VOL. XVIII.

Bilharziosis, so called after its discoverer, Dr. Bilharz, is a disease caused by a parasite finding entrance into the body in some way not yet clearly understood, and setting up an inflammation in the various tissues infected. For a time it was thought that the only source of the disease was drinking the water of certain streams in Egypt

and South Africa. Closer observation has demonstrated the danger of infection to be equally great from digging in the soil, or from bathing in such waters; the parasite thus entering through the rectum, vagina, urethra, or abrasions of the skin.

The male is about one-half an inch in length a unisexual trematode worm-rather flattened, acquires a cylindrical appearance from thinned lateral margins of the body being infolded ventrally so as to overlap and form a sort of channel (the gynæcophonic canal) for the reception of the female during and after copulation.1

The female is longer and thinner than the male, and quite cylindrical. The eggs, or ova, are about 1-160 of an inch in length and pointed at one end, which is armed with a short, sharp spine terminal, in position when the ova are lodged in the urinary passages; but lateral when they lie in the mucosa of the bowel. The outer layer of the ova is a tough, hard shell of kreatin ; inside this the yoke segments and develops into a ciliated embryo; the shell is ruptured and the now free swimming ciliated trematode probably

* Read before the Brooklyn Surgical Society, March 3, 1904.

No. 7.

passes into the body of some intermediate host belonging to the snail tribe, where it changes into a circaria to be subsequently acquired by man. The circaria stage and the host are unknown; and just how the cycle from worm, ova, embryo to worm again, is completed is not quite clear. That this intermediate host is necessary in man is now doubted by some. Many sur geons have demonstrated in the infected tissues. numerous cysts that are lined with amorphous together copulating, and ova containing live empigment, containing the male and female worm bryos; and thus they believe it quite possible that the embryo may there develop into the full grown

worm.

There has been a great deal of discussion as to the way in which the ova became scattered through the body. The distoma were first discovered in the large abdominal veins, and it was thought to be probable they would spread through these vessels if at all. This view was believed to be confirmed by finding numerous eggs in the small veins in the mucous membrane; but they have not been observed in the arteries, and it is not probable that they could make their` way through the capillaries or against the direction of the blood stream in the veins. The most

satisfactory explanation would seem to be that the eggs deposited by the female in the bladder. or intestines are carried by the lymph stream into the tissues and there perhaps partly transferred as emboli from the vessels to other organs. To sustain this theory is the fact that numerous ova have been found in rows in the lymphatic vessels. Whatever be the mode, or channel through which the eggs reach the tissues, it is known that no organ is exempt from their invasion.

The portal vein usually contains great numbers of them and the liver is quite extensively involved, the lesion produced being not unlike nutmeg liver. While the heart, stomach, spleen and pancreas are occasionally infected, it is in the lower colon, sigmoid flexure, rectum and uropoietic system that the serious pathological lesions are found.

The simplest, slightest and first change in the vesical mucous membrane consists of spots of hyperæmia, which are sometimes sharply outlined. and sometimes somewhat obliterated at the borders. There are many small extravasations of blood, the mucous membranes at such places being swollen and puffy, often, but not always, coated with viscid mucus, or with a greyish-yellow, yellow or sanguinous exudation. Quanti

ties of the ova of the distomum are found in these discharges.

In isolated cases the entire mucous membrane of the bladder exhibits marked injection and ecchymosis, but in the great majority of the cases the process is limited to small spots, varying in size from a bean to a ten cent piece, particularly on the posterior wall. Frequently, at a later stage of the disease, are found greyish-yellow, or dull-white elevations of the mucous membrane, mingled with many spots of pigment. Sometimes there are smooth, leather-like coatings beneath the mucous membrane that appear as if they had lain in alcohol. The coating may be friable, presenting a fine debris and permeated with urinary salts, or a firm sand, consisting of eggs and eggshells, which cannot be removed without destroying the mucous membrane. All these changes are attributable to extravasation and to a process of inflammation set up by the distoma invading the smaller branches of the veins, and there depositing their ova, and the subsequent protrusion of the eggs from the ruptured vessels. Quite often on the vesical mucous membrane there are single or heaped-up excrescences or vegetations of a yellowish or a sanguineous ecchymosed appearance. They are slightly raised, wart-shaped or fungoid, the top split resembling condyloma, or shaped like cockscomb or raspberry, the base being somewhat restricted.

