illUUIUIillllllllllil 
 
^1 
 
 \1 
 
 1 
 
1$*0P 
 
 «**$»** 
 
 3^ 
 
 00^ 
 
 T0$> 
 
 V7 
 
 e 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/bilharziosisOOmadd 
 
Fig 1.— The bilharzia worm (Schistosomum haematobium). To the right 
 is a coupled pair of worms, the female lodged in the gynecophoric 
 canal of the male. To the left is seen a cross-section of a pair, 
 to show the mode of formation of the gynecophoric canal, in which 
 a single cross-section of the female worm is visible. Both figures 
 semi-diagrammatic. 
 
 (Photograph of a drawing by Professor Looss, figured in Mense's "Handbttch 
 der Tropen-UranlJiciten" Vol. 1.) 
 
BILHARZIOSIS 
 
 BY 
 
 FRANK COLE MADDEN 
 
 M.D.Melb., F.R.C.S.Eng. 
 
 professor of surgery egyptian government school of medicine, senior 
 surgeon kasr-el-ainy hospital, cairo 
 
 ILLUSTRATED 
 
 NEW YORK 
 WILLIAM WOOD AND COMPANY 
 
 MDCCCCVII 
 
 PATHOL rnpvl 
 
RC 
 'Si 
 
 Ml3 
 Won 
 
PREFACE. 
 
 In this monograph I have endeavoured to give a 
 resume of the present state of our knowledge of 
 Bilharziosis ; and, in doing so, have naturally had 
 to draw largely upon the work and experience of 
 others in the same field. To these observers I 
 wish here, at the outset, freely and frankly to 
 acknowledge my great indebtedness. 
 
 I am especially beholden to my friend and col- 
 league, Professor Looss, who has taken infinite pains 
 in providing me with an abstract of that portion of 
 his article in Mense's " Handbuch der Tropen- 
 krankheiten" which deals with the life-history and 
 mode of infection of the Bilharzia worm. 
 
 Again, much of the pathological description of 
 the disease is the result of a study of specimens 
 in the Pathological Museum of the School of Medi- 
 cine in Cairo, prepared by Professor W. St. Clair 
 Symmers, formerly Professor of Pathology in this 
 School, now Musgrave Professor of Pathology in 
 Queen's College, Belfast. For his kindness in re- 
 el vising an earlier manuscript of mine on the subject 
 . and allowing me to avail myself so fully of the 
 
 JZj 
 
 CO 
 CO 
 
 C3 
 
vi PREFACE. 
 
 material at his disposal, I am deeply grateful; but 
 I must accept all responsibility for any inaccuracies 
 that may appear in the text. 
 
 In the clinical paragraphs I have included much 
 of the work published by my former colleague, Mr. 
 Frank Milton, in various papers, in my endeavour 
 to make this side of the picture as complete as 
 possible ; and, throughout the whole monograph, 
 I have avoided the discussion of controversial points, 
 upon which much work is still to be done, and have 
 tried to approach the subject from the standpoint 
 of a practical surgeon. 
 
 I am also indebted to Dr. H. P. Keatinge, the 
 Director of the School, for his ready assent to the 
 publication of photographs of specimens and cases 
 from the School collections ; and, finally, to my 
 friend and colleague, Professor A. R. Ferguson, 
 the present Professor of Pathology in the School 
 of Medicine, for so carefully revising with me the 
 whole manuscript, I take this opportunity of ex- 
 pressing my sincerest thanks. 
 
 Cairo, 1907. 
 
CONTENTS. 
 
 The Parasite 
 
 PAGE 
 
 9 
 
 II. 
 
 The Pathological Changes produced by Bilharzia . 18 
 
 III. 
 
 Bilharziosis op the Urinary System 
 
 30 
 
 IV. 
 
 Bilharziosis op the Intestinal Tract 
 
 64 
 
 V. 
 
 Bilharziosis of the Female Generative Organs 
 
 73 
 
 VI. 
 
 Bilharziosis of the Skin and Subcutaneous Tissues 
 
 7o 
 
LIST OF ILLUSTRATIONS. 
 
 Fig. 1. — The bilharzia worm .... Frontispiece 
 
 „ 2. — Section of bilharzial tissue in the meso- 
 
 recturu ...... To face page 10 
 
 ,, 3. — A bilharzia ovum in the urine . . ,, ,,10 
 
 ,, 4. — Section of bilharzial cirrhosis of the liver ,, ,, 12 
 
 „ 5. — Free-swimming bilharzial miracidium . ,, ,,12 
 
 ,, 6. — Section of portion of a bilharzial 
 
 papilloma . . . . . . ,, ,,18 
 
 ,, 7. — The mucus membrane in early bilharziosis 
 
 of the bladder .....,,,, 18 
 
 „ 8. — More advanced bilharziosis of the bladder ,, ,, 22 
 
 ,, 9. — Bilharzial papillomata in the large intestine ,, ,, 22 
 
 ,, 10. — Ulceration of the large intestine (" bilhar- 
 zial dysentery ") . . . . . ,, ,, 27 
 
 ,, 11. — Extreme case of bilharziosis of the bladder ,, ,, 27 
 
 „ 12. — Section of "bilharzial scirrhus " of the 
 
 bladder „ 29 
 
 „ 13. — Advanced bilharziosis of the bladder . ,, ,,36 
 
 ,, 14. — Bilharziosis of the penis and scrotum in 
 
 a young boy „ „ 57 
 
 „ 15. — Bilharziosis of the penis in a boy of nine . ., ,, 59 
 
 ,, 16. — Bilharziosis of the sigmoid flexure and 
 
 meso-sigmoid . . . . . ,, ,,68 
 
 „ 17. — Bilharzial papillomata protruded from 
 
 the anus ...... n „ 68 
 
 ,, 18. — Bilharzial papillomata of the vulva grow- 
 ing from the left labium majus „ ,, 73 
 
 ,, 19 — Smaller papillomatous mass growing from 
 
 right labium majus in same case . ,, ,, 74 
 
 ,, 20. — Bilharziosis of the vulva and vaginal 
 
 orifice. ..... To follov) Fig. 19 
 
 ,, 21. — Bilharzial papilloma growing from pos- 
 terior lip of cervix uteri . . . To face page 76 
 
 ,, 22. — Scarring left after operations on bilharzial 
 
 sinuses ......„„ 76 
 
 ,, 23. — Epithelioma around anus originating on 
 
 site of old bilharzial disease ..,,,, 76 
 
 ,. 24. — Epithelioma of the penis, scrotum, and 
 inguinal glands secondary to old 
 bilharziosis. .... To follov) Fig. 23 
 
BILHARZIOSIS. 
 I. 
 
 THE PARASITE, 
 
 The pathological conditions included in the term bil- 
 harziosis are produced by the presence of the bilharzia 
 worm, Schistosomum hcematobium, in the human body. 
 
 Geographical distribution. — The bilharzia worm 
 is endemic in Egypt, and also, to a more limited extent, 
 in South Africa. Endemic centres appear to exist in 
 Syria, the Soudan and Uganda, Madagascar, Mau- 
 ritius, Reunion, China, Cyprus, and the West Indies ; 
 and sporadic cases of bilharziosis, probably contracted 
 in one or other of these centres, have been reported 
 in many other countries, for instance, in England and 
 Australia, among the troops who have recently returned 
 from South Africa. 
 
 Description and life-history. — The worm be- 
 longs to the group of the Trematodes, but is dis- 
 tinguished from the majority of this group by having 
 male and female separate individuals. 
 
 The male worm, to the naked eye, is about 1 cm. 
 long, milky-white in colour, cylindrical in shape with 
 tapering extremities. Microscopically, its body is seen 
 to be thickly studded with minute warty projections, 
 each tipped with short stout bristles. Two suckers, 
 
10 BILEABZIOSIS. 
 
 one behind the other, are seen on the under surface 
 of the body, near the anterior extremity. Under the 
 microscope it will also be seen that the body of the 
 worm is not cylindrical, but thin and flattened, and 
 that the lateral margins of the body are folded towards 
 the ventral surface to form a long open canal — the 
 gynecophoric canal — in which the female lies during 
 the period of sexual activity. 
 
 The female worm is much longer and thinner than 
 the male and is often found lying within the gyneco- 
 phoric canal, generally with part of the anterior and 
 posterior extremities protruding. She can, however, 
 completely withdraw herself into the canal. (Figs. 1 
 and 2.) 
 
 The most common habitat of the worm is the 
 portal vein and its tributaries within the liver. 
 
 Here the worms are small, often very small, are 
 not yet sexually active, and the male and female 
 occur separately, not coupled. Exceptionally, how- 
 ever, coupled pairs of worms may be met with in 
 this situation. 
 
 The worms are also found in the mesenteric veins 
 and their larger tributaries. Here they are larger 
 than those found in the portal vein and mostly occur 
 as coupled pairs. They are sexually mature, but the 
 female does not contain many ova. 
 
 The other common habitat of the worm is the 
 vessels of the submucous tissue of the bladder and 
 rectum and, to some extent, also, of other parts of 
 the intestinal tract. 
 
Fig. 2. — Photo-micrograph of section of bilharzial tissue in the meso-rectum 
 (see Fig. 16), showing several coupled pairs of worms in situ. To 
 the left and above, the female has been so much coiled up that 
 three cross-sections of it have been made. Below and to the right 
 no^female is present. 
 
 (From a preparation b%i Professor Looss, figured in Mcnse's " Handbueh 
 dcr Tropen-l;rcm~kheiten," Vol. 1.) 
 
 Fig. 3.— A bilharzia ovum, with calcified contents, in the urine. The 
 shell and its end spine are particularly well seen. 
 
 (From a photo-micrograph in the Photographic Album of the School of 
 Medicine, Cairo.) 
 
THE PARASITE. 11 
 
 Worms found in these situations are fully de- 
 veloped, physically and sexually, they nearly always 
 occur in coupled pairs, and the uterus of the female is 
 distended with ova. 
 
 Exceptionally, worms may be found in the vessels 
 of other organs of the body, notably the lungs 
 (Symmers). 
 
 From these observations it would appear that the 
 worms travel from the liver in the veins of the portal 
 system generally, to the vessels in the submucous 
 tissue of the bladder and rectum and other parts of 
 the intestine. Some even escape into systemic 
 veins, by way of their communications with the 
 portal system, and may thus reach the lungs or 
 other organs even more distant. 
 
 It will be noted that the course of the worms is 
 against the blood stream. This mode of progression 
 is probably effected by strong muscular movements on 
 the part of the male worm, which carries the female, 
 lodged in its gynecophoric canal, with it. 
 
 The ova are of a blunt spindle shape, about 0*16 
 mm. long on an average. They are encased in a thin 
 yellowish shell. Two forms of ova are to be distin- 
 guished. The most common (normal) ovum has a 
 terminal spine, which may vary in size within narrow 
 limits in different ova, or even be entirely absent. 
 The second (abnormal) ovum presents a large lateral 
 spine, which varies considerably in size and position. 
 These lateral-spined ova are usually seen in small 
 numbers in the uterus of young females and are 
 
12 BILHARZIOSIS. 
 
 commonly found in the liver, and, more rarely, in the 
 lungs. (Figs. 3 and 4.) 
 
 The ova are laid into the blood and the laying 
 begins when the female is still in the liver. The ova, 
 being thus free in the blood-stream, are washed away 
 through the larger vessels until they reach a smaller 
 capillary than they can traverse, and here they become 
 impacted. Thus, the ova that are laid when the 
 worms are still in the portal vein, or in the larger 
 veins of the portal system, may be washed back into 
 the liver and become fixed there ; or may even pass 
 through this organ and reach the pulmonary or the 
 systemic circulation. In the latter case they are 
 ultimately infarcted in the smaller capillaries of 
 distant tissues or viscera. 
 
 When the ova are laid in the smaller vessels, as, 
 for instance, in those of the submucous tissue of the 
 bladder or rectum, the capillaries may become com- 
 pletely packed with ova, to such an extent that the 
 walls of the vessels burst and the ova pass into the 
 substance of the organ and become fixed there. By 
 the muscular movements of the viscus, aided also by 
 their peculiarly penetrating shape, the ova slowly 
 travel in the organ ; and some approach the surface of 
 the mucous membrane and are eventually extruded and 
 passed with the urine or faeces. This movement of 
 the ova in the tissues is comparable with the wander- 
 ing of a needle, which has penetrated the skin and lies 
 loose in the subcutaneous tissues. 
 
 In the exceptional cases in which worms are found 
 
Fig. 4. — Section of bilharzial cirrhosis of the liver, showing many lateral- 
 spined ova. 
 
 (From a specimen, prepared by Professor Symmers, in the Pathological Museum 
 of the School of Medicine, Cairo. Photo-micrograph by Mr. F. S. Willmore.) 
 
 r 
 
 Fig. 5. — The free-swimming bilharzial miracidium. Semi-diagrammatic. 
 (From a wall-diagram drawn by Professor Looss, and figured in Mense's 
 " Handbuch der Tropen-lerankheiten," Vol. 1.) 
 
THE PARASITE. 13 
 
 in the systemic circulation, the ova are passed directly 
 into the circulating blood and are thus directly carried 
 to unusual seats. 
 
 At the time of its formation in the female the 
 impregnated ovum contains an unsegmented egg-cell 
 and a number of yolk-cells. It is then much smaller 
 than the ova found in the tissues, increasing in size as 
 the process of development goes on within it. By the 
 time the ovum is passed in the urine or faeces it con- 
 tains a fully developed embryo or miracidium. If such 
 ova get into water, or if water be added to the urine 
 or faeces, the miracidium hatches out in a few minutes 
 and swims actively about by means of its cilia. In 
 urine and in almost any other fluid, except water, 
 the miracidium dies in about 24 hours without hatch- 
 ing out ; and even in water, once it has hatched out, it 
 cannot be kept alive for longer than 24 to 48 hours. 
 (Fig. 5.) 
 
