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Lorsque le document est trop grand pour Atre reproduit en un seul cllchA, il est film* i partir de Tangle supArieur gauche, de gauchn A droite, et de haut en bus, en prenant ie nombre d'images nAcessaire. Les diagrammes suivants illustrent la mithoda. ire. ] 1 2 3 1 2 3 4 8 6 BILIIAEZTA H.E:\rATOBlUM. Blood Flukk. BY Harrison R. Ross, M.D., ... ^ Surgeon to Jeitery Hale's Hospital, Quebec. Billiarz, in the year 1S51, while engaged in the study of tlie diseases of Egypt, discovered that the endemic haematuria of that country was due to the presence in certain veins of a trematode worm to which lio gave the name of " Di stoma ILTraatobium," afterwards better known as '•' Billiarzia TTfpnuitobiuui;' after the discoverer. This disease, while very prevalent in Egypt, Arabia, Mauritius, ^ and certain parts of South Africa, is practically unknown in America — being only met witli in imported cases. These have evidently been very rarely found up to the present time, as in my search through the literature of the subject I have succeeded in finding reports of only four or five, all of which were seen in the United States. As I have at present two cases of Billiarzia under observation, the patients having been infected while on military service in South Africa, it has occurred to me that in view of the many Canadians and immi- grants who, having served with the British forces during the late Boer War are now settled m Canada, the disease may be more often met with than formerly. That a large number of the men were infected with this parasite during the campaign is beyond doubt, as pointed out by Plardy and Douglass in a very interesting article on the subject in the Lancet, of October, 1903. "What information I have been able to glean seems fully to bear this out. Haematuria, — the primary and practically the only symptom of the disease in the first few years of its course. — being one common to so many pathological conditions of the genito-urinary tract, there is at once suggested a wide range of possibilitii's. But if the fact can be elicited that the patient had resided in a country where the parasite is indi- genous the possibility ov Bilharzia would at once be suggested, and if confirmed by a microscopic examination of the urine a great deal of unnecessary and painful instrumentation might be avoided. V, ROSS — BILHARZIA H«MATOBIUM. 597 As there is very little to be found relative to this parasite in our text books, the sul)ject being loft to writers on Tropical Medicine, a sliort description of the wonn and ova together with the accompanying plate may he of assistance in recognizing the latter under the microscope. The worm is a soft white creature, differing in shape and size in the two sexes. The body of the male, about 12 Jnm. long by 1 mm. broad, is flat with the edges enfolding over the ventral surface forming a cylinder wherein the female is enclosed during congress. The reniale is filiform in shape and longer than the male, measuring about '?0 mm. and darker in colour. The ovum, the most important feature for t1ie purpose of diagnosis, is oval aijd measures about 0.16 mm. in lengtli, though there is a con- siderable variation in size in those seen on any one slide under the microscope. They present a terminal or lateral spine, as the case may be, — viiich difference has not as yet been satisfactorily explained. While the spine is invariably at the end on the ova found in the urine, it is said that those found in the fseces present the lateral spine. In on article by ITerl)ert (Junn in the Journal of the Amcriatn Medical Association, Vol. XLVT, Xo. 14, he expressed the opinion that the lateral-spined ova are produced by a different species of worm. Apparently ver\' little has been added to our knowledge of the habitat and life liistory of the Avorm since the investigation of Bilharz. Tn regard to the mode of infection, while it is generally admitted that the parasite gains entrance into the human body by being swallowed in infected food and water, it seems probable that it may directly infect the bladder and rectum through the external orifices while bathing. By whatever channel the worm gains entrance into tlie body it eventu- ally finds its way into the veins of the portal circulation and urinary organs, principally in those surrounding the bladder and rectum, where tlicy make for themselves in the walls of these viscera under tlie mucus lining, a smooth Availed nidus communicating with the veins and wliich ii in reality nothing but the altered blood vessel. The ova then lorce their way from the nest into these hollow viscera and appear in the urine and faeces, the sharp spines Avith which tlioy are armed possibly assisting them in their migration through the interveninir tissues. Tlie parasite itself is never found in the excreta. Tt would appear tliat, in the vast majority of cases of Bilharzia, the lesions caused by the parasite and the migrating ova must be very sliglit indeed, as little inconvenience is experienced by the host, — the only p;"mptoms being the presence of some small clots of blood in the urine, the slight burning in the urethra on micturition. 41 598 ROSS — UILHAHZ!A H-EMATOBIUM. In Xatal a very large number of the male inhabitants harbour tlie parasite, but few are seriously inconvenienced. This applies parti- cularly to the young boj's of the country, who seem to be exceedingly suscoptil)le, but, as a rule, on arriving at puberty they then throw off the disease. Bilharzia may, however, give rise to the most intense suffering; in. cessant desire to mioturaie. dysentery, profuse hceinaturia and melania being tbe principal symptoms. Tlie patient loses weight and beoomos aniBMiie ajid dull from loss of blood. In thesi' severe cases tihe mucoiis membrane of tlie bladder will be found swollen and hypera.'naie, with ecch3'mosed patches varying in size co that of a shilling and coated with a tough mucus or layer of grayish yellow exudation. When the intestines are i'^volved the walls of the rectum show similar lesions, and dysentery, tenesmus and melfpna set in. Even in those mild cases in which the patient is not aware that he harliours the disease, the ova acting as foreign bodies in the bladder, not