Considerable attention has been given to the histological characteristics of the blood of those suffering from Bilharziosis. Unlike many of the parasitic diseases, there is little or no diminution of the red blood cells, or of the hæmoglobin," but there is always a slight leucocytosis. The percentage of coarse grained eosiniphile leucocytes is, with very few exceptions, much above the average percentage found in normal blood. This increase goes hand in hand with a proportional diminution in the polymorphonuclear leucocytes. Less frequent is an increase in the large mononuclear leucocytes, and when this is present it is associated with a diminution of the lymphocytes. It is not improbable that the amorphous pigment-like masses found in the cavities, in which

worms are present, contain some element or virus that alters the blood.

Geographically, there is now a wide distribution of the disease first discovered among the natives in the desert of the Nile. The dysentery of the Mauritius has long been known to be caused by this parasite. From time to time in medical literature, cases have been reported in India, Persia and the countries on the shores of the Mediterranean. Since the war in South Africa between the British and the Boers it has excited considerable interest, not only because of the number of soldiers affected, but because of the fact that these men have seemingly carried the disease out of Africa to the different stations to which they were assigned since the war. Nor is it from the soldier only that we may expect the spreading of the disease, but also from the numerous class of men constantly passing from one country to another in the pursuit of trade or pleasure.

Within two years on this side of the Atlantic a few cases have been seen in New York, some in Canada from the returned regiments, and one case has been reported from the West Indies, which has been attributed to the Boer prisoners or British troops. During the same time many men in the British Army have been invalided to England because of their sufferings from this disease.

As many of the ships trading between Africa and this port berth at the piers in Brooklyn, it is to be expected that cases of Bilharziosis will be seeking treatment at our hospitals. I have seen one such in a sailor who came to the Polhemus Memorial Clinic for relief from the intolerable pain in the bladder and abdomen. Clinically, the parasite does not seem to have the same power of impairing or destroying tissue in the young as in those more advanced in years, and therefore the suffering may be very slight, or the disease pass almost without complaint. In the majority of cases it will extend or run its course over a period of from two to ten years. Whether this considerable difference in time is due to reinfection in some, or greater resistance on the part of other individuals (it is known that the black race is almost immune), or whether the parasite loses its vitality earlier in some cases than in others, are questions that remain unanswered. Once they find lodgment in the tissues, they set up an inflammation in the mucous membrane which is followed by the formation of new fibrous tissue that replaces the glandular elements. Quite frequently, there is great over

growth of the normal elements of the parts attacked with the formation of polypi and growths taking on all the clinical characteristics of malignant disease. It is noteworthy that many of these cases suffering from this parasite develop and die of intercurrent cancer of the bladder and rectum that may be either of sarcomatous or carcinomatous variety. But whether the parasites merely play the part of irritants in a person in some way predisposed to malignant disease, or whether the relationship between the parasite and proliferous tissue growths, which we are accustomed to speak of as cancer, is even more connected and intimate, are points among others which naturally become prominent in connection with the consideration of this subject.

The symptoms first complained of are malaise, backache, and pain referable to either the bladder or rectum. From the rectum there may be a discharge of a viscid yellow, or greenish-yellow mucus, sometimes mixed with blood. The tenesmus is severe and persistent, and the rectum may be more or less prolapsed; the mucous membrane is congested and infiltrated, while here and there over the surface may be numerous small ulcers, or small polypi containing worms.

In the ischio-rectal region may be abscesses, or perineal fistulæ, the walls of which are thick and fibrous in character and in which are often numerous worms and ova. The sigmoid is frequently so thickened as to be distinctly palpated in the iliac fossa, but the disease rarely extends above the descending colon, although ova have been found in the small intestine. The mesentery is often much thickened and inflamed by the eggs of the distomum that find there way there through the lymph vessels from the intestines.