 Many ova die during development, and their con- 
 tents become granular and finally calcified. Micro- 
 scopically, such ova present a blackened opaque ap- 
 pearance. (See Figs. 3 and 4.) These calcified ova, 
 indeed all ova, will vary in size according to their 
 stage of development. 
 
 Further Development. — The complete cycle 
 of development of the bilharzia worm is still un- 
 known. From analogy with other Trematodes it 
 seemed reasonable to infer that, in order to become 
 a young worm, the miracidium must pass through a 
 further stage of development in some intermediary 
 
14 BILHARZIOSIS. 
 
 host. No intermediary host has ever yet been dis- 
 covered. Looss, working under the most favourable 
 conditions, in the very midst of bilharziosis in 
 Egypt, has utterly failed to find any intermediary 
 host, or to induce any species of animal or plant 
 life to harbour the miracidium. He is, therefore, of 
 opinion that man himself acts as the intermediary host. 
 Two modes of infection are possible on this 
 hypothesis. 
 
 1. By the mouth, being introduced through the 
 medium of the drinking water. 
 
 In this connection, Looss has shown that free- 
 swimming bilharzia miracidia are killed in a 1 in 
 1000 watery solution of hydrochloric acid, almost 
 instantaneously, and in less than three minutes in a 1 
 in 2000 solution. For this reason, infection through 
 the stomach, the secretion of which contains a stronger 
 solution of hydrochloric acid, is practically impossible. 
 
 2. By the skin, by penetration. Looss holds the 
 view that the miracidia probably penetrate the skin, 
 find their way to some resting place, probably the 
 liver, and there pass through a sporocystic stage ; the 
 final outcome of which is young worms of both sexes, 
 similar in appearance to those found in the veins of 
 the liver. The presence of certain so-called germinal 
 cells in the body of the miracidium indicate con- 
 clusively that there must be a sporocystic stage in 
 the cycle of development. 
 
 In support of this infection-by-skin theory, it has 
 been noted that, in the country districts of Egypt, it 
 
THE PARASITE. 15 
 
 is the agricultural labourer, or fellah, who works all 
 day in the wet irrigated fields, who is most commonly 
 affected: and that it is the scavengers, street sweep- 
 ers, gardeners, and small children (who love to go 
 about bare-footed in the puddles and wet), who are 
 especially subject to bilbarziosis, among the town 
 dwellers. In the country, the whole agricultural 
 population drink plain unfiltered Nile water ; but in 
 the towns the water is treated by nitration and sup- 
 plied by Water Companies. In spite of the supposed 
 protection against infection thus afforded, certain 
 classes of the town-dwellers do become subject to bil- 
 harziosis; and, as has just been pointed out, the 
 classes most affected are made up of individuals 
 whose habits, in other respects, are similar to those 
 of the agricultural labourer. 
 
 Any small puddle may become denied with the 
 urine or faeces of a patient suffering from bilharziosis ; 
 and, in a very short time, the water or mud is alive 
 with miracidia, which may become applied to the 
 bare feet, legs, or hands, penetrate the skin and 
 so lead to infection. In this way, too, constant 
 re-infections may occur and a cure is almost im- 
 possible. 
 
 Children who contract bilharziosis during the bare- 
 feet period of their existence may grow out of their 
 disease in a few years' time ; for re-infection does not 
 occur, owing to their altered habits and indoor oc- 
 cupations. It has frequently been noted, also, that 
 when a patient suffering from bilharziosis leaves the 
 
16 BILHARZIOSIS. 
 
 country in which he contracted it he may eventually 
 be completely cured. 
 
 It is a remarkable fact that, of the cases of 
 bilharziosis treated at Kasr-el-Ainy Hospital, Cairo, 
 which drains all parts of Egypt, except Alexandria, 
 nearly 90 per cent, come from Cairo and the country to 
 the north of Cairo. This is the only part of Egypt 
 now perennially irrigated, and comprises the rich agri- 
 cultural lands of the Delta ; whereas the country to the 
 south is entirely inundated during the rise of the Nile 
 and, after its subsidence, receives only just sufficient 
 water for the purposes of cultivation. Thus in the 
 north the fields are practically always under water; 
 while in the south the supply is strictly limited and 
 the northern wet sodden condition of the ground does 
 not prevail (Milton). 
 
 Of a total of 1,346 cases of bilharziosis admitted 
 for treatment in the hospital, during a certain term of 
 years, about 94 per cent, were males ; and the greater 
 number of cases occurred between the ages of 15 and 
 45. It was remarkable that the proportion of female 
 cases to male was as 1 to 9, under the age of 15 years ; 
 but above that age, when the girls marry and begin 
 to lead more of an indoor life, it was as 1 to 20, a very 
 significant fact in view of what has already been 
 stated regarding the mode of probable infection 
 (Milton). 
 
 Further, Talaat has shown that bilharziosis in 
 women is common among the poorer agricultural popu- 
 lation, all of whom work in the fields with the men. 
 
THE PARASITE. 17 
 
 It is much less frequent in the better classes and in 
 those who are mainly occupied with domestic duties. 
 In the towns, the disease is altogether less common 
 than in the country and is only met with in women 
 whose work brings them in contact with wet soil or 
 mud, and in children, and it is quite unknown among 
 the better classes. 
 
 It is well recognised that almost every Egyptian 
 of the agricultural class, in Lower Egypt at all events, 
 has had bilharzial hematuria at one time or another. 
 A careful investigation of a series of 100 consecutive 
 admissions to the hospital, irrespective of their disease, 
 showed that 35 of them had bilharzia ova in the urine ; 
 but only 2 of this number complained of symptoms of 
 bilharziosis (Milton). 
 
 A great many cases must eventually recover with- 
 out symptoms at any time sufficiently serious to call 
 for medical treatment ; the severe cases being found 
 among those whose occupation renders them particu- 
 larly liable to repeated re-infections and in whom,, 
 sooner or later, septic infection supervenes. 
 
II. 
 
 THE PATHOLOGICAL CHANGES PRODUCED 
 BY BILHARZIA. 
 
 The pathological effects of Bilharzia are due, 
 primarily, to the deposit of the ova in the tissues. 
 These ova soon excite a small-celled infiltration around 
 them, as is the case with any foreign body, and to 
 such an extent may this infiltration proceed that, at 
 times, the true structure of the affected parts is almost 
 completely replaced by ova, leucocytes and young 
 connective tissue cells. (Fig. 6.) 
 
 The pathological manifestations may be divided 
 somewhat arbitrarily into two classes of lesions, the 
 hypertrophic and the atrophic. In the former occurs 
 a marked proliferation of cells, especially epithelial 
 cells, leading, particularly, to the formation of papil- 
 lomatous growths : whereas, in the atrophic form, the 
 principal change is due to the presence of what may 
 be called bilharzial granulation tissue. This becomes 
 fibrillar, and, in fact, goes through all the various 
 changes of inflammatory granulation tissue of more 
 acute origin ; the final result being a peculiar white 
 dense contracting fibrous tissue, a true scar tissue, 
 which may contain very few ova in its substance. 
 
 The hypertrophic form is especially found in connec- 
 ts 
 
Fig. 6.— Section of portion of a bilharzial papilloma, showing the enormous 
 crowding of the tissues with ova. 
 
 (From a specimen, prepared by Professor Symmers,in the Pathological Museum 
 of the School of Medicine, Cairo. Photo-micrograph by Mr. F. S. Willmore.) 
 
 Fig. 7.— General swelling and infiltration of the mucous membrane in 
 early bilharziosis of the bladder. 
 
 (From a specimen, prepared by Professor Symmers, hi the Pathological 
 Museum of the School of Medicine, Cairo.) 
 
PATHOLOGICAL CHANGES. 19 
 
 tion with bilharziosis of viscera lined by mucous 
 membrane ; the atrophic being more usual in the 
 disease as it affects the connective tissues, either of 
 the subcutaneous area or of the viscera. In certain 
 cases the two forms may be seen side by side in the 
 same viscus. 
 
 CEETAIN PATHOLOGICAL APPEARANCES COMMON TO BIL- 
 HARZIOSIS OF VISCERA LINED BY MUCOUS MEMBRANES. 
 
 The changes about to be described may be found 
 in any part of the genito-urinary tract from the pelvis 
 of the kidney to the meatus of the urethra ; from just 
 beyond the duodenum, along the whole length of the 
 intestinal tract, to the anus ; and from the vaginal 
 orifice to the internal opening of the cervical canal 
 of the uterus. 
 
 General swelling and infiltration of the 
 mucous membrane. — One of the earliest manifesta- 
 tions of bilharziosis of mucous membranes is a charac- 
 teristic velvety swelling of the whole thickness of the 
 membrane. The surface is dark-red in colour and has 
 the appearance of a " thick pile velvet"; its superficial 
 layers are coated with a viscid tenacious mucus and, 
 but for this protection, they would be easily rubbed 
 off on the least friction. The mucous membrane 
 strips off easily from the deeper structures, and is so 
 much swollen and thickened as to be thrown into folds. 
 It often has a very fine brownish-yellow powdery 
 appearance in its substance, sometimes throughout its 
 whole extent, but, usually, more marked in some parts 
 
20 BILEABZIOSIS. 
 
 than in others, and is very vascular throughout its 
 whole thickness. It looks almost as if wet sea-sand 
 had been scattered throughout the deeper parts of the 
 mucous membrane. It is easy to understand that any 
 squeezing of this soft, friable, vascular mucous mem- 
 brane by the muscular walls behind it, as in the act of 
 expelling urine or faeces, may lead to a rubbing away 
 of the surface in certain parts and the occurrence of 
 haemorrhage from the eroded area. (Fig. 7.) 
 
 In some cases, scattered irregularly over the surface 
 and sown, as it were, on the softened mucous membrane, 
 are crops of small, friable papillomata, like large 
 granules, or forming elevated ridges of swollen tissue. 
 This condition is best seen in the rectum, and especially 
 well when a portion of the mucous membrane is pro- 
 lapsed during defalcation. 
 
 The change in the mucous membrane must take a 
 considerable time to develop ; for, with it, the rest of 
 the wall of the viscus is usually much thickened, by 
 hypertrophy of the muscular layer and the formation 
 of bilharzial fibrous tissue throughout it. 
 
 If a snip of this infiltrated mucous membrane be 
 taken and a smear made on a slide, bilharzia ova will 
 be found. A section of the wall of the affected viscus 
 shows the mucous membrane swollen, thickly infiltrated 
 throughout with leucocytes, and crowded with ova. 
 These are densely packed in the deeper parts of the 
 epithelium and in the subjacent tissue, the basement 
 membrane being perforated at certain points. In most 
 places, at this early stage, the epithelial lining of the 
 
PATHOLOGICAL CHANGES. 21 
 
 mucous membrane is intact, but the ova raay be seen 
 pushing right up to it, and they soon cause a necrotic 
 melting away of the surface cells. By the excessive 
 crowding of the tissues with ova and cells the parts, 
 in spite of their vascularity, begin to lose their vitality 
 and a molecular disintegration takes place. As this 
 process involves the epithelial layer the eggs are 
 shed, together with small round cells, degenerated 
 epithelial cells and blood corpuscles. By the crowd- 
 ing of the ova behind, those in front are gradually 
 pushed towards the surface and are shed in a con- 
 tinuous stream as soon as the least erosion occurs. 
 
 Looss has prepared a series of sections which show 
 that the ova may even escape from the surface of a 
 mucous membrane the epithelial layer of which is 
 quite intact. The ova are seen lying between the 
 epithelial cells and in all stages of their passage 
 through the epithelial lining. 
 
 The fine capillaries and veins immediately beneath 
 the epithelial lining, and the loose connective tissue 
 in which they occur, are also filled with ova ; while in 
 the deeper submucous tissue coupled pairs of worms 
 are found in the vessels. In the muscular coat there 
 may be collections of ova with an occasional couple of 
 worms at some distance from them. The further 
 appearances vary with the duration of the disease ; and 
 on this will also depend the amount of small-celled 
 infiltration and young fibrous tissue that will be present. 
 
 Sandy patches. — Another comparatively early 
 change, characteristic of bilharziosis of mucous mem- 
 
22 BILHABZIOSIS. 
 
 branes, is the occurrence of brownish-yellow sandy 
 patches, showing- apparently through the membrane, 
 which, over these areas, is thickened and dry. The 
 patch appears to be made up of very fine grains, not 
 unlike powdered sulphur, which are irregularly grouped 
 together into small heaps at certain points. At a later 
 stage the whole mucous membrane, of the bladder 
 particularly, may be so altered, in colour and structure, 
 that a regular calcified lining, which gives a character- 
 istic gritty feeling on examination with a sound, is 
 formed. The walls of the affected viscus will gener- 
 ally be found much thickened, partly from muscular 
 hypertrophy, but also from the deposit of bilharzial 
 fibrous tissue throughout the various layers. (Fig. 8.) 
 On cutting into such a sandy patch it will be found 
 hard, thickened, and gritty, and the tissue easily turns 
 the edge of the razor used in cutting the sections. On 
 miscroscopical examination, the appearances are very 
 similar to those described in the preceding change ; 
 except that there is much more hard thickening of all 
 the parts concerned and the majority of the ova in 
 and under the epithelial layer are calcified. Deeper in 
 the section in the submucous tissue the blood-vessels, 
 especially the veins, will be seen dilated and varicose, 
 and pairs of worms will be found within their lumen. 
 Looss has pointed out that in the immediate neighbour- 
 hood of the worms no free ova are found, and from the 
 position of the worms in certain serial sections, he sug- 
 gests that the female stretches out her thin attenuated 
 body along the ultimate radicles of the submucous 
 
Fig. 8.— More advanced bilharziosis of the bladder, with much sandy 
 change and considerable thickening of the coats of the viscus. Some 
 small papillomata are seen on the posterior wall. 
 
 Fig. 9. — Bilharzial papillomata in the large intestine. 
 
