering of the coli bacilli from the intestinal tract, has also been experimentally proven (Wreden). The intestinal epithelium lutist have been destroyed either by disease or by artificial means. Escherich is strongly inclined to acknowledge the possibility of this mode of infection in some of the cystites, particularly those in which the bladder disease follows in flammatory intestinal diseases, especially inflammatory processes in the lowest part of the intestinal canal:—"Colitis contagiosa." According to Escherich, an infection of the urinary tract in this manner is pos sible not only by the bacterium coli, but also by streptococci. This mode of origin, according to Eseherich, is probably the rule in the extremely rare cystitis of boys.
The second question which must be answered is whether the eoli bacilli or other bacteria after having gained an entrance will always, regardless of the circumstances, produce an inflammation of the mucous membrane. The pure cases of bacteriuria, prove that this is not so. \Ve may maintain with absolute certainty, even without referring to this fact, that the bladder membrane does not always react with in flammation to entering germs. The fact that cystitis is seldom pri mary, but far oftener follows other diseases, especially those of the intestines, supports the opinion that in order to bring about an inflam mation there must be some disposing condition present in the bladder. Guion believes that the chief predisposing factor is retention of the urine. Retention of the urine may be due, not only to local obstruc tion, such as strictures, diverticultn, ete., but it may also result from con ditions impairing the general health of the children, because in these cases the urinary discharge. otherwise well regulated, fluty he interfered with.
Additional factors disposing to cystitis, are cold (sitting on ice), diminished diuresis, hyperternia, irritation and lesions of the mucous membrane by foreign bodies and by calculi, irritations by toxins, etc. (Escherich).
Om: knowledge of the character of cystitis, due to the bacterium coli and the proteus has been advanced by the important discovery of Pfaundler, who demonstrated that a bouillon culture of bacilli grown on urine and mixed with the blood serum of the same patient, will produce, even if considerably diluted, the agglutination which has been proved by Gruber's experiments to occur in coli infection.
The technique employed by Pfaundler was in every essential the same as that recommended by Widal. The blood was taken by vene section and added to the serum in the usual manner. Pfaundler took the microbes he wished to examine from a pure culture (agar-agar), twenty-four hours old and deposited three drops in a bouillon tube.
This emulsion he mixed with the serum in proportions of 10 to 1, 30 to 1, 50 to 1, and 100 to 1. From each of the four mixtures, and from one serum-free emulsion, as a control proof, he took one small drop and brought them together on one common sterile cover-glass, which was inverted in the usual manner over a concave glas.s slide. The observation was effected with a strong dry lens. -Where reaction is positive after twenty four hours, the following apperances develop: "The small rods grow out into delicate extremely long threads, which appear claw-like and inter WOVell and form lumpy groups under slight magnification. The groups are either isolated, or else arc connected by extremely delicate fila ments. Between the single filaments the liquid is perfectly free from form elements. The threads and filaments do not present the least, indication of mobility. Under high powers the threads appear partly articulated, granular, and sometimes thickened into clubs. The threads are greatest in length, the filaments are densest in the reaction where the serum dilution is the least (Fig. 15).
Considering the morphological conduct described above, Pfaundler designates the reaction as the thread reaction. It can therefore only be called positive when it develops in a dilution of at least 30 to 1. To produce this reaction, the conditions are: The employment of a serum and of microbes from the sante pa tient, and the presence of fever dur ing the presence of infection as an in dication of the general disturbances, but the reaction fails not only in light cases of brief duration but in serious cases which end in death. It has been established in a series of case.s by means of this reaction, dis co v ered by- Pfaundler, that colon bacilli, or the proteus in the urine are not insignificant parasites, but arc of pathogenic import in man, since they produce through their toxins a specific reaction in the body.
Course and Complications Pyelitis and Pnelonephritis.— The course varies according to the etio logical factor and according to the participation in the inflammation of the renal pelvis or the kidney, for instance, if extraneous bodies or calculi are the casual factors of the cystitis, the affection will last for a time, and a cure will be effected only after the removal of the cause. Those varieties due to the bae terium coli and to the proteus, and the lactis aerogenes will be more quickly relieved than those which result from streptococci and staphylo cocci, whose course is more malignant. The cystites due to diphtheria, and to the bacilli of tuberculosis, belong to a more serious class, and often terminate in death.