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A Disorder which is Often Overlooked
Presence of living micro in the urine is a relatively common condition, but the in definiteness of the symptoms often leads to its existence being unsuspected. The different theories of the origin of the condition are here discussed, its symptoms described and its treatment indicated.
BACILLUS.    A rod-shaped bacterium is called a bacillus (plural, bacilli), this word being of Latin origin and literally meaning a little rod. From peculiarities in their shape the bacillus of tetanus, or lockjaw, is called the drumstick bacillus, and the bacillus of cholera the comma bacillus. The bacillus coli communis is a normal inhabitant to the human bowel, but if it passes through the bowel wall, in consequence of a wound or an ulcer or anything else, it gives rise to inflammation, often of a very virulent type. In the condition known as bacilluria the urine teems with it. Among other important diseases due to bacilli mention may be made of tuberculosis, typhoid fever, leprosy, diphtheria, anthrax or wool-sorter’s disease and plague. There are bacilli which do not cause disease at all for instance, the lactic acid bacillus, which is responsible for the souring of milk. A variety of this, the Bulgarian bacillus, is used for the artificial souring of milk.
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Bacilli and other bacteria may be found in fresh urine under many conditions of local and general disease, and even in health; but the term bacilluria is reserved for a condition in which, apart from any gross disease of the urinary system, a considerable number of living bacilli are to be found in the urine as it is passed, and in which these are derived from the kidney itself. The kidney has the power of excreting dead germs in small quantities; it is of the essence of badiluria that the germs should be living and capable of multiplication in the urine during its passage along the urinary channels. In cases the number of germs presem is so small that they can only be detected after careful search or by cultivation of a sample of the urine on suitable media. More often they are present in much larger numbers, and they may be so abundant as to give a milky appearance or a sheen to the urine as it is passed. Both the bladder and the urethra, especially in its lower stages, may harbour germs while maintaining an appearance of perfect health; it is therefore essential when baeilluria is suspected that possible contamination from the latter source should be avoided by withdrawal of the urine for examination with all aseptic precautions through a sterile catheter into a sterile vessel.
Living Germs from the Colon
There are several organisms which may appear in the urine; by far the most common is the bacillus coli communis, identical with the germ always present in the large bowel. In typhoid fever the special bacillus of this disease is very often excreted in the urine. It may persist for long periods after the disease which gave it origin has run its course until it is eradicated its host is a carrier of typhoid infection and remains a grave danger to others. In bacilluria the organisms mentioned may occur alone or in combination with others, but in over 70 per cent, of the cases bacillus coli is present alone.
The nature of the infection suggests its source, but opinion is still divided as to the route by which germs from the bowel may reach the kidney. That bacilluria should be especially common in little girls is suggestive of infection by direct spread along the short urethra from contamination of its orifice; the fact that it can be shown in animals that an injury of the mucous membrane of the lower bowel is followed by the appearance of intestinal germs in the bladder is in favour of the lymphatic route, while excretion of organisms of tuherole, typhoid and streptococcal septicaemia lends support to the blood-infection hypothesis.
Bacilluria may he latent and unsuspected; it is relatively common, and is very liable to be overlooked. Its symptoms vary in severity from vague malaise with slight fever and a little frequency of micturition to those of an acute illness with high fever, accompanied by shivering, constant desire to pass water, painful urination and a profound disturbance of general health. The condition is common in children of tender years and is far more common in girls than in boys; in adult life it is commoner in women than in men, and it is one of the well-recognize complications of pregnancy.
In young children the symptoms are usually much more severe than in older children or adults. The child is taken ill suddenly with a high temperature, furred tongue, perhaps vomiting, often a shivering fit or in very young children its infantile equivalent—a convulsion. There may be little to point to a urinary cause for the illness, and the diagnosis may be obscure until the urine is investigated from this point of view; but usually the child has symptoms of an irritated bladder together with painful or infrequent urination.
In bacillus coli infection the urine is always acid in reaction, and contains in addition to bacilli a few pus cells and a few cells from the lining membrane of the upper urinary passages. The symptoms often show a tendency to remission followed by fresh outbursts, but sometimes they maintain their original severity for several weeks. In other cases there may be persistent slight ill-health with slight irregular rises of temperature, but no rigors or urgent signs; in such cases the most striking symptom may be frequent bed- wetting. In virtually all cases there is some disturbance of the bowels, generally in the form of constipation.
Complications follow so insidiously or occur so early in the course of an attack of bacilluria that their signs and symptoms are almost inseparable from those of the causal illness. The pelvis of the kidney becomes congested or inflamed—pyelitis; the kidney substance itself may be infected—nephrosis; or, if suppuration occurs, as it sometimes does, a condition of pyonephrosis, or kidney abscess, may develop. Cystitis or inflammation of the bladder may supervene, causing much pain and the passage of mucus and blood. In the bacilluria of children and pregnant women some degree of pyelitis is almost constant; it immediately increases the severity of the condition and calls for urgent treatment. The diagnosis of these conditions can only be properly made by a doctor, and treatment should be carried out under his directions.
Chronic Condition without Symptoms
After some long time the patient becomes as it were acclimatised to the condition and though the bacilluria persists there is entire freedom from symptoms. There is, however, always a tendency to relapse after a chill or intestinal disorder.