 (From specimens, prepared by Professor Summers, in the Pathological 
 Museum of the School of Medicine, Cairo.) 
 
PATHOLOGICAL CHANGES. 23 
 
 capillaries. Having stretched herself to her fullest ex- 
 tent, she deposits her mature ova and then withdraws 
 into the gynecophoric canal of the male, of which 
 she has retained hold throughout this stretching and 
 depositing process. The ova thus set free in a very 
 fine capillary remain where they have been placed, 
 the tissues between them and the withdrawing worm 
 closing in again ; thus, a considerable interval is left 
 between the depositor and her deposit. 
 
 Patchy hyperaemia. — The early sandy patches 
 are usually associated with some hyperaemia of the 
 mucous membrane beyond their margins ; but this 
 hyperaemia may sometimes occur, independently of 
 any other change, as quite the earliest manifestation in 
 the bilharzial series. This is altogether different from 
 the general vascularity of the mucous membrane 
 already noticed. In these hyperaemic areas the mucous 
 membrane is thickened and infiltrated with ova, as 
 in other early manifestations, and around them and in 
 them are irregular extravasations of blood. 
 
 Bilharzial vesicles. — In some cases of bil- 
 harziosis of mucous membranes rounded globules, con- 
 taining a clear or, sometimes, a turbid fluid are seen, 
 like small blisters on the epithelial surface. These 
 globules, which are superficially covered by stretched 
 and flattened epithelial cells, suggest that they have 
 their origin in small retention cysts. They resemble 
 closely the small mucous cysts seen in the buccal 
 mucous membrane, and probably have a similar 
 pathology. 
 
24 BILEABZIOSIS 
 
 The formation of papillomata. — In certain 
 cases the principal change is one of proliferation of 
 epithelium. Small warty outgrowths may be seen 
 arranged quite irregularly over the mucous membrane, 
 sometimes surrounded by a zone of hyperseinia, which 
 varies considerably in size and colour, or in the 
 midst of a sandy patch. These outgrowths have the 
 structure of an ordinary papilloma, the central very 
 vascular core of loose connective tissue being directly 
 continuous with the submucous tissue, in which, at 
 the extreme base of the papilloma, a coupled pair of 
 worms may sometimes be found. The core itself is 
 infiltrated with leucocytes, in which lymphocytes pre- 
 dominate, and numbers of ova are scattered irregularly 
 throughout it. It will be noticed that in certain places 
 the ova come right up to the epithelial covering of 
 the papilloma. In some parts the epithelium has the 
 appearance of being scooped out from below; while 
 in other sections the surface epithelium is entirely 
 missing and the ova are seen streaming out from the 
 broken surface. The epithelium, often very delicate, 
 as the fine filaments of the papillomata are so thin, is 
 very easily shed, and thus early permits of secondary 
 bacterial invasion. 
 
 The papillomata, which are of all conceivable 
 shapes and sizes, are of a dark-red colour, fairly firm 
 in consistence, but have a velvety friable surface ; 
 but, as the disease progresses and the surface epi- 
 thelium undergoes necrosis, they become granular 
 and shaggy and bleed very readily on the least fric- 
 
PATHOLOGICAL CHANGES. 25 
 
 tion. In the blood thus discharged ova and granular 
 debris, consisting of leucocytes, degenerated epithelial 
 cells, connective tissue cells and red blood corpuscles 
 are found. Later, the papillomatous change becomes 
 more and more marked and there is no limit to the 
 diversity of form or size of the individual outgrowths. 
 Very often a bunch of papillomata seems to sprout 
 from a raised plateau of thickened mucous membrane, 
 and these papillomata have a rather bulbous appearance 
 at their extremities. All forms may give off secondary 
 extremely minute papillae. Leuckart writes : "One may 
 find on the mucous membrane of the bladder single or 
 grouped excrescences, not unlike condylomata, with 
 or without pedicles, which may present manifold 
 variations of shape and may be as large as a bean. 
 On section, the mucous membrane is thickened and 
 the submucous connective tissue hypertrophied. 
 Both are pervaded by a rich network of capillaries, 
 the vessels being sometimes dilated, and here and 
 there changed into rather large cavities, which often 
 contain full-grown specimens of the bilharzia. In the 
 parenchyma of the excrescences, which is formed 
 chiefly of the submucous tissue, numerous eggs are 
 found." (Fig. 9.) 
 
 Sessile masses. — In other specimens the papillo- 
 matous formation is not so marked ; but irregular 
 hummocks, involving often a considerable extent of 
 the mucous membrane, are met with. These masses 
 form irregular raised prominences, which may en- 
 croach upon the cavity of the viscus to a large extent 
 
26 BILHARZIOSIS. 
 
 and sometimes almost fill it. They are very vascular 
 and, have the structure of loose fibrous tissue covered 
 with a thickened mucous membrane, which is infil- 
 trated with ova, and, at first, they are covered with 
 epithelium. Later, on the surface of the elevations 
 small pits and finally ulcers may form, the surface 
 epithelium having necrosed, exposing a richly vascular 
 and highly cellular granulation tissue. The whole 
 viscus affected with this change is always very much 
 thickened, and many of the earlier, more superficial, 
 changes are present in what remains of the mucous 
 membrane. Papillomata and sessile masses often 
 occur side by side in the same organ. 
 
 Ulceration. — Sometimes small pits may be found 
 in the mucous membrane without any papillomatous 
 or sessile changes. These may be scattered over the 
 surface, perhaps in the midst of a sandy patch, or, 
 sometimes as the principal lesion in a thickened, in- 
 filtrated bladder. Then, again, ulcers may be the 
 second stage of the vesicular formation already men- 
 tioned, the vesicle bursting and a minute necrosis of 
 the tissue taking place, owing to the obstructed blood 
 supply caused by the presence of ova and small 
 celled infiltration ; in other cases crevices form at the 
 base of papillomata or over a sandy patch and ulti- 
 mately form ulcers. At a later stage of the disease 
 larger and more definite ulcers may form, especially 
 in the intestine. They are produced by the separ- 
 ation of a papilloma from its base. A distinct ring 
 of necrosing tissue is seen round the pedicle, and the 
 
Fig. 10.— Ulceration of the large intestine, resulting from the sloughing 
 off of bilharzial papillomata (" bilharzial dysentery"). 
 
 Fig 11.— Extreme case of bilharziosis of the bladder with formation 
 of much dense scirrhusdike tissue. The cavity of the bladder is 
 almost non-existent. 
 
 (From specimens, prepared by Professor Symmers, in the PatholorjiccO 
 Museum of the School of Medicine, Cairo.) 
 
PATHOLOGICAL CHANGES. 27 
 
 various appearances of papilloma, commencing ne- 
 crosis, partial separation and finally complete separ- 
 ation, with the formation of deeply-punched-out, 
 gumma-like ulcers, can be studied in good specimens. 
 It is this condition of late ulceration in the large 
 intestine which is most commonly responsible for 
 " bilharzial dysentery." (Fig. 10.) 
 
 Another form of ulceration is met with in the 
 atrophic types of bilharziosis. This finds its best 
 illustration in bilharziosis of the skin and subcutan- 
 eous tissue, in connection with which it will be again 
 referred to. 
 
 The condition of the structures deep to the 
 mucous membrane varies considerably. In the 
 early stages the bilharzial change seems to affect 
 mainly the mucous and submucous coats, with but 
 little infiltration of the muscular coats ; but, later, the 
 whole organ is infiltrated. The change deep to the 
 submucous coat is, as elsewhere, due to an infiltra- 
 tion of small cells and ova, and is best understood by 
 considering it the formation of a (bilharzial) granu- 
 lation tissue, which goes through all the changes com- 
 mon to that tissue. The tissue thus formed varies 
 considerably in density and extent. 
 
 Thus in most of the specimens of sandy patches 
 and of infiltration of the mucous membrane, in fact 
 in all the changes already described, there has been 
 some thickening of the visceral walls, either local or 
 general. In many cases this thickening would appear 
 to be one of the earliest effects produced by bilharzia ; 
 
28 BILHARZIOSIS. 
 
 and many of the so-called early changes occur in an 
 organ already much thickened by an infiltration not 
 only of the mucous membrane but of all the layers of 
 the wall of the viscus deep to that structure. Even 
 hypersemic patches are often seen on the internal 
 surface of a thickened bladder, and must then be 
 only a manifestation of an increase in an irritation 
 which has already been going on for some consider- 
 able time. In fact, one can best judge of the 
 chronicity of a bilharzial infection in a hollow organ 
 by the thickness of the walls of the viscus and the 
 degree of fibrous transformation of its surrounding 
 tissues. 
 
 Sometimes a very hard indurated fibrous mass is 
 produced in the muscular and deeper structures of the 
 affected viscus ; and eventually the whole essential 
 structure of the parts is completely destroyed. In 
 such cases very little of the mucous membrane re- 
 mains. In certain cases a mass of bilharzial granu- 
 lation tissue appears to spread inwards and makes the 
 cavity of the organ much smaller, in much the same 
 way that a bone with congenital syphilitic changes, by 
 becoming harder, denser, and thicker in all directions, 
 eventually almost, if not completely, obliterates the 
 central medullary canal of the bone. The analogy is 
 a good one, as the bilharzial fibrous tissue is often a 
 true sclerosis. Very few ova are found in this hard 
 tissue. (Fig. 11.) Sometimes the structure of this 
 mass resembles that of a scirrhous cancer with ova 
 lying in between the columns of epithelial cells, but 
 
Fig. 12.— Section of the so-called bilharzial scirrhus of the bladder. 
 Numbers of ova are seen lying in between groups of epithelial 
 cells. 
 
 (From a specimen, prepared by Professor Summers, in the Pathological Museum 
 of the School of Medicine, Cairo. Photo-micrograph by Mr. F. S. Willmore.) 
 
PATHOLOGICAL CHANGES. 29 
 
 opinion is still divided as to the true significance of 
 this aj)parently cancerous appearance. (Fig. 12.) 
 
 A special condition in which the connective tissue 
 of the meso-csecuni, meso-colon, and meso-rectum is 
 densely infiltrated, is seen in certain cases of bil- 
 harziosis of the large bowel, and will be referred to in 
 a later section. 
 
 The extreme variety in the pathological manifesta- 
 tions, and their great diversity of form, is probably 
 to be explained by repeated re-infection, to which the 
 patients must be constantly subject, living, as they 
 do, always amidst the same unfavourable conditions. 
 Indeed short of a complete exile from Egypt the 
 affected person, usually an agricultural labourer, can 
 hardly get away from the risk of re-infection. The 
 multiplicity of the lesions, due to a new beginning 
 being constantly made in the series of pathological 
 changes, is thus not difficult to understand. 
 
III. 
 
 BILHARZIOSIS OF THE URINARY SYSTEM. 
 
 A vaeiety of interstitial nephritis of bilharzial origin 
 has been described, and bilharzia ova have been found 
 in the substance of the kidneys by Kartulis and others. 
 Papillomatous growths occur in the pelvis of the kid- 
 ney; and both the hypertrophic and the atrophic forms 
 of the disease are met with in the ureters ; but the 
 bladder is by far the most common seat of bilharzi- 
 osis. It is probable that the disease here, as in other 
 organs, is only one of the local manifestations of 
 bilharziosis, and not a centre from which extension 
 takes place, by contact or proximity of tissue, to other 
 parts of the urinary tract in communication with it. 
 Infection of a part by bilharzia is due to a centrifugal 
 distribution, the centre being the blood in the portal 
 vein and its tributaries, and there is no local propaga- 
 tion of the worms in the tissues. Each manifestation 
 is due to the local effect of certain couples, or colonies 
 of couples, and the effects are limited by the extent 
 of surface or area over which each couple is able to 
 disseminate its ova. Large areas of disease are due 
 to the combined action of many couples working side 
 by side, each taking charge of a particular area for 
 destruction. 
 
 30 
 
BILHAEZIOSIS OF THE URINARY SYSTEM. 31 
 
 Bilharziosis of the bladder. — The general swell- 
 ing and infiltration of the mucous membrane, described 
 in some detail in the preceding section, is probably 
 the earliest manifestation we know and recognise, 
 and this condition is seen at its best in the bladder. 
 Photographs and drawings fail to give an adequate 
 idea of this very characteristic appearance with its 
 wet sea-sand scattered about in the substance of 
 the swollen membrane, and, it may be, thickly 
 infiltrating the whole of the prostate. (Fig. 7.) 
 In the fresh state such a surface is thinly coated 
 with a peculiarly tenacious mucus, in which ova 
 may be found, and which appears to be a great 
 protection to the membrane. Were the surface bereft 
 of this slippery mucus and dry, it would be very 
 friable and easily abraded by the least friction. As it 
 is, it is not until the sandy change becomes marked 
 that the surface of the mucous membrane becomes dry, 
 harsh, and thickened. This may occur to such an 
 extent that the internal lining of the bladder comes 
 to resemble a cyst wall which has undergone an almost 
 general calcification. The surface has then the appear- 
 ance of being coated with much dry sun-baked sand, 
 as opposed to the earlier appearance of wet sea-sand, 
 which is definitely deep within the substance of the 
 mucous membrane. (Fig. 8.) 
 
