A case which I saw in the Liverpool Royal Infirmary under the care of Dr. Davidson, and which seemed at first sight to be one of in termittent hmmoglobinuria, disclosed, on further investigation, the occasional presence in the blood-stained urine of ova closely resem bling, if not identical with, those of bilharzia. The patient a man aged about forty, was a native of the Scottish highlands, and had never been abroad.
When the vessels of the ureter or renal pelvis are the habitat of the parasite, the results are usually more rapidly fatal, from the produc tion of hydronephrosis, of pyelonephritis, or of acute suppuration of the kidneys. Obstruction of the vesical orifice of one or both ureters occasionally takes place from their involvement in the bladder tumors, and hydronephrosis or pyelonephritis may result. Males are much more liable to the disease than females. Provided the patient can be kept alive and free from reinfection, the disease must evidently have a self-limited duration, dependent on the natural period of life of the parasite. This is not yet very definitely ascertained, but appears to vary from one or two to ten years. It is to be noted that the eggs of bilharzia often form the nuclei of uric acid calculi, which may not give rise to symptoms of their presence until some years after all indications of the parasitic disease, have disappeared." As bearing upon the clinical features and surgical treatment of this disease, I will quote the following remarks by Dr. Mackie relative to a specimen he forwarded me, which was shown at the Pathological Society of London by Mr. Butlin." It is now preserved in the mu seum of St. Bartholomew's Hospital. Dr. Mackie thus describes it: "Specimen of diseased bladder, kidneys, rectum, and dilated and thickened ureters, from a fatal case of severe hwmaturia from bil harzia hdematobia. The old man came under my care suffering from dreadful continued pains, and passing almost pure blood mixed with enormous quantities of debris containing ova of bilharzia. To ease the pain and examine his bladder, to see if the surface could be scraped or any tumor removed, I performed perineal urethrotomy. The bladder was found to be studded full of papillomatous-feeling tumors, bleeding freely. It was no use trying to remove any, as they were in dozens. So nothing further was done. The pain was eased, the haamaturia di
minished, but he died of urannia, a week afterward. Post-mortem ex amination showed that the walls of the bladder were full of small tumors filled with ova." To another specimen of the same kind of disease, Dr. Mackie refers in the following words : " This specimen is from a man who came to hospital for hmmaturia, passing blood and debris, with pus and mucus, suffering agony. I performed perineal ure throtomy, and drained the bladder, which, as usual, stopped the hem orrhage; but he died about a fortnight after of rupture of the bladder from destruction of the walls by ulceration caused by bilharzia." Dr. Mackie goes on to remark : " For some years I have been directing my attention to this disease in connection with urinary fistula, which is nearly as common as hmmaturia, and which I have proved to my sat isfaction is caused by the same parasite, as in every case I find the ova in hundreds in the hard tissue around the fistulous tracks in the perineum. In every case there is hmmaturia with ova in the bladder with a history of sudden phlegmon and perineal abscess, with no his tory of injury, or stricture, or gonorrhoea, or anything urethral to ac count for it. For a long time these cases of perineal urinary fistula) puzzled me; men came in with their perinaaums a large fibrous mass, riddled with sinuses and fistula3, through which the urine passed on micturition; hut no stricture, their urethra admitting easily the larg est catheter, or, as often remarked to strangers, I believe their urethra would take in my little finger, and no history of previous stricture." Various suggestions have been made relative to treatment, their ob ject being to effect the destruction of the parasite in the blood. Har ley recommends the administration of the oil of turpentine and of male fern, with a little chloroform, in order to expel the ova from the urinary passages, and a solution of bicarbonate of potassium to relieve renal irritation. Dr. Fonguet " also advocates the use of male fern, observing that "the blood disappears from the urine after a few days' treatment. I employ the capsules of the ethereal extract of male fern, taking care to administer the medicine one hour before meals." For a similar purpose I believe the iodide of potassium, in twenty-grain doses, has been given.