To positively confirm the diagnosis of Bilharziosis, it is necessary to find the ova in the mucous discharge from the rectum, or in the urine. Usually this is not difficult, for if on the first examination of the mucus from the rectum no eggs are found, a brisk calomel or saline purge will bring away great numbers of them. The urine should be centrifuged when the ova can nearly always be found in varying numbers, as well as some leucocytes, a large proportion of which are coarse grained eosimophiles.

In the uropoietic system the lesions are the most serious, and from the bladder, as a rule, the patient finds the first warning of his trouble. While urinating, the stream is observed to be dark in color, or slightly red, and at the end of micturition a little pure blood may be forced

SEDIMENT OF BILHARZIA URINE, BILHARZIA OVA (ONE WELL.DEFINED IS SEEN IN LOWER LEFT-HAND CORNER, HALF INCH FROM MARGIN), CRYSTALS OF OXYLA IES, ETC.

In the bladder the symptoms are those of acute or chronic cystitis, that may be complicated by tumors or urinary calculus. The miseries of one with an urethra so swollen and obstructed as not to admit the passing of a catheter, a urethral fistula carrying urine to be discharged over the abdomen or through numerous openings in the perineum, and a bladder that has become infected, need not be further described. Once the bladder has become diseased, the ureter may follow the same course as the urethra, and thus we

may have strictured or obstructed ureters, a hydro-nephrosis, or a pyo-nephrosis, with their accompanying symptoms and sequelæ.

The prognosis in Belharziosis would seem to be more grave in some countries than in others. Physicians in Cape Colony say it causes few deaths, but in Egypt it saps the strength of the young and causes adults to die in the prime of life, there being a mortality of from eight to ten per cent. in that country.

The fact that the disease may be merely local in the beginning or soon after the parasite enters the urethra or rectum, makes an early diagnosis and prompt treatment of the greatest importance. As it has been my purpose to bring this subject to the attention of this Society, rather than to offer any suggestions as to its treatment, I shall merely add that the application of the general surgical principles that are appropriate for the various lesions met with, cannot but give relief to those so distressingly afflicted.

I owe my best thanks to Dr. Eugene A. Pool, of Manhattan, who kindly allowed me to use his splendid photomicrographs.

BY RICHARD WARD WESTBROOK, M.D., Adjunct Attending Surgeon, Brooklyn Hospital. This is one of the burning questions for the surgeon at the present time, and it is no less important for the medical practitioner. On the latter depends the decision as to whether his patient with gall-stone disease, shall receive early surgical treatment, as well as his patient with a diseased appendix. Unanimity prevails among the profession as to appendicitis being a surgical

There is no question

able to determine for us. able to determine for us. but that the surgeon is coming to look more and more upon the gall-bladder as he does upon the appendix vermiformis, as a useless appendage, capable of producing unlimited mischief when diseased, and "better out than in" at any time. This feeling was well expressed by Prof. Roswell Park, two years ago, in a short paper read before the American Surgical Association. In this paper he called attention to many points of similarity between the gall-bladder and the appendix, and advocated strongly the radical and complete routine extirpation of the gall-bladder. I do not believe that our present knowledge entirely warrants this attitude, although the leaning toward extirpation is generally growing. How far we are warranted in treating the gallbladder as we do the appendix is the problem which I wish to discuss to-night, by taking up with you the following questions. Is the gallbladder very similar, anatomically, to the appendix? Has it any useful function in the economy? Do gall-stones originate also in the ducts outside the gall-bladder? Do gall-stones recur after operations for their removal? Can they be cured by medical treatment? Do not the demands of safe surgery often require the preservation of the gall-bladder in surgical procedures? And, what are the conditions of the biliary passages where the gall-bladder is, without question, better out than in.

IS THE GALL-BLADDER VERY SIMILAR, ANATOMICALLY AND PATHOLOGICALLY, TO THE APPENDIX?