 Another change is a patchy hyperemia associated 
 with minute extravasations, either as an independent 
 manifestation, or in an already thickened and in- 
 filtrated mucous membrane. This may be confined to 
 
32 BILHARZIOSIS. 
 
 the region of the trigone or scattered irregularly over 
 the posterior surface of the bladder. On these hy- 
 perseniic patches in the substance of a swollen mucous 
 membrane, or as quite distinct lesions in themselves, 
 may be larger or smaller dry sulphury sandy patches. 
 These have the general characters already described 
 and map out definite areas, which are irregularly dis- 
 tributed over the surface of the bladder upon thickened 
 patches of the mucous membrane. As the disease pro- 
 gresses, larger and larger areas become affected, and as 
 adjoining patches unite, the thickened internal lining 
 of the organ becomes hard and on section grates under 
 the knife, not only from the presence of calcified ova in 
 the mucous membrane, but also from the granular 
 phosphatic deposit which has occurred on its surface. 
 At the same time the associated thickening increases 
 and soon involves all the coats of the bladder, until 
 the viscus resembles a calcified cyst, with thickened 
 walls. " As the patches increase in size, they also 
 increase in thickness, owing to the overgrowth of the 
 surrounding tissue, due to the irritation of the presence 
 of the eggs, and also to the fact that Nature, striving 
 to undo the mischief she has permitted for the sake of 
 the propagation of the bilharzia species, tries to render 
 the eggs harmless within the host by enveloping them 
 in fibrous tissue and isolating them, as she does to 
 foreign bodies embedded in living tissue elsewhere." 
 (Milton.) 
 
 Sometimes a row of bilharzial vesicles makes a 
 border round the trigone, or a few tiny warty projec- 
 
BILHARZIOSIS OF THE URINARY SYSTEM. 33 
 
 tions occur in the same situation, with or without the so- 
 called earlier manifestations. As has already been 
 pointed out, these changes frequently occur in an 
 already much thickened and generally hypersemic 
 bladder ; and before the sandy patches have had time 
 to develop, considerable general infiltration of the 
 whole thickness of the bladder with ova and small 
 round cells has been going on. The calcification of the 
 ova, which is the principal change in the sandy patch, 
 takes at least a year to develop. 
 
 From the early stages in the pathological changes 
 above described onwards, the different forms of bil- 
 harzial lesions are very much mixed ; and it is difficult 
 to present the progress of the disease in anything like 
 regular order. In almost every infected bladder all or 
 many of the different manifestations are to be found, 
 in greater or less degree, but the principal change is 
 that of marked epithelial proliferation and the forma- 
 tion of papillomata. The papillomata, the general 
 structure of which has already been described, occur 
 in many shapes, from the fine villous form to the large 
 bulbous-ended variety. It is not at all unusual to find 
 a bunch of fine papillomata sprouting from a small 
 raised plateau of thickened mucous membrane. Even 
 at this early stage, there is much more firmness about 
 a bilharzial papilloma than in an ordinary soft fibrous 
 or myxomatous polypus. The bilharzial papillomata 
 are, however, very friable and bleed readily in ad- 
 vanced cases ; and, at times, become so soft as to form 
 large shaggy masses, with a fleecy surface, growing in 
 
34 BILHARZIOSIS. 
 
 clusters from the wall of the bladder. The papillomata 
 have a- special predilection for the trigone and the 
 posterior surface generally ; but after a time they are 
 seen widely distributed over the mucous membrane. 
 So profuse may be the growth of papillomata that 
 almost the whole cavity of the bladder may be filled 
 with them, and as concurrently there is an increase in 
 the thickness of the bladder wall, the actual reservoir 
 space becomes very small indeed. In other cases, 
 sessile masses, not unlike condylomata, but much 
 firmer and extensive, form the prominent features of 
 the bilharzial changes. These elevations are of various 
 sizes and shapes and are usually associated with con- 
 siderable papillomatous formation also. They consist 
 of a loose fibrous tissue foundation, capped with 
 much thickened infiltrated mucous membrane. Their 
 structure is thus similar microscopically to a papil- 
 loma and they undergo exactly the same secondary 
 changes. 
 
 Another change, which must begin very early, is 
 thickening of the coats of the bladder from the irrita- 
 tion of the bilharzia worms and their ova. This in- 
 volves all the coats of the bladder, and the organ is to 
 all appearances like an hypertrophied organ resulting 
 from some chronic obstruction to the outflow of 
 urine. There is some true hypertrophy of the muscu- 
 lar coat from overwork, due to the increased frequency 
 of micturition, the obstruction to the outflow, and the 
 straining entailed in emptying the bladder, but quite 
 as much, if not more, of the thickening is due to the 
 
BILRARZIOSIS OF THE URINARY SYSTEM. 35 
 
 formation of bilharzial granulation tissue and its subse- 
 quent transformation into fibrous tissue. The prostate 
 is often found infiltrated, as are also the vesicular 
 seminales, which, in advanced cases, are almost lost 
 in a fibrous mass, that is welding the base of the 
 bladder to the surrounding connective tissue. There 
 is not usually much enlargement of the prostate, as here 
 the atrophic form of the disease is most commonly 
 found, and contraction, rather than proliferation of the 
 new tissue, is the rule. In later stages, any true pros- 
 tatic symptoms that may be present are masked by the 
 presence of cystitis, stone, etc. 
 
 Probably the most usual condition of the bladder 
 in severe bilharziosis is as follows : — The bladder in- 
 ternally is thickly infiltrated with extensive patches of 
 dry sandy change, so that portions of the wall are 
 almost entirely converted into a calcified plate ; or it 
 is filled with papillomata of various sizes and shapes, 
 very irregularly distributed throughout the mucous 
 membrane. The walls of the bladder are much 
 thickened and infiltrated, and the cavity is considerably 
 contracted. From this thickening and the presence of 
 the papillomatous masses the actual urine space is very 
 small, and the cavity is often eccentrically placed. 
 " Owing also to the calcification of the bladder wall 
 the effect of muscular contraction is largely lost, and 
 the bladder is more like a dilatation in a firm-walled 
 tube than a cavity in a contractile organ " (Milton). 
 The prostate is infiltrated throughout with calcified 
 ova, and may be somewhat enlarged. The urine 
 
36 BILHARZIOSIS. 
 
 collects in the depressions between the papillomatous 
 masses and decomposition readily occurs, so that the 
 surface of the masses and the mucous membrane 
 generally may be thickly coated with phosphates ; 
 and, owing to obstruction at their orifices, the ureters 
 become dilated and hydronephrosis with all its con- 
 secutive and, later, septic consequences soon results. 
 
 Other cases are seen with enormous thickening, 
 deep to the mucous membrane, extending throughout 
 all the coats of the bladder. This has a section like 
 caseous tissue, or may be quite fleshy, like sarcoma. 
 In some instances there is only a very narrow slit left 
 as a representative of the bladder cavity. What 
 remains of the mucous membrane is dark, ragged, and 
 degenerated, and shows the remains of papillomata. 
 (Fig. 13.) 
 
 Another fairly common change of the same kind 
 consists in the formation of an exceedingly soft mass 
 of tissue, often with the consistence and colour of 
 softened brain matter. This, which usually springs 
 from a considerable area of the mucous surface, may 
 almost completely occupy the cavity of the viscus. 
 It is not uncommon to find that the remainder of the 
 cavity is filled with recent blood clot and fragments 
 of necrosed tissue from the surface of the mass. 
 
 As the thickening of the bladder proceeds, it comes 
 to be felt as a hard mass above the pubis, and it may 
 increase to such an extent as to reach almost to the 
 umbilicus, with or without infiltration of the abdominal 
 wall. In other cases the thickening is not so much of 
 
Fig. 13. — Advanced bilharziosis of the bladder. The narrow crescentic 
 area below and to the left represents all that remains of the cavity 
 of the viscus. 
 
 (From a specimen, 'prepared by Professor Symmers, in the Pathological 
 Museum of the School of Midicine, Cairo.) 
 
BILHARZIOSIS OF TEE URINARY SYSTEM. 37 
 
 the bladder itself, but involves all the loose connective 
 tissue round it and the adjacent organs. The most 
 usual site of this change is anteriorly, whence it extends 
 into the structures of the abdominal wall. The 
 following case illustrates this condition very well : 
 The patient was a young woman, who gave a four 
 months' history of a tumour in the lower part of the 
 abdomen, associated with painful micturition for some 
 time preceding the appearance of the swelling. A 
 lump was found above the pubis, extending upwards 
 almost to the umbilicus and laterally to each semilunar 
 line. The mass was of stony hardness, and running 
 into its substance were two unhealthy-looking sinuses, 
 which did not, so far as could be made out, communi- 
 cate with the bladder. There was not the least 
 tenderness on examination or pain, the only incon- 
 venient symptom being marked frequency of micturi- 
 tion, which was explained by the discovery of a 
 large stone in the bladder. The vagina, uterus and 
 urethra were quite healthy, and the urine contained no 
 ova. An incision was made in the middle line through 
 the hard mass and exposed the wall of the bladder, 
 which was thickened with bilharzial tissue, especially 
 at the apex. The bladder was opened and a large 
 ovoid stone removed. The bulk of the tumour was 
 in front of the bladder, and the sinuses ran down 
 through the mass to a space full of soft degenerated 
 bilharzial tissue, just above the apex of the viscus. 
 The whole thickness of the abdominal wall was infil- 
 trated with the growth, in which, except for a few 
 
38 BILHARZIOBIS. 
 
 fibres of the rectus muscle, nothing but a fibrous 
 structure could be made out. 
 
 Microscopically the growth consisted of firm white 
 fibrous tissue, in which no ova could be found. The 
 opening in the bladder gradually closed, and, though 
 the tumour remained as before, considerable relief 
 was experienced by the removal of the stone. 
 
 There is still considerable discussion as to the 
 nature of these hard masses produced by bilharzia. 
 Some would have one believe that they are all cancer- 
 ous, the exciting cause of the malignant change being 
 bilharzia ova ; but, certainly, most of them are simply 
 masses of dense fibrous tissue, practically scar tissue, 
 the density being specially marked owing to the 
 essentially chronic nature of the inflammatory process. 
 There are, however, cases of apparently typical scir- 
 rhus cancers in connection with bilharzial changes in 
 the bladder, and, in such, microscopic section shows 
 the ova, often in very large numbers, lying between 
 the masses of cancer cells. (See Fig. 12.) Clinically 
 there is very little to help in the differential diagnosis 
 of these bilharzial fibrous masses from those really 
 cancerous, though sometimes a secondary enlarge- 
 ment of neighbouring glands and the extreme rapidity 
 of growth are in favour of cancer. " The co -existence 
 of carcinoma and bilharzia is generally regarded as 
 fairly common, but, I think, it does not in reality 
 occur so frequently as some writers would lead one 
 to expect." (Milton.) 
 
 Occasionally sinuous fistulous tracks, lined with 
 
BILHARZIOSIS OF TEE URINARY SYSTEM. 39 
 
 bilharzial granulation tissue, form in the hard masses, 
 whether carcinomatous or not, and, communicating by 
 means of a narrow opening with the bladder below, 
 discharge a small amount of filthy urine, pus and 
 granular debris on the skin surface. These fistulas 
 in the midst of hard tissue are specially found in the 
 suprapubic region, sometimes opening at the um- 
 bilicus, or in the perinseum. In the umbilical fistulse 
 a track runs down between the muscles of the an- 
 terior wall of the abdomen and the peritoneum, and 
 ends in a soft degenerated mass round the upper part 
 of the bladder, but without, apparently, opening into 
 it. This degenerated mass is found in the prevesical 
 and lateral vesical spaces, while the bladder walls are 
 thickened and severely affected with bilharzia, but 
 there is no direct communication between the lesions 
 within and without the bladder. It seems as if these 
 cases begin as a bilharzial infiltration of the loose 
 connective tissue round the bladder in front, which 
 ultimately makes for the umbilicus along the urachus 
 in the lines of least resistance. 
 
 Rarely, an enormous proliferating mass may burst 
 through the walls of the bladder and present in the 
 peritoneal cavity where, once leakage of urine has 
 taken place, fatal peritonitis rapidly ensues. 
 
 The secondary backworking effects of bilharziosis 
 of the bladder on the ureters and kidneys are 
 in no way different from those produced by any 
 other obstruction to the outflow of urine ; indeed, the 
 dilatation of the ureters and the pelvis of the kidney, 
 
40 BILHARZIOSIS. 
 
 due often to blocking of the vesical orifice of the 
 ureter, »may almost be considered the natural conse- 
 quences of bilharziosis of the bladder, since so much 
 obstruction to the outflow of urine is offered by the 
 many lesions in that viscus. Further, the ureter 
 itself is not unfrequently the seat of bilharzial changes, 
 papillomata and a general infiltration of the mucous 
 membrane being the most common lesions, and thus, 
 quite apart from any assistance rendered by the 
 bladder, considerable hydronephrotic changes may be 
 produced. One never finds these mechanical changes 
 in ureters and kidneys without also a septic infection, 
 arising from the condition into which the bladder 
 passes after the onset of cystitis. A rapidly spread- 
 ing septic inflammation is soon developed and ex- 
 tends not only to the ureters and the pelvis of the 
 kidneys, but also into the substance of the latter organ, 
 with all the severest accompaniments of the worst type 
 of septic surgical kidney. " When it happens, as is so 
 frequently the case, that the contents of the bladder 
 are represented by a collection of decomposing organic 
 tissue and stinking urine, the step to a septic inflam- 
 mation of ureters and kidneys, from simple dilatation 
 of the ureters and hydronephrosis, is easily taken." 
 (Milton.) On the other hand, severe symptoms may 
 sometimes be produced by apparently insignificant 
 manifestations. Thus one has seen an autopsy on a 
 case of marked double hydronephrosis in which the 
 causal lesions were two small bilharzial papillomata 
 at the vesical openings of both ureters. 
 
BILHARZ10SIS OF THE URINARY SYSTEM. 41 
 
 The very frequent association of bilharziosis of the 
 bladder and of the urethra will be again referred to. 
 
