ENDEMIC HAEMATURIA OR HEMATURIA.
This term is applied to forms of limmaturia chiefly met with in tropical countries, and is dependent upon the presence of a parasite. The Bilharzia hcematobia was first discovered in the portal vessels of man in 1851, by Dr. Bilharz, of Cairo, after whom Cobbold subse quently named the parasite. In 1864, Dr. John Harley discovered the ova of the worm in the urine of a patient from the Cape of Good Hope. Subsequent investigations have shown that this parasite has a wide area of distribution in Africa, where it affects men and apes, and, to a less extent, sheep and oxen. The diseases of man dependent on its presence are a certain proportion of the cases of chronic endemic Egyptian dysentery, the majority of cases of endemic hEernaturia of Egypt, Natal, and the Cape, and also, in all probability, the endemic htematuria of the Mauritius.
This parasite is a unisexual trematode worm; the male, about half an inch in length and rather flattened, acquires a cylindrical appear ance from the thinned lateral margins of the body being infolded ven trally so as to overlap and form a sort of channel (the gymecophoric canal) for the reception of the female during and after copulation. The female is longer and thinner than the male, and quite cylindrical. The eggs are oval, about of an inch in length, and pointed at one end, which is armed with a short, sharp, spine terminal in posi tion when the ova are lodged in the urinary passages, but lateral when they lie in the mucosa of the bowel (Zancarol). The outer layer of the ovum is a tough, bard shell of keratin; inside this the yolk seg ments and develops into a ciliated embryo, the shell is ruptured, and the now free swimming ciliated trematode probably passes into the. body of some intermediate host belonging to the snail tribe, where it changes into a cercaria, to be subsequently again acquired by man through the medium of stagnant drinking-water. The cercaria stage and its host are unknown.
I am indebted to Sir W. Roberts for the plate illustrating bilharzia in urine from a case which he had an opportunity of seeing in the Manchester Infirmary (Fig. 48). The patient was a groom, aged nine teen, in the service of the Viceroy of Egypt, and had been in the habit of drinking unfiltered Nile water, and of eating watercress freely.
In man, the adult male and female worms reside, in a few cases, in the vena cava inferior and its tributaries, but the true home of the parasite is in the portal vein and its numerous tributaries. Kartalis has counted three hundred, mostly in sexual pairs, in the portal sys tem of a single case. The parasites, after impregnation, are to be found in largest numbers in the submucosa of the bladder, ureter, renal pelvis, and rectum. Here, lying in large smooth-walled spaces, which are dilated blood-vessels, the female deposits her eggs, which pass on to the surface of the mucosa, possibly by the boring action of their spines, assisted materially, in the case of the bladder, by the contraction of that viscus. As they become free, the surface of the
mucosa is lacerated, and blood escapes freely from the torn capillaries and is discharged with the ova and urine. Although empty shells have been found in the left heart, and many ova in the lungs and liver of some cases, by Dr. Mackie, of Alexandria, still the Bilharzia infarcta of Sonsino do not appear to be of frequent occurrence except in the neighborhood of the living parasite; the position of the pa rents prevents the ova from making their way into the larger veins, and acts as a block to direct them toward the anastomosing capilla ries, which, from their size, they camiot pass along.
When bilharzia are lodged in the veins of the urinary apparatus, they produce symptoms varying according to their number and posi tion. In Natal, especially, many boys harbor the parasite without much inconvenience; their general health is usually good ; they have occasional attacks of lassitude, with pain in the loins or perinmum, generally after exertion, and they have intermittent hmmaturia, of which, however, they take but little notice, as it mostly disappears before puberty. The ova may, as Dr. Harley has pointed out, be still present in the urine when all other signs of existence of the para site have disappeared. In more serious cases the symptoms are, in addition to those already named, the presence of muco-pus along with the ova and blood in the urine, frequent micturition, vesical tenesmus, and all the signs of chronic cystitis. The blood is usually passed almost pure at the end of micturition, and nearly always contains many ova. Post mortem or after a cystotomy, the mucous membrane is found to be swollen and ecchyMosed in patches, usually on the posterior wall of the bladder, or showing here and there elevated thickenings, covered with a gritty material, composed partly of urates or uric acid, and partly of ova. In the interior of the thickenings are many yellowish-white specks, made up entirely of ova, lying in dilated vascular spaces. In other cases, where death has resulted from exhaustion or the supervention of typhoid symptoms, the bladder is small and contracted, its muscular wall greatly thickened, and the mucosa and submucosa involved in large, irregular, elevated lumps, with shreddy surfaces, lying - mainly at the base and around the urethral orifice and constituting a veritable tumor of the bladder. It would appear (Bilharz and Meckel) that sixty-three per cent of the Egyptian fellaheen are infested with bilharzia.