When bacilluria is recognized early its successful treatment is simple; if it has been allowed to drag on for several weeks its cure becomes much more difficult. General treatment includes confinement to bed until the temperature has been normal for at least a week; warmth, abundant fluids by the mouth, and attention to the bowels with a view to keeping the large intestine empty and to reduce its bacterial content as much as possible. Diet must be non-putrefactive and flatulent distension must he guarded against; for these reasons flesh foods and eggs must be forbidden, and it is well to refrain from the use of saline aperients, owing to their tendency to produce gaseous distension of the gut.
Special treatment has as its first aim the alteration of the reaction of the urine; in coli infection it must be changed from acid to alkaline.  Staphylococcal and streptococcal infections may occur as well as bacilluria and cause similar symptoms, and then the urine must be made acid. Drugs which have an alkalizing action are the citrates and carbonates of sodium and potassium; very large doses may be required, and they should be continued for at least a week after the urine has become alkaline. Suitable doses for a child of three are potassium citrate 20 grains and sodium bicarbonate 15 grains every two hours; these amounts may have to be doubled and the larger doses be continued for several days before it becomes safe to reduce the amount or frequency of the dosage.
In chronic eases relapse is common, and vaccines, prepared, if possible, from cultures of the special strain of organism present in the patient’s urine, may be necessary.
Staphylocoeeal and strepteeoceal infections call for the use of urinary antiseptics; of these the best is hexamine, which in the presence of an acid splits up, with the formation of formaldehyde; this is excreted by the kidney, and has a powerful disinfectant effect upon bacteria. Hexamine has to be given with certain precautions; it is apt to upset digestion and must be carefully watched; on no account should it be given in combination with an acid or acid salt, lest premature formation of formaldehyde should occur and its value as a urinary disinfectant be abolished. it is best given in a tumblerful of water in doses of 10 to 15 grains for an adult, between meals and followed half an hour inter by a drug with the power of rendering the urine acid. Such drugs are acid phosphate of sodium in 20 grain doses, boric acid in 5 to 10 grain, and sodium benroate in 15 grain doses. The prevention of bacifiurin lies in the avoidance of constipation and the use of a correct diet.
Baeilluria is very liable to recurrence; this often happens when the patient is first allowed to get up. Careful attention to the bowels and protection from chill are important items in the treatment during convalescence. Tonics of iron, arsenic and the glycerophosphates are called for as soon as the infection has been overcome.
In addition to acute and chronic Bright's disease, which are described under that heading, there are certain inflammatory conditions of the kidney to which the term nephritis may be applied. These include temporary disturbances of its health as the consequence of poisons circulating in the blood and derived from something swallowed or absorbed, as from certain germs, such as those of diphtheria. In these conditions there may be a temporary disturbance of the kidney leading to the passage of a concentrated urine containing albumin or blood, but unless the poisoning is very severe it is unusual for the general symptoms of acute Bright's disease to develop; the kidney rapidly returns to normal after absorption of the irritating substance is discontinued.
As a consequence of inflammation of the urinary tract the kidney may itself become inflamed. In these case, the inflammation affects first the pelvis of the kidney, i.e. the expanded upper end of the ureter, giving rise to a condition of pyelitis.
Pyelitis is liable to affect the kidney in two ways; it may lead to gross dilatation of the pelvis of the kidney, converting this into a large, painful bag of pus without marked. involvement of the cellular structures, a condition known as pyonephrosis (q.v.), or it may affect both the pelvis and the body of the kidney, when it is called pyelonephritis: Pain and irregular fever, often with rigors, are symptoms of both states.
The urinary tubules of the hidney discharge their contents into the expanded upper end of the ureter, known as the pelvis of the kidney. It is liable to become inflamed as a result of infection with microorganisms carried to it through the blood or lymph or reaching it by direct spread upwards from the lower reaches of the urinary tract as in a bladder infection (cystitis). This condition is known as pyelitis. Infection with germs from the bowel is the most common type, and is associated with the passage in the urine of large quantities of the common colon bacillus, a condition termed bacilluria (q.v.). Other organisms may cause pyelitis, e.g. the staphylococci and streptococci of acute infections of the bladder or urethra; but these organisms may also originate from a putrefactive bowel. As a consequence, in any case of pyelitis, bowel putrefaction must be assumed until proven otherwise. Needless to say, most cases of pyelitis are concomitant with constipation.
Pyelitis is one of the serious complications of pregnancy. It causes fever, malaise ard usually, frequeucy of micturition. In these cases the organism is derived from the bowel. In children, especially little girls, pyelitis is quite common. Any unexplained ill health of children associated with some variable degree of fever should arouse suspicion of pyelitis. In many cases the symptoms are very severe. Acute cases of pyelitis respond quickly to treatment. This consists in confinement to bed, clearing of the bowels by an active aperient or purge by Epsom salts, copious drinks of water and the administration of snfficiently large doses of alkalies to keep the urine definitely alkaline, potassium citrate being the most effective, but calcium salts can also be used. As a urinary tract disinfectant, Lugol’s iodine/iodide solution, several drops to a glass of water, four or more times daily for 7-14 days, as a course of treatment.
Chronic pyelitis is sometimes very resistant to treatment. This is particularly the case when mixed infection with several organisms is present. In these cases urinary antiseptics such as iodine and sulfa drugs which will increase the acidity of the urine are used in alternation with the alkaline treatment. And if these fail good results may be obtained by the use of vaccines prepared from the actual organisms found in the urine of the individual case.