 Early symptoms of bilharziosis of the 
 bladder. — The very earliest pathological manifesta- 
 tions of bilharziosis do not appear to give rise to any 
 symptoms for a considerable time; but, as the infil- 
 tration and swelling of the mucous membrane progress, 
 the softening of the surface layers of the epithelium 
 increases, probably from the irritation of the urine, as 
 well as from the gradual molecular disintegration due 
 to the bilharzial process, and a centre of irritation is 
 produced ; and that, usually, in the naturally most 
 sensitive portion of the bladder, the trigone. This 
 will give rise to some increased frequency in micturi- 
 tion and, perhaps, a feeling of heat in the perinseum 
 or the rectum, or along the course of the urethra. 
 Further, in the attempt to get rid of the irritant, that 
 is, to expel the urine from the irritated trigone, an 
 increased straining occurs at the end of the act of 
 micturition. If a small piece of the swollen vascular 
 mucous membrane becomes nipped between the con- 
 tracted muscular bands of the wall of the bladder, 
 some hsematuria may be present, especially at the 
 end of micturition. " The amount of blood lost is, as 
 a rule, insignificant, and would probably never be 
 noticed by the patient if it were mixed with the urine 
 as it is passed ; but the peculiarity of this haemorrhage 
 is that the few drops of blood which are lost are voided, 
 either with the last few drops of urine, or else escajDe 
 from the urethra after the act of micturition is alto- 
 
42 BILHABZIOSIS. 
 
 gether finished ; whereby the attention of the patient 
 is caught by the marked difference in the appearance of 
 the last part of the evacuated fluid. In a large number 
 of cases hsematuria begins without any subjective symp- 
 toms ; but, as a rule, soon after the patient notices the loss 
 of blood, he begins to complain of pricking or scalding 
 in the urethra during micturition, together with a sense 
 of pain or weight in the perinseum." (Milton.) This 
 state of irritation, much of which may be due to an 
 early infiltration of the prostate, with occasional 
 haematuria, may persist for a long time before any 
 more definitely characteristic symptoms appear ; 
 indeed, many cases go no further than this for several 
 years. 
 
 The signs above noted may be so slight that the 
 possibility of bilharzia as a cause may not have been 
 considered. Nothing can be made out on abdominal 
 examination except, perhaps, some tenderness on deep 
 pressure just above the symphysis pubis. Examina- 
 tion with a finger in the rectum and a sound in the 
 bladder may disclose distinct thickening of the 
 bladder wall and, perhaps, some enlargement of the 
 prostate, which may also be tender. On introducing 
 the sound it usually passes without difficulty, but 
 there may be considerable pain as the point of the 
 instrument enters the bladder. The mucous membrane 
 may feel soft and swollen but, at this early stage, no 
 roughness of the wall will be felt except, at times, 
 posteriorly where the mucous membrane is thrown 
 into ridges and feels harder than in other situations. 
 
EILHARZIOSIS OF THE URINARY SYSTEM. 43 
 
 Early papillomata or warty projections are difficult to 
 feel with the sound, but a bunch of them may some- 
 times be made out in the region of the trigone. On 
 the withdrawal of the sound a small quantity of blood 
 may escape from the urethra or be passed with the 
 next urine. 
 
 If there are other symptoms pointing to the pos- 
 sibility of bilharziosis these local signs may be dis- 
 covered when one is on the look-out for them, but they 
 are often so indefinite that they may very easily be 
 missed in an ordinary routine examination of the 
 bladder. The urine is acid and clear, except at the 
 very end of micturition, when some thick tenacious 
 mucus may be passed with it. Repeated examina- 
 tions, especially of the deposit of the whole day's 
 urine (if necessary, after centrifugalising the deposit), 
 may reveal the presence of ova, which at once con- 
 firms the diagnosis. The ova are much more likely 
 to be found if hsematuria is present, especially if the 
 last few drops of urine are examined. Obviously if 
 there is hsematuria the urine will contain a small 
 amount of albumen and blood corpuscles. 
 
 Certain cases, even when there is an early for- 
 mation of papillomata, present no symptoms whatever 
 except painless hsematuria, varying in amount and 
 coming somewhat irregularly, especially with the last 
 squeeze. 
 
 In these early stages, the general health does not 
 suffer to any appreciable extent ; but after a time the 
 constant haemorrhage, insignificant in amount though 
 
U BILHAEZIOSIS, 
 
 it may be, gives rise by its persistence to anaemia, 
 with all its usual accompaniments. In all anaemias in 
 Egypt the presence of ankylostoma must also be 
 suspected and search made accordingly for ova in 
 the fasces. 
 
 It is not at all uncommon to find ankylostoma and 
 bilharziosis associated in the same patient. 
 
 In a somewhat more severe case the symptoms will 
 present an aggravation of those already described, but 
 are still, mainly, irregular haematuria and some in- 
 creased frequency of micturition. The urine will con- 
 tinue to be acid, fairly clear at most times but contain- 
 ing blood and mucus at the end of micturition. To 
 examine such urine for ova the whole quantity passed 
 in the t tventy-four hours should be taken and allowed to 
 settle in a conical glass. The supernatant fluid is 
 drawn off, as soon as a good deposit has formed, and 
 a small quantity of the residue taken off in a pipette 
 and placed on a slide. The specimen will contain, 
 besides the usual constituents, blood corpuscles, 
 epithelial cells, small round cells, connective tissue 
 cells, amorphous masses and granular debris, pus 
 cells and ova. The ova have the spine at the end, and 
 contain either living or dead miracidia. Often the 
 contents of the ova are a granular debris or a calcified 
 mass. (See Fig. 3.) The ova which contain living 
 miracidia are clear and more or less transparent and 
 with high powers the structure of the miracidia may 
 be clearly made out. 
 
 Ova are sometimes found in the spermatic fluid 
 
BILHARZIOSIS OF THE URINARY SYSTEM. 45 
 
 (Lortet and Vialleton), especially in cases in which the 
 vesiculse seminales are affected. 
 
 Sooner or later the urine becomes decomposed, as 
 will be readily understood when the condition of the 
 bladder is recalled, and all the symptoms of acute 
 cystitis set in. There is nothing to distinguish this 
 form of cystitis from any other except the almost con- 
 stant hematuria and the presence of bilharzia ova 
 in the urine. Once cystitis has started the patient is 
 practically never free of it, though after a time the 
 acuteness of the condition passes off and a steady 
 chronic form persists. The urine will now be alkaline, 
 turbid, offensive, dark-brown in colour from the blood 
 in it, and will contain mucus, pus, albumin, phos- 
 phates, granular debris, epithelial cells, blood cor- 
 puscles and ova, the latter in great numbers. At a 
 late stage the ever-present symptoms of cystitis and 
 the almost constant micturition, from the irritation 
 within and the small size of the cavity of the bladder, 
 the pain and scalding in the urethra during the 
 passage of urine, the pain above the pubis, in the 
 perinseum and in the rectum, the latter often with a 
 great deal of tenesmus, soon make the patient's life an 
 absolute misery to himself. He gets very little rest at 
 night and it is difficult to imagine even an Egyptian 
 allowing this condition to go on without any attempt 
 at treatment, yet such is constantly the case. 
 
 The bladder condition may become at any time 
 still further aggravated by the deposit of phosphates 
 on the abraded mucous membrane or on the ragged 
 
46 BILEABZIOSIS. 
 
 tops of papillomata or sessile masses. The whole 
 interior of the bladder may be thickly crusted with 
 these phosphatic masses, which go on increasing as 
 the cystitis persists and the urine is always alkaline. 
 Pieces of these incrustations may break off and form 
 the nucleus of phosphatic stones, thereby greatly in- 
 creasing the patient's misery. These stones are a 
 frequent accompaniment of bilharziosis of the bladder, 
 and are formed in exactly the same way as a stone 
 forms on any other foreign body in this organ. A 
 great many stones are, however, met with in bil- 
 harzial bladders which consist of uric acid or oxalate 
 of lime, with, sometimes, alternating layers of phos- 
 phates. Such stones must form originally in acid 
 urine, that is, before it has become alkaline and there 
 has been any deposit of phosphates. Renal colic is 
 comparatively uncommon in Egypt, and it would 
 seem probable that many uric acid stones form in the 
 bladder on a nucleus of bilharzial ova or, more prob- 
 ably, upon a small piece of a papilloma, in a bladder 
 in which the urine is still acid, the occasional layer 
 of phosphates being formed when a mild attack of 
 cystitis has supervened and subsequently yielded to 
 treatment. The average Egyptian pays so little at- 
 tention to the comparatively severe symptoms of bil- 
 harziosis and the cystitis with it that, as soon as the 
 stone is removed, he will never consent to remain in 
 hospital for further treatment of the original bladder 
 condition. 
 
 The conditions found on abdominal, rectal, or 
 
BILEABZIOSIS OF THE URINARY SYSTEM. 47 
 
 combined examination, and also with the sound, will 
 vary with the pathological changes within the viseus 
 and in its immediate neighbourhood. Many of the 
 grosser lesions, such as tumour masses, sandy patches, 
 concretions, and stones, can be felt with a sound, and 
 the extent and contour of the bladder cavity and the 
 thickness of the walls determined. Especially must 
 a careful search be made for stone, the presence of 
 which may be the cause of the marked severity of 
 the symptoms. Considerable difficulty in the intro- 
 duction of the sound may sometimes be experienced, 
 owing to the implication of the urethra in the bil- 
 harzial process, and the presence of stricture, which 
 occurs in one variety of urinary fistula. 
 
 In certain cases there may be an almost constant 
 oozing of blood from the shaggy surface of degener- 
 ated papillomata, and the urine may be almost entirely 
 blood, altered by decomposition. This may clot in 
 large masses in the bladder, giving rise to acute re- 
 tention, with very severe pain, for which the only 
 possible treatment is removal of the masses of ne- 
 crotic tumour and blood clot piecemeal, through a 
 perinseal opening — usually a Cock's puncture — and 
 afterwards washing out the bladder with very hot 
 water and inserting large drainage tubes. It is quite 
 impossible to wash out the bladder in this condition 
 through any catheter passed by the urethra. Masses 
 of degenerated tissue and thick dark clotted blood 
 have to be evacuated and free drainage must be pro- 
 vided to give any hope of relief. Retention of urine 
 
48 BILHABZIOSIS. 
 
 may also occur from the blocking of the urethral 
 orifice by papillomata, phosphatic concretions, stone, 
 granular debris and the like. 
 
 The last stage in an advanced bilharziosis of 
 the bladder is somewhat as follows : The patient is 
 usually a man, though a few very severe cases are 
 met with in women, and he is very weak and anaemic, 
 thin and haggard, and absolutely miserable. He has 
 constant micturition and dribbling, with pain in the 
 penis and deep down in the peringeum near the rectum. 
 He very often carries his scrotum in his hand in an 
 attempt to relieve the pain. The history is usually 
 absolutely untrustworthy, the native mind having no 
 idea of the duration of time. On examining the penis, 
 the meatus will be wet and there is a constant slight 
 dribbling going on. On passing water a very small 
 quantity is voided and there is much pain, especially 
 at the completion of the act, followed by a slight tem- 
 porary relief. The urine varies in appearance, but is 
 usually very offensive, dark-red and turbid, and, on 
 standing, deposits phosphates, debris, blood, and ova. 
 On examining the abdomen a hard mass may be felt 
 in the suprapubic region. This lump is usually not 
 in the least tender, is very irregular and stony, and 
 may extend upwards as far as the umbilicus and to 
 any extent laterally. One or both kidneys will be 
 found enlarged and tender, and the ureters may be 
 felt much dilated through the unusually thin ab- 
 dominal wall. The whole course of the urethra may 
 be hardened or, on the other hand, it may be quite 
 
BILEARZIOSIS OF TEE URINARY SYSTEM. 49 
 
 unaffected. On rectal examination the bladder will 
 be felt firm and contracted, or simply as a thick hard 
 mass; and bimanually, with the other hand on the 
 abdomen, the great thickening of and around the 
 bladder will be well appreciated. On introducing 
 the sound, it can often just be passed beyond the 
 neck of the bladder, and then only with severe pain, 
 into a very much contracted cavity. Masses of bil- 
 harzial tissue may be felt, crusted with concretions, 
 but, in many cases, such is the contraction of the 
 space within the bladder that beyond feeling that the 
 end of the sound is free within a small cavity, very 
 little else can be made out. 
 
 The usual treatment and fate of these advanced 
 cases is that a perinseal opening into the bladder is 
 made to relieve the incessant pain. The incision, 
 passing through a very hard mass, opens, at what 
 seems to be a great distance from the skin surface, 
 into a very small cavity, which is at first difficult to 
 recognise as that of the bladder. On introducing the 
 finger and dilating up the wound great masses of 
 degenerated tissue are found, coated with phosphates, 
 and almost completely filling what remains of the 
 bladder cavity. Large pieces of concretions or struc- 
 tureless "pinkish cream-cheese" come away. The 
 bladder walls, when they can be made out at all, are 
 greatly thickened and all the surroundings are much 
 indurated. A lot of decomposing blood clot may also 
 be evacuated, mixed with very offensive urine. If 
 there is room a drainage tube is introduced into the 
 
50 BILHARZIOSIS. 
 
 bladder and stitched to the edges of the wound (which 
 is itself closed by suture), and the urine drained into a 
 vessel at the side of the bed by syphon action. The 
 patient has great relief for two or three days after 
 operation; then he starts a diarrhoea, which nothing 
 will stop, and one can see him visibly melting away. 
 His temperature goes up and stays up and becomes 
 typically septic. His anaemia and weakness are 
 extreme, and in about a fortnight he dies from sheer 
 exhaustion, with great emaciation and the severest 
 possible symptoms of septic kidneys, or with uraemia. 
 The condition is really quite hopeless from the first ; 
 but, for a day or two after operation, so great is the 
 relief afforded that the unwary surgeon is inclined to 
 congratulate himself on his opportune interference. 
 