uncommonly become encrusted with urinary salts and furm tlio nucleus of small calculi whiJi, as a rule, pass out througli tlie uretln-a. It is rejnarkable, liowe^ tliat in Egypt not only does this occur more frequently than in othti lountries where the parasite is indigenous, but the disease often leads to the formation of very large stones necessitating surgical measures for their removal. The course of the disease is slow and insidious, often lasting many years before any serious symptoms develop, but eventually it may spread throughout the whole urinary ti-act and the ureters become occluded by the masses of ova and the infdtration of the walls. The danger to life depends very much upon the severity of the infc- tion, but is, as a rule, not serious, as in the great majority of cases the parasite dies within the host and recovery follows. Even, however, in slight infections it is the cause of a very distinct predisposition to intercurrent diseases. BOSS — UlLHAIiZIA Hi^^IMATOBIUM. 699 The treatment of Bilharzia is unsatisfactory in the extreme, and while the symptoms may be relieved to some extent, nothing has as yet l)een found that will affect the parent worm and thus rid the patient of the disease, though a large numl)or of drugs have been tried, among which are cliielly the urinary antiseptics as urotropine, ben- zoic acid, salol and methylene blue. Draughts containing male fern or turpentine seem to have been most used, but with indifferent success. The condition of the bladder may be treated by irrigations contain- ing one of the many mild antiseptics generally used for that purpose with a very fairly satisfactory but temporary result. Tlie general health should receive attention and be kept up by good food and tonics — iron being indicated where there is a severe loss of blood. Of the two cases I now have under observation the first came to me complaining of "passing blood in the urine, vague pains over the region of the kidneys, sliglit burning on micturition and increased fre- quency, loss of weight, and a general feeling of weakness and lassitude." His appearance was, liowpver, good, temperature and pulse normal, mucous membranes good colour. On his first visit to me I did not go into the history of the case, but mer'^iy inquired into the symptoms and made a three-beaker test of the urine, wliich showed the whole bulk to be distinctly blood-tinged, and in the third beaker a large quantity of blood clots, varying in size from a grain of rice to that of a pea, also a considerable quantity of deposit. This specimen was handed to Dr. W. H. Delany, pathologist at Jeffery Hale's Hospital, who reported that it contained besides blood and vesical epithelium a great number of the ova of Bilharzia Haematoi.Ium. TJpon again seeing the patient T learned that in 1900 he went out to South Africa with one of the Canadian Contingents and sen'ed there for three j'ears, being stationed for a gooo part of the time in Natal. Shortly after his discharge in 1903 he noticed for the first time an increased frequency in tlie desire to micturate, and occasionally the passage of a few small clots of blood at the end of the act. The presence of these olots gradually became more and more frequent until, at last, it occurred each time he voided urine. During the first two years there were no further symptoms, but about a year ago the quantity of blood increased and he began to suffer from pain in the region of the kidneys and perineum, with a general feeling of weakness ar^ lassitude. Eecently he has at times been troubled with diarrhoea, and occasionally has noticed streaks of blood in the stools. As the nature of his employment necessitated a good t X V 600 ROSS — BILHARZIA HiEMATOBIUM. deal of heavy work and exposure, which seemed to aggravate all the Hymptoms, he was obliged to give it up. Since the beginning of the trouble he has been under almost constant treatment for some one of the many troubles of which ha?tnaturia is ft symptom, the actual condition never having been recognized. The examination of the interior of the bladder, while not altogether satisfactory on account of the blood obscuring the view, reveals no marked changes in the mucosa beyond a general hypcra'miii, nor could any changes be detected in the mucous membrane of the rectum. My second case very well illustrates the fact that while a patient may have a considerable number of ova in the urine he does not neces- sarily suffer any inconvenience, even though the disease is of some years standing. This man, after having served in South Africa for several years in the Constabulary, noticed on three or four occasions a very small clots of blood in his urine — and, although he had very often heard of ■'•' Red Water " and had actually known of several men in his com- pany who had suffered from it, he did not seem to connect his own symptoms with the disease, as they were so slight and his general health perfect. The ova in this case, while not so numerous as in the first, can be found without difTuculty on every elide marlo from the deposit in the urin.i wliich contains also a ccnsidernblc amount of pus and epithelium and a few red blood cells. Dr. Delany reports that in both cases the ova contained in the urine present the terminal spines, and that he has been unable to find any in the fteces notwithstanding the fact that one of the patients has symptoms of beginning trouble in the rectum. The examination of the blood of these two patients, as is always the case in parasitic diseases, shows an increase in the number of Eosinophiles to seventleen per cent, and five per cent, respectively. While in the past Bilharzia Haemaitobium has been looked upon in America rather as a m.edical curiosity than as one of the diseases we have to deal with, it appears to me, from what I can learn of the pre- valence of the disease among the men who served in South Africa, that it may now be much more often met with, — as in all probahility many of the ex-soldiers now scattered throughout the Dominion harbour the parasite, and sooner or later will present themselves for diagnosis and treatment. I wish to add my sincere thanks to Dr. Delany for his valuable assist- ance, and particularly for the diagnosis in both these cases. V .,>^