 Treatment of bilharziosis of the bladder. — 
 Our first duty, in connection with the treatment of 
 this awful disease, is candidly to admit that there is 
 nothing yet known that has any effect whatever upon 
 the actual cause of the trouble, the bilharzia worm 
 itself. And, taking into consideration the early 
 pathology and habitat of the worm, it is difficult to 
 see how we can expect to kill the invader in the blood 
 without doing fatal damage to the whole organism at 
 the same time. There is this to be said, however, 
 that there are certainly many instances of spontan- 
 eous cure of the disease, hematuria and the bladder 
 irritability lasting for a varying period and then dis- 
 appearing, never to recur. This fortunate ending 
 can only be expected to happen if the patient is re- 
 
BILHARZIOSIS OF THE URINARY SYSTEM. 51 
 
 moved from the possibility of re-infection ; and can 
 never occur among the ordinary rank and file of the 
 sufferers from this disease, namely the agricultural 
 labourers of Egypt. Even though a patient exiles 
 himself entirely from Egypt, cases are reported in 
 which ova have continued to be passed in the urine 
 for several years afterwards. What it is that leads to 
 the death of the worm within the body we do not 
 know ; but it is comforting, to some extent, to realise 
 that this happy result does sometimes occur, though, 
 even after the death of the worms, symptoms may 
 persist for a long time, until all the ova are eliminated 
 from the body in the urine or faeces or encapsuled. 
 
 In the earliest clinical stages of the disease, when 
 some slight irritability and painless and temporary 
 hematuria are present, very good results frequently 
 follow the administration of the liquid extract of male 
 fern, given regularly in fifteen minim (1.0) doses, 
 three times a day, in capsule. A long course of male 
 fern and washing out the bladder with increasingly 
 strong solutions of nitrate of silver, starting with 
 a 1 in 10,000 solution, or with a four per cent, 
 solution of quinine, has sometimes a good effect 
 in checking the hematuria and relieving the irri- 
 tation. Boracic acid in five grain (0.30) cachets 
 three times a day, or irrigations of the bladder with 
 adrenalin in normal saline solution, may also prove 
 of service. 
 
 One also gives full directions as to diet, but 
 it must be admitted that, even if such are carried 
 
52 BILHARZIOSIS. 
 
 out, very little benefit is likely to result. As the 
 disease progresses and cystitis sets in (in hospital 
 practice one rarely sees a case before this has hap- 
 pened), considerable, if only temporary, benefit may 
 result from strict anti-cystitic treatment. The diet 
 consists of milk and milky foods generally, vegetable 
 soups and farinaceous food of all kinds, meat being 
 avoided. The best diluent and cleanser is plain 
 water, which may be given in large quantity. Bar- 
 ley water and Vichy water (Source Celestins) are also 
 largely used and, medicinally, the changes must be 
 rung on salol, urotropine, benzoic acid and the ben- 
 zoates and boracic acid, in appropriate doses. Better 
 than any of these, however, is the time-honoured 
 buchu and hyoscyamus mixture, usually made up 
 with bicarbonate or acetate of potassium, fifteen 
 grains (1.0) ; tincture of hyoscyamus, half-a-drachm 
 or more (2.5) ; glycerine or syrup of orange, half-a- 
 drachm (2.5) ; and infusion of buchu to the fluid 
 ounce (25.0). This mixture is given four times a day 
 for an extended period. 
 
 Except to give a certain amount of relief, by 
 clearing the bladder of accumulated debris and de- 
 composing urine, washing-out the bladder accom- 
 plishes little ; and, even in the earliest stages, it 
 cannot be looked upon as exerting any local curative 
 or inhibitory effect on the disease. For this mechan- 
 ical washing out of the viscus, plain sterilised water, 
 or boracic or quinine solution, may be used. 
 
 From this stage onwards, treatment must be 
 
BILHARZIOSIS OF THE URINARY SYSTEM. 53 
 
 entirely symptomatic ; and, later, the question of the 
 advisability of drainage of the bladder has to be 
 considered. In general, it may be said that in all 
 cases the drainage opening, if any, must be made in 
 the perinseum and not in the suprapubic region ; and, 
 further, before it is decided upon at all, a careful 
 examination must be made for stone, which, in spite 
 of the already awful condition of the bladder, may 
 and does give rise to a great aggravation of the 
 symptoms. After the removal of the stone, immense 
 relief usually follows and the patient considers he is 
 cured of all the symptoms worth worrying about. 
 Drainage must be undertaken when the urine is very 
 foul and there is evidence of early septic absorption, 
 the operation being either a Cock's puncture or a 
 median perinseal cystotomy, followed by prolonged 
 washing-out of the bladder and the introduction of a 
 drainage tube, through which the washing may be 
 continued for some time, until the urgency of the 
 symptoms disappears, after which the wound is 
 allowed slowly to close of itself. Sometimes a fistula 
 is left which, though acting to some extent as a 
 safety valve, distinctly adds to the patient's discom- 
 fort. Drainage is imperatively called for in all cases 
 of acute retention, either from blocking of the urethral 
 orifice by stone, concretion, growth or debris, or from 
 clotted blood, as already described. The presence of 
 a drainage opening adds a very considerable risk in 
 all these cases, as septic infection very readily sets 
 in in such a filthy bladder and goes very rapidly 
 
54 BILHARZIOSIS. 
 
 upwards to the kidneys. In cases of haemorrhage the 
 injection of very hot water or adrenalin solutions 
 may be of temporary service. 
 
 All stones should be treated, as far as possible, by 
 lithotrity ; and, in spite of the extensive changes in 
 the bladder, the results of this operation, qua opera- 
 tion and as a reliever of symptoms, are remarkably 
 good. It might almost be stated as a golden rule 
 that no stone in a bilharzial bladder should ever be 
 treated by a cutting operation, unless the condition 
 of the bladder is such as to call for drainage, or 
 the pain is so severe and constant as to require 
 the bladder to be put at rest, by providing a free 
 artificial outlet for the urine. Further, if a cutting 
 operation is done, it must be in the perinseum and 
 not in the suprapubic region. It seems almost as if 
 the further you keep away from the kidneys with 
 the knife the better the immediate result and the 
 prognosis for the future. 
 
 It must always be remembered that the true cause 
 of death even from a very early stage in the proceed- 
 ings, lies in the ureters and kidneys ; moreover a fatal 
 result in cases of stone after a cutting operation and, 
 for that matter, after lithotrities, rare as they are, is 
 almost always to be ascribed to the condition of the 
 kidneys and ureters and the septic complications 
 already present there at the time of the operation. 
 
 Some temporary relief may be obtained in severe 
 cases by such palliative measures as hot fomentations 
 to the abdomen, morphia and belladonna suppositories, 
 
BILHARZIOSIS OF THE URINARY SYSTEM. 55 
 
 hot baths, passing urine with the penis immersed in a 
 cup of hot water, etc., but all of these are only con- 
 fessions of failure to cope with the disease in anything 
 like a satisfactory manner. 
 
 For cancer associated with bilharziosis, and the 
 fibrous indurations in and surrounding the bladder, 
 nothing can be done; though some relief may be 
 afforded by hypodermic injections of morphine for the 
 pain, and a temporary respite from the awful irrita- 
 tion and constant micturition may be obtained by 
 perineal drainage. These measures are unfortunately 
 only adopted in our endeavour to give the patient 
 a more comfortable death. 
 
 Bilharziosis of the urethra.— The male urethra 
 is very frequently the seat of bilharziosis, and is far 
 more often affected than the female urethra. When 
 the disease does occur in the female it is usually part 
 of a general involvement of the bladder, instead of 
 being a separate local manifestation, as is the case 
 in the male canal. 
 
 Occasionally small elevations, resembling a urethral 
 caruncle, but containing bilharzia ova, are met with at 
 the orifice of the female urethra ; and, quite recently, 
 a case came for operation in which there was a papil- 
 lomatous mass — with much general infiltration of the 
 mucous membrane — which was attached by a loose 
 pedicle to the base of the bladder and had protruded 
 from the urethral orifice of a small girl, forming a mass 
 the size of a large walnut. The tumour had all the 
 typical bilharzial characters. 
 
56 BILHABZIOSIS. 
 
 Symptoms. — The symptoms of early bilharziosis 
 of the male urethra are usually localised pain in the 
 perinseum and a hard, tender lump at the seat of the 
 pain. There is a certain amount of difficulty in pass- 
 ing urine, and this symptom may be so marked 
 that many cases are sent into hospital as impacted 
 stone in the urethra. On careful examination with 
 the sound it will be found that, though there is often 
 some little difficulty in passing the instrument beyond 
 the lump in the perinaeum, it goes fairly easily, with a 
 little coaxing, into the bladder ; and, except for some 
 roughness at the thickening, no stone is to be felt. 
 The point of the sound may catch in the wall of a 
 small thick- walled cavity in passing, and the grating 
 thus produced may be easily mistaken for the rubbing 
 against a stone impacted in this situation. As the 
 disease advances the lump becomes larger and softer 
 and approaches the skin surface in the posterior part 
 of the scrotum, or just behind it, with all the symptoms 
 of a subacute periurethral abscess. Eventually this 
 leads to a thinning of the skin and a discharge of thick 
 offensive pus and granular debris, and, very soon, a 
 slight leakage of urine from the opening during the 
 act of micturition. In this way a urinary fistula is 
 produced and will persist indefinitely unless radical 
 treatment is adopted. On cutting down in such a case 
 one opens into a thick- walled cavity, which has a small 
 connection with the urethra and is filled with pus, 
 granular debris, and a few drops of urine. The granular 
 tissue will contain ova ; the walls of the urethra above 
 
Fig. 14. — Bilharziosis of the penis and scrotum in a young boy. The glans 
 penis and the prepuce, indeed the whole penis is in a condition 
 of false elephantiasis, and riddled with sinuses, as is also the 
 scrotum. The sinuses are really fistulas in connection with extensive 
 bilharziosis of the urethra. Old bilharzial sinuses are also seen in 
 the left iliac region. 
 
 (Photograph of a case in the Author's wards in Easr-el-Avny Hospital, Cairo.) 
 
BILHARZIOSIS OF THE URINARY SYSTEM. 57 
 
 and below the fistula will be thickened and its mucous 
 membrane softened and infiltrated with bilharzial 
 granulation tissue. 
 
 Treatment. — The treatment of such a case con- 
 sists in the complete removal of all the infiltrated 
 tissue right up to the level of the urethra, while the 
 urethral edges of the fistula must be well scraped 
 with a sharp spoon and all the granular tissue removed. 
 If there is any stricture of urethra an external ureth- 
 rotomy must be performed also. The wound is care- 
 fully plugged with gauze and allowed to granulate up 
 from the bottom, a full- sized catheter being passed at 
 short intervals while the healing process is going on. 
 In the majority of cases a fistula has already 
 formed before any treatment is sought, and these cases 
 present every degree of severity, from a single 
 perinaeal fistula, usually to one side of the middle line, 
 just behind the scrotum, with little, if any, surround- 
 ing inflammation, to the formation of a hard indurated 
 tissue, occupying the whole perineum and surround- 
 ings and riddled with fistulous openings in various 
 directions. The skin of the scrotum is often hardened 
 and swollen with firm oedema, and the fistulous track 
 can be felt coming up from the urethra, as a firm 
 column of almost stony hardness. The urethra is 
 also thickened and hard and may be much narrowed 
 in its anterior part and the meatus much contracted. 
 The fistula discharges pus, granular debris and urine, 
 and there may be considerable eczema around the 
 opening. There may also be a thin purulent discharge 
 
58 BILHARZIOSIS. 
 
 from the meatus, which may easily be mistaken for 
 that of chronic gonorrhoea. On passing a sound it 
 usually enters the bladder easily, though in some 
 cases, owing to the destruction of a portion of the 
 urethra by the disease, an absolutely impermeable 
 stricture may be present. The fistulous track runs in 
 the substance of a very hard fibrous tissue which is 
 directly continuous with a much thickened urethra, 
 the bilharzial change in which extends for any length 
 along it. The fibrous sheath is lined internally with 
 soft bilharzial tissue, which extends up to the base 
 of the ulceration forming the urethral end of the 
 fistula. Ova are to be found in this soft tissue, and 
 sometimes worms may be seen in open spaces 
 beside the fibrous sheath of the fistulse and in the 
 periurethral tissue. 
 
 From the preceding, comparatively mild, cases all 
 grades of severity are met with. The penis, the 
 scrotum, the skin, and soft parts of the perinseum and 
 the buttocks, and even the suprapubic region, may 
 all be individually or collectively riddled with fistulse, 
 having the characters just described, the intervening 
 soft parts being transformed into masses of scar tissue. 
 The fistulse branch in all directions, each separate 
 branch often opening at a considerable distance from 
 the original, " but it will be noticed that all the fistulse 
 arise from a very short length of the urethra, namely, 
 that portion between the posterior margin of the 
 scrotum and the bulb." (Milton.) It is not so 
 common to find fistulse arising from the penile urethra, 
 
Fig. 15.— Bilharziosis of the penis in a boy of nine. The false elephanti- 
 asis of the glans, prepuce, and skin of the penis generally is 
 well seen, but there are no sinuses or bilhax-ziosis of the urethra 
 in this case. (It may sometimes be difficult to diagnose this con- 
 dition from filarial elephantiasis, but the comparative freedom of 
 the glans in filarial invasion is an important feature.) 
 
 (Photograph of a case under the care of Mr. 0. IV. Richards in Easr-rt-Ainy 
 Hospital, Cairo.) 
 
BILHARZIOSIS OF THE URINARY SYSTEM. 59 
 
 but, when they do so, there is usually considerable 
 destruction of the urethra in its anterior part, and 
 the prepuce, skin of the penis, and the organ generally 
 often becomes transformed into a mass of false ele- 
 phantiasis, a condition which is also seen in the 
 scrotum in the case of fistulae traversing this struc- 
 ture. (Figs. 14 and 15.) 
 
 In some instances the glans penis is much infil- 
 trated and may be extensively destroyed by ulcer- 
 ation, and, although the urethra is also affected, it 
 seems that the deposit originated in the tissues of the 
 glans itself. 
 
 No hope of cure can be expected in bilharzial 
 urethral fistulae unless the whole affected tissue 
 is removed. Very extensive operations are often 
 necessary to effect this, and half -measures are useless. 
 The fistulae must be followed up in their whole length 
 and they and their surrounding fibrous tissue, how- 
 ever extensive it may be, freely excised. Large por- 
 tions of the scrotum may require removal, as well as 
 portions of the skin and subcutaneous tissues of the 
 perinaeal, gluteal, ischio-rectal and suprapubic regions. 
 To dissect out certain tracts the scrotum may require 
 to be split in half. The testicles are almost never 
 affected, though fistulous tracks burrow in all direc- 
 tions in the scrotal tissues. If penile fistulas are 
 present they must be just as radically excised, and, 
 in all cases, after the urethra itself has been freely 
 scraped, the wounds must be made as clean as pos- 
 sible and tightly plugged with gauze, to allow them 
 
60 BILEARZIOSIS. 
 
 to granulate up from the bottom and from the level 
 of the urethra. 
 
 The treatment of the urethra varies with the con- 
 dition. In some cases the mass of fibrous tissue 
 seems to be closely incorporated with the urethral 
 walls and an external urethrotomy must be done 
 through this mass into the urethra and any stricture 
 freely divided in the incision. In other cases the 
 fistula can be traced in between the corpus spongiosum 
 and the corpora cavernosa to the side of the urethra, 
 where it opens laterally or even in the roof. This 
 mass of tissue must be removed right up to the canal 
 and the ragged opening into the urethra well scraped 
 with a spoon and all the soft bilharzial tissue removed. 
 Three or four days after the operation a full-sized 
 catheter is passed and then every few days until heal- 
 ing is complete. The large open wounds often take 
 a considerable time to heal, but with careful packing 
 and proper attention the result of these cases is usually 
 very satisfactory, though repeated operations are often 
 necessary. Sometimes an operation, similar to that 
 for the complete removal of an elephantiasis of the 
 scrotum, has to be performed ; and in this case it is 
 often advisable to place a drainage tube in the bladder 
 through the urethral incision for some days to prevent 
 any infiltration of the new scrotal wound with urine. 
 When the urethra is very much destroyed, and there 
 is difficulty in finding any track at all, once the remains 
 of the canal have been found a large catheter must 
 be tied in the bladder for a few days. 
 
BILEARZ10SIS OF TEE URINARY SYSTEM. 61 
 
 In nearly all cases of bilharziosis of the urethra 
 the bladder is affected with the disease, and the ulti- 
 mate j3rognosis of the case must depend upon the 
 bladder, ureter and kidney condition rather than upon 
 that of the urethra. 
 
 In his " Three Lectures on Bilharzia," Milton 
 divides these urinary fistulas into roof and floor fistulas 
 as follows : ' ' By far the greater number of these fistulas 
 take their origin from the roof, or pubic side, of the 
 urethra ; those coming from the floor, or perinasal 
 side, being quite the exception. The floor fistulas, 
 though usually found in the urethra just in front of 
 the bulb, are not so strictly confined to this part as 
 the roof fistulas and are fairly frequent in the penile 
 urethra. It is very rare to find the corpora cavernosa 
 infiltrated with bilharzial tissue, all fistulous tracks 
 running in the corpus spongiosum, or between it and 
 the adjacent corpus cavernosum. The roof fistulas 
 are probably formed originally by the destruction of 
 a portion of the urethral wall by bilharzial deposit, 
 which extends into the substance of the corpus spongi- 
 osum and then into the space between this structure 
 and the corpus cavernosum on one side or the other. 
 It is thus directed towards the perinasum, where it 
 eventually arrives at the skin and opens externally, to 
 one side of the middle line, and the fistula is complete. 
 
 " The amount of inflammation involved in the for- 
 mation of a roof fistula is very small, in marked contrast 
 to that occurring with floor fistulas. In the latter 
 variety the destruction of tissue occurs on the perinasal 
 
62 BILHARZIOSIS. 
 
 side of the urethra with the formation of an nicer, 
 which, being in a dependent position, acts as a trap, 
 catching and retaining the decomposing matter from the 
 bladder. A septic inflammation is set up in this ulcer 
 trap and a periurethral abscess formed, with gradually 
 increasing surrounding fibrous induration, owing to the 
 constant irritation. This fibrous tissue becomes firmer 
 and firmer, until it is almost of stony hardness, and 
 gradually approaches the surface of the perinseum, bear- 
 ing in its centre a gradually elongated pouch, constantly 
 filled with pus, urine and decomposing matter. The 
 urethra in front of the ulcer becomes thickened by irri- 
 tation of the discharges of the filthy cavity into its 
 lumen. The result is that the whole urethra, from the 
 site of the fistula even to the meatus, is narrowed and, 
 not uncommonly, there may be complete obliteration of 
 the canal by cicatricial tissue, due to the final healing 
 of long-continued ulceration of the urethra, set up and 
 maintained by the discharge from the fistula abscess. 
 In roof fistula there is no obstruction of the urethra 
 at all." 
 
 The pathological conditions met with in the 
 urethra are mainly those of general infiltration of 
 the mucous membrane and ulceration. Not unfre- 
 quently small raised grape- like projections may occur 
 on the mucous surface, but there is an absence of any 
 extensive papillomatous change. 
 
 Reference will be made later to other forms of 
 fistulas, due to bilharziosis, in the region of the per- 
 inaBum, which sometimes secondarily acquire a com- 
 
BILHARZIOSIS OF THE URINARY SYSTEM. 63 
 
 munication with the urethra ; and there are certain 
 other cases, in which there is a deposit of bilharzial 
 tissue in the form of a hard lump in the corpus spon- 
 giosum, or even in the corpora cavernosa, which can 
 sometimes be completely removed by operation and 
 which is then seen to have no connection with the 
 urethral canal. Sometimes, again, an external sinus 
 leads down to a hard mass of similar characters, but 
 without any urethral communication. The structure 
 of these masses is typical bilharzial tissue, and they 
 are due to the presence of a pair or a small colony 
 of worms and their ova in the venous spaces of the 
 erectile tissue ; and, though it is probable that they will 
 eventually open into the urethra, at this stage the 
 mucous membrane of the canal is entirely unaffected. 
 
IV. 
 
 BILHARZIOSIS OF THE INTESTINAL TRACT. 
 
 As might be expected, from the extensive distribution 
 of the bilharzia worm and its ova in the portal circula- 
 tion, the intestines may be severely affected ; and, next 
 to the bladder and urethra, the lower part of the in- 
 testinal tract, especially the rectum, is the most fre- 
 quent seat of the disease. 
 
 Ova have been found in the muscular wall of the 
 stomach, the condition being later verified post-mortem 
 (Goebel), but not in the mucous membrane, and 
 bilharzial manifestations may be found in any part of 
 the mucous membrane of the intestinal tract, from the 
 ileum to the anus. 
 
 Three main sets of lesions may occur in the intes- 
 tines. The first consists in the formation of much re- 
 dundant mucous membrane, due to its general infiltra- 
 tion, and of papillomatous and sessile masses. In the 
 second of the series, ulceration is the most prominent 
 feature ; while in the third the most striking change is 
 a very marked induration and thickening of the con- 
 nective tissue between the layers of the peritoneal 
 attachments of the gut. 
 
 In every part of the tract liable to infection, the 
 only part apparently free being the stomach and duo- 
 
 64 
 
BILHARZIOSIS OF THE INTESTINAL TRACT. 65 
 
 denuin, papillomata, usually definitely pedunculated, 
 and of varying sizes and shapes, are the most common 
 manifestations. In some cases they are but sparsely 
 scattered over the surface of a vascular infiltrated 
 mucous membrane, but in others very thickly studded 
 throughout it ; and towards the lower part of the sig- 
 moid flexure and in the rectum large pendulous masses, 
 dragging with them a good deal of lax mucous mem- 
 brane, occur and may be extruded from the anus on 
 slight straining. 
 
 The papillomata in the intestine present no special 
 local characteristics, but in some situations, particu- 
 larly in the descending colon, they are extremely liable 
 to slough off at their base. A dark ring of necrosis is 
 seen round the pedicle, which gradually deepens until 
 separation takes place at this line, leaving a raw sur- 
 face, which remains as an ulcer with rather ragged 
 edges and an excavated base. There may be consider- 
 able general thickening of the coats of the bowel in the 
 neighbourhood of these ulcers, but there is no local in- 
 duration at their base. In some specimens all stages 
 in the separation of the papilloma and the formation 
 of an ulcer may be seen. When a large area of the 
 mucous membrane of the gut is studded with ulcers of 
 this nature, both from its appearance and the symptoms 
 it produces, it well merits the name of " bilharzial 
 dysentery " which has been given to it. (See Fig. 10.) 
 Another pathological change consists in a great 
 thickening of all the coats of the gut with extensive 
 dense fibrous tissue formation between the layers of 
 
66 BILRABZIOSIS. 
 
 the peritoneal attachments. This condition is most 
 commonly seen in the meso-C8ecum, transverse meso- 
 colon, meso-sigmoid and the meso-rectum, but it is not 
 confined to these situations. Within the thickened gut, 
 the calibre of which is much diminished by papillomata 
 and sessile masses, a lot of thick mucus is present ; and 
 it is difficult to see how the f seces can pass the affected 
 section, and yet one has never seen a case of intestinal 
 obstruction due to this bilharzial change. It may be 
 that the mucus acts as a lubricant and so allows masses 
 of faeces to slip past the narrowed portions of the gut. 
 The clinical aspects of this condition are very 
 well exhibited by the case of a young man who 
 gave an indefinite history of colicky pains in the abdo- 
 men and the passage of blood and mucus in the 
 motions for nearly two years. Ova were found in 
 the fseces and small papillomatous growths in the 
 rectum. Above the umbilicus, in the middle line of 
 the abdomen, was a curved hard tumour, dull on per- 
 cussion, freely movable and somewhat tender. Both 
 liver and spleen were enlarged. On opening the 
 abdomen a soft nodule, the size of an almond, was cut 
 through on the anterior parietal peritoneum, and simi- 
 lar masses were found in the omentum. The mesen- 
 teric glands were enlarged, but were much firmer in 
 consistence than the nodules. The transverse colon 
 was found to contain a large hard tumour within its 
 lumen ; and, on making an incision into the gut, 
 a fleshy mass with a smooth undulating surface, 
 firmly incorporated with the wall of the colon at 
 
BILHARZIOSIS OF THE INTESTINAL TRACT. 67 
 
 its meso-colic attachment and extending for some 
 six inches or more along it, was found. In this 
 case there was not much thickening or fixation of the 
 meso- colon ; but in the case of another patient with a 
 tumour, in the same situation, the induration between 
 the layers of the peritoneal attachment was much 
 more marked. Similar conditions have been found 
 about the caecum and the sigmoid, and in these situa- 
 tions the appendices epiploicse, in addition to the 
 peritoneal folds, were the seat of a firm bilharzial 
 infiltration. The lumen of the gut was filled with 
 innumerable papillomata, or much constricted in its 
 calibre by elongated sessile masses, and externally 
 masses of varying size and firmness were scattered 
 over the serous surface. The appendix may be found 
 firmly matted to the caecum and its surroundings, or 
 independently the seat of a bilharzial process. The 
 mesenteric glands in the neighbourhood of these 
 massive lesions in and around the gut are swollen and 
 infiltrated, and there is generally also an ulceration 
 in other parts of the tract, the main symptoms being 
 those of dysentery, the presence of the mass and of ova 
 in the fseces and other symptoms of the general infec- 
 tion confirming the bilharzial nature of the condition. 
 (Fig. 16.) 
 
 All the cases of this nature I have hitherto diag- 
 nosed have been treated by an exploratory laparotomy 
 and then by a simple enterotomy over the site of the 
 mass in the bowel. Through this opening pieces of 
 papillomata have been removed and the diagnosis 
 
68 BILHABZIOSIS. 
 
 thus confirmed, and then the small incision has been 
 sutured and the abdomen closed. In every case the 
 result of this procedure has been most satisfactory ; 
 the dysenteric symptoms have completely disappeared 
 and the tumours appreciably diminished in size. Why 
 they should do so one cannot imagine but the fact 
 deserves to be mentioned, as when one remembers the 
 very general involvement of the other portions of the 
 intestinal tract in these cases, no severe operation, 
 such as excision of the affected portion of the gut, 
 can ever be justified. 
 
 Many of the changes already described as common 
 to mucous membranes in general are well seen in the 
 intestine and especially in the rectum; "but the 
 changes which are most marked and most fully devel- 
 oped are those which make for an increase of growth 
 rather than the changes that bring about necrosis; 
 and thus the disease develops on different lines from 
 those followed in the bladder, where necrosis is more 
 marked. Thus the hard indurated patches common 
 in the bladder are never found in the rectum ; but, 
 instead, the mucous membrane becomes hypertrophied 
 and excessively vascular, the surface layers are deeply 
 injected and readily bleed when handled, and the 
 appearance of the surface resembles rich red velvet. 
 After a time, the elements of the mucous membrane, 
 probably owing in part to their excessive nutrition, 
 take on abnormal growth, with thickening of the 
 structure and general increase in bulk, and with ex- 
 cessive local overgrowth, which takes the form of 
 
Fig. 
 
 16.— Bilharziosis of the sigmoid flexure and meso-sigrnoid. The 
 processes of submucous tissue running up into the papillomata are 
 well seen, and also the filling of the lumen of the gut with masses 
 ot bilharzial growth, and the great thickening of all the coats of 
 the bowel. The meso-sigmoid is enormously thickened and infil- 
 trated with bilharzial tissue, in which many coupled worms are 
 to be found. {See Fig. 2.) 
 
 (From a specimen, prepared by Professor Symmers, in the Pathological 
 Museum of the Scliool of Medicine, Cairo.) 
 
 Fig. 17.— Two enormous masses of bilharzial papillomata protruded from 
 the anus of a boy of twelve. They were removed with considerable 
 temporary relief. 
 
 (Photograph of a case in the Authors icards in Easr-el-Ainy Hospital, Cairo.) 
 
BILHABZIOSIS OF TEE INTESTINAL TRACT 69 
 
 polypoid adenomatous tumours. Near the anus these 
 polypoid tumours bear some resemblance to ordinary 
 haemorrhoids, but within the gut, and especially be- 
 yond the internal sphincter, they differ materially 
 from these latter. In the first place, in a given area 
 they are infinitely more numerous than piles ever 
 are ; and, instead of being rounded and smooth like 
 haemorrhoids, their surface is velvety, from thicken- 
 ing of the mucous membrane itself, and the outline is 
 broken up in all directions by the formation of secon- 
 dary polypi, growing from their own surface and 
 branching in all directions, until the larger and fully- 
 developed tumours bear a great resemblance to red 
 branching coral. These tumours extend high up in 
 the rectum beyond the reach of the finger, and this is 
 so invariably the case that it would suggest the idea 
 that the affection of the rectum begins from above, 
 in the neighbourhood of the sigmoid flexure, and pro- 
 ceeds downwards." (Milton.) As in other parts of 
 the intestinal tract, stricture of bilharzial origin is 
 never found in the rectum. 
 
 In the lower part of the rectum, the most common 
 seat of intestinal bilharziosis, the symptoms are those 
 of tenesmus, with an irritative diarrhoea and the passage 
 of thick glairy mucus and blood. Very often mucus 
 and blood are passed without any faecal matter at all, 
 and the straining may be almost continuous, and 
 the tenesmus very severe, especially if pendulous 
 masses are protruded from the anus and caught by 
 the sphincter during defaecation. This also increases 
 
70 BILHARZIOSIS. 
 
 the bleeding, and gives rise to very great pain. On 
 examination the anus is usually somewhat patulous, 
 and, on slight straining, a polypoid mass, and with 
 it a good deal of lax swollen mucous membrane, may 
 be protruded. The papillomata have the usual bil- 
 harzial characters, and bleed readily on digital exam- 
 ination. A large number of polypi of various sizes 
 and forms may be felt round the anus and as far up 
 the rectum as the finger can reach. On removing the 
 finger thick pieces of mucus are discharged. The 
 microscopical examination of this mucus and blood 
 reveals the presence of ova. (Fig. 17.) 
 
 At a later stage of the disease there may be a com- 
 plete prolapse of first a ring of thickened and swollen 
 mucous membrane, perhaps bearing on its surface 
 many ranges of sessile and papillomatous masses, and, 
 in extreme cases, a large part of the rectum may be 
 almost constantly prolapsed. 
 
 It sometimes happens that fistulse form in con- 
 nection with bilharziosis of the rectum. They cause 
 considerable destruction of the parts round the anus 
 and buttocks or may even extend to the peringeurn. 
 The mode of their formation is very similar to that 
 described in the case of urethral fistula?, and the treat- 
 ment must follow the same lines. 
 
 Treatment, — The treatment of bilharziosis of the 
 intestinal tract resolves itself into that of bilharzial 
 dysentery and of rectal bilharziosis. The ' ' dysentery " 
 must be treated with all the various drugs and the 
 strict regime of a case of true dysenteric diarrhoea, and in 
 
JBILEABZIOSIS OF TEE INTESTINAL TRACT. 71 
 
 some cases large injections of astringent lotions may 
 be of service. Reference has already been made to the 
 good effect of an exploratory laparotomy and of enter- 
 otomy when the dysentery is complicated with tumours 
 of bilharzial origin. The treatment of bilkarziosis of 
 the rectum must be almost entirely palliative and 
 symptomatic. The severe tenesmus may sometimes 
 be temporarily relieved by stretching the sphincter ani 
 under an anaesthetic, and, at the same time, a strong 
 astringent lotion — sulphate or chloride of zinc, for ex- 
 ample — may be injected into the rectum, or the actual 
 cautery may be applied in longitudinal lines all round 
 the lumen of the gut. Protruding masses must be cut 
 off, after ligaturing their pedicles. In other cases a 
 deep ring of lax and prolapsed mucous membrane may 
 be excised, like an extensive Whitehead's operation, or 
 an excision of a portion of the whole thickness of the 
 rectum may even be justifiable and be attended with 
 very good results. At best, however, any treatment 
 gives but temporary relief ; the dysenteric symptoms 
 persist in making the patient's life a perfect misery to 
 himself, even if the tenesmus and other distressing 
 symptoms in the lower portion of the intestine are 
 relieved. 
 
 Reference has already been made to the occurrence 
 of bilharzial deposits in the peritoneum, omentum and 
 mesenteric glands, and ova have also been found in 
 the pancreas. Bilharzial abscess of the liver also occurs, 
 and Kartulis and Symmers have described a periportal 
 cirrhosis of the liver with, in addition, thickened 
 
72 BILHARZIOSIS. 
 
 patches of bilharzial fibrous tissue on the surface of the 
 organ. Similar patches have been demonstrated on 
 the spleen, but so far no cases of ova in the sub- 
 stance of the spleen have been reported. The ova have 
 also been found in gall-stones and in the pancreas 
 (Symmers) ; and, among extra- abdominal sites, they 
 have been discovered in the fine capillaries of the walls 
 of the alveoli of the lungs and even giving rise to a 
 form of chronic interstitial pneumonia. (Chaker.) 
 
 The blood in the haemoptysis due to this condition 
 contains ova. Griesinger has also reported the presence 
 of ova in the blood circulating through the heart. 
 
= » 
 
 K £. 
 
 
 
 
 
 
 
 teo 
 
 c 5 
 
 IB S 
 
 
 
 
 
 
 
 c ~ 
 
 
 
 - H 
 
 M ti' 
 
 ?~ 
 
 p X 
 
 
 
 
 
 o a 
 
 
 
 
 
 
 '^> -s 
 
 
 
 
V. 
 
 BILHARZIOSIS OF THE FEMALE GENERATIVE 
 ORGANS. 
 
 In the general invasion of the body by the bilharzia 
 worm the female generative organs do not escape; 
 and here all the changes common to bilharziosis of 
 mucous membranes may occur. In my own personal 
 experience cases involving all parts of the tract from 
 the vulva to the internal os uteri have been met with. 
 
 On the vulva, papillomatous masses, much resem- 
 bling venereal warts at first sight, are most common. 
 A bilharzial infiltration of the skin around the vaginal 
 orifice may be associated with these masses. Or an 
 area of crumbling ulceration, involving a triangular 
 space including the upper edge of the hymen and the 
 vestibule, and even extending into the clitoris and 
 destroying it, may occur and cause considerable de- 
 struction of tissue in this situation. The urethral 
 orifice may be completely surrounded by such an 
 ulceration. Sometimes the ulceration takes on an 
 excessive growth at the edges, and may easily be mis- 
 taken for epithelioma. (Figs. 18, 19, 20.) 
 
 Within the vagina, the general infiltration of the 
 mucous membrane with wet sea-sand deposits and 
 much redundancy of the membrane is the most usual 
 
 73 
 
74 BILHABZIOSIS. 
 
 change, though ranges of papillomatous outgrowths 
 may also be found. A certain proportion of cases 
 present signs of ulceration and, in rare instances, a 
 vesico -vaginal fistula is formed by extension of a 
 marked bilharziosis of the bladder through the 
 anterior vaginal wall. 
 
 Firm polypoid excrescences are not unfrequently 
 found on the cervix uteri, their pedicles sometimes 
 extending within the cervical canal nearly to the in- 
 ternal os. In most of these cases there is some infil- 
 tration of the mucous membrane of the vagina, often 
 only quite high up in the fornices, which gives one a 
 clue to the diagnosis, for at first sight early epithelio- 
 matous growths may be suspected. (Fig. 21.) 
 
 Small fibro-adenomatous tumours, containing bil- 
 harzia ova, may also occur on the cervix ; but, so 
 far, no evidence of infiltration of the mucous mem- 
 brane of the uterus itself is forthcoming, though 
 several suspected scrapings have been examined. 
 
 Whenever possible these various manifestations 
 must be treated by excision, scraping, or removal as 
 the case demands. 
 
 Symmers has noted the occurrence of a mass of 
 fibrous tissue involving the ovary and the upper edge 
 of the broad ligament in a young child. Microscopical 
 examination disclosed the presence of bilharzia ova. 
 
1 J «'!U ~ 
 
 1 ® r-I=H 
 
 lui: 
 
 
 5 
 
 
 
 
 
 
 
 
 
 
 ?"^_3"S 
 
 Si 
 
 
 
 
 
 
 
 ti ■*> " H r* 
 
 
 
 
 
 i. 
 
 
 «m «-= « ° tf 
 
 ° 2 ^ ° « 
 ®5S o g, 
 
 ^ _ i3 ■— 
 
 ~ 6' 
 
 
 '. _ go 
 
 == 9 *> £ a 
 
76 BILHARZIOSIS. 
 
 filtrated also, and is gradually converted into a hard 
 scar tissue, the openings of the various sinuses being 
 surrounded by prominent buttons of granulation 
 tissue. 
 
 The only possible treatment of these cases is to 
 dissect out the whole track completely, cutting wide 
 of the thick fibrous tissue tubes through healthy 
 tissue. In most situations where these sinuses occur, 
 such a radical operation is not possible, in which case 
 the sinuses must be freely laid open and very thor- 
 oughly scraped with a sharp spoon, until every vestige 
 of granular tissue is removed, and the wound then 
 plugged and allowed to heal from the bottom. Many 
 operations may be required, as each new track must 
 be opened up as it forms, and, in the end, a large area 
 may be transformed into a mass of scar tissue extend- 
 ing over a considerable area. (Fig. 22.) 
 
 Sometimes these independent sinuses acquire a 
 secondary connection with adjoining cavities, more 
 often with the rectum than with either bladder or 
 urethra, in which case they lose all their individuality 
 and become bilharzial fistulas of the more ordinary 
 type, though there may not be any affection of the 
 viscus with which they communicate. 
 
 On the skin surface one sometimes sees patches, 
 made up of a number of small rounded elevations 
 closely packed together, on a darkly pigmented base ; 
 and, again, a peculiar form of ulceration may be 
 present. "A few small discrete infiltrated spots of 
 dark colour, raised above the level of the skin, may 
 
Fig. 21. Fig. 23. 
 
 Fig. 21.— Bilharzial papilloma growing from the posterior lip of the cervix 
 uteri. The case was diagnosed epithelioma, and vaginal hysterectomy 
 was performed. 
 
 (Photograph of the uterus removed by the Author in Kasr-el-Ainy Hospital, 
 Cairo. The case icas figured and described in the second volume of the 
 Records of the School of Medicine. Cairo, 1904.) 
 
 Fig. 23.— Epithelioma around the anus originating on the site of old 
 extensive bilharzial disease in and around the lower end of the 
 rectum. Scars of old bilharzial sinuses are seen scattered through- 
 out the surrounding skin. 
 
 (Photograph of a case in the Author's wards in Kasr-el-Ainy Hospital, Cairo.) 
 
 Fig. 22.— Extensive scarring left after multiple operations on bilharzial 
 sinuses, originating in the subcutaneous tissue. The whole area 
 was riddled with sinuses which had no connection with either 
 rectum or urethra. 
 
 (Photograph of a case in the Author's wards in Kasr-el-Ainy Hospital, Cairo.) 
 
SKIN AND SUBCUTANEOUS TISSUES. 77 
 
 occur. These spread and run together, and having 
 reached a certain size, break down and form ulcers, 
 which spread in an irregular way and very slowly. 
 The surrounding skin is healthy, though there may be 
 outlying bilharzial papules. The edges of the ulcer 
 are irregular, crenated and sinuous, and they show 
 no sign of healing, though there may be scar tissue 
 around them from pre-existing bilharzia. The ulcer is 
 somewhat raised, and its base is irregular, and the dis- 
 charge is scanty and serous. It is quite painless and, 
 on scraping, one finds a gelatinous bilharzial tissue 
 coated with feeble granulations. This granular tissue 
 burrows into healthy tissues and forms little pockets 
 below and beyond the borders of the ulcer." (Milton.) 
 The only satisfactory treatment is complete excision or 
 vigorous scraping, as before explained. 
 
 In certain situations, particularly around the anus 
 and on the site of ulceration of the glans penis, an 
 epithelioma sometimes develops. The structure of such 
 growths is that usually associated with epithelioma ; 
 but bilharzia ova are freely distributed throughout the 
 section. (Kartulis.) As in the case of bilharziosis 
 with scirrhus cancer (page 38), the true significance 
 of this association is not yet properly determined. 
 (Figs. 23 and 24.) 
 
 The treatment of such cases resolves itself into 
 that of epithelioma. 
 
78 BILEARZIOSIS. 
 
 BIBLIOGRAPHY. 
 
 A very complete bibliography of bilharziosis has 
 been compiled by Looss in Mense's " Handbuch der 
 Tropen-krankheiten," and since that publication a series 
 of articles has appeared in the Transactions of the 
 Egyptian Medical Congress 1902. Papers on interest- 
 ing cases by W. H. Clayton- Greene in the Lancet of 
 December 17th, 1904, P. Gr. Stock in the Lancet of 
 September 29th, 1906, E. C. Freeman in the Journal 
 of the Royal Army Medical Corps, page 145, vol. 
 for 1905, and a most interesting and instructive article 
 on " A remarkable case of Bilharziosis," by Professor 
 Symmers, in the ''Studies in Pathology." written by 
 Ahinini to celebrate the Quatercentenary of the Uni- 
 versity of Aberdeen, 1906, may also be mentioned. 
 
Printed by 
 
 Cassell & Company, Limited, La Belle Salvage, 
 
 London, E.G. 
 
QH15dEb5t.e 
 
 COLUMBIA UNIVERSITY LIBRARIES 
 
 "04 12226262 
 
 HEALTH SCIENCES LIBRARY