Park says that both structures are hollow receptacles, more or less tubular in shape, both normally contain a certain amount of secretion from which calcareous deposits may be precipitated; both are lined with mucosa, continuous with that of the intestine, and in both bacterial infection and inflammation begin so soon as occlusion or interference with the exit of their secretions occur. This is all true, but here the

analogy ceases. The appendix is a simple structure, clearly vestigial and without function, simattached to the cæcum, whence it may be shipped off and the little opening closed, with no possible loss resulting from its absence. But not so the gall-bladder, which is a functional and continuous part of a system of bile-ducts of wide extent, reaching out into the substance of the liver and down to the duodenum, and incorporating with itself the exit of the pancreatic duct, near its duodenal orifice. Infection within the gall-bladder means usually infection within the bile-duct system, and cutting away the in

fected gall-bladder with its stones does not remove the essential condition of danger, the infection of the bile-channels. The appendix differs widely from the gall-bladder, in that its blood supply is from a single terminal artery without anastomosis, allowing rapid gangrene as a very frequent occurrence in inflammation here. The gall-bladder, on the other hand, has a very free blood supply, not only through the branches of the cystic artery, but also through anastomoses with the hepatic vessels where the gall-bladder is fixed to the liver. Acute gangrenous inflammation of the gall-bladder is consequently of rare occurrence. The walls of the appendix are made up of tissue which permits of little distention without necrosis and perforation, while the gall-bladder may distend enormously without necrosis or rupture. The removal of the appendix is ordinarily a simple matter to the surgeon, with its single artery to tie, and its accessible position. But the gall-bladder must be removed from the under surface of the liver, leaving a bare, oozing area, and the cystic duct is in close relation with the hepatic and cystic arteries, the portal vein and even the inferior vena cava.

Anatomically and pathologically, therefore, the resemblances are not really very great between the gall-bladder and appendix. But clinically, just as an appendix, the subject of chronic disease, will disturb the functions of the parts adjacent to it-bowels, ovary, or even bladder-so will the gall-bladder, in similar conditions, by adhesions to omentum, stomach and intestines, give rise to pain and dyspeptic symptoms, usually referred to the stomach.

HAS THE GALL-BLADDER ANY IMPORTANT FUNCTION IN THE ECONOMY?

This is an interesting question. Some observers are inclined to regard it as a rudimentary or vestigial structure like the appendix, but this does not hold, as the study of lower forms of life does not show that it represents any more highly developed organ than it is found to be today. Its distribution in the lower forms is very peculiar, it being present in some and absent in other members of the same order for no apparent reason. The ox has a gall-bladder, but the horse has none. The goat has a gall-bladder, but the deer has none. The hawk has it, but not the dove. But, in general, the presence or absence of the gall-bladder depends upon the character of the food of the animal, and the type of the digestion. For instance, most of the flesh eaters have a gall-bladder, and in them the type

of digestion is the intermittent, there being periods of rest between periods of active digestion. But in many of the vegetable eaters, digestion is carried on nearly continuously, and here the gall-bladder is often absent and the bile flows fairly constantly through the bile-ducts directly into the duodenum. These facts suggest the function of the gall-bladder as being merely that of a storage reservoir, where, in the intervals between digestion, the bile is carried, the sphincter muscle at the duodenal end of the commonduct not permitting it to flow out into the intestine. Yet, as a storage reservoir, it is entirely insignificant, its capacity being only about an cunce, while the daily amount of bile secreted is from thirty to forty ounces. The gall-bladder has been also considered a flush-tank, which can at intervals expel its contents in such a way as to clear the common-duct of infective agents which may enter it from the intestinal canal. This view would seem the more likely in the light of recent observations, which go to show that what little antiseptic property the bile possesses is derived from its admixture with the gall-bladder secretion. But the theory does not hold good, as in some lower forms more than one duct conveys the bile to the duodenum, and one of these ducts may be provided with a gall-bladder where another may not. (See Fig. 4.) It has been looked upon, too, as a tension-bulb, in some way regulating the tension in bile-ducts and liver; but its inadequate muscular structure and disadvantageous position, with its fundus lower than its outlet, seem to contradict that theory.

Whatever the function of the gall-bladder, it is surely not an indispensable organ. Apparently, patients from whom it has been removed get on quite as comfortably and healthfully without it as those who have normal gall-bladders. It is, however, rather too early to say that it has practically no function, and may be sacrificed without consideration of possible usefulness. Its variability in the different forms simply emphasizes the fact that it is a modified portion of the hepatic duct-system, and must be considered as a part of a functional whole. The accompanying chart will show some of the variations of the bile-duct system in different lower forms. Fig. 1 shows the form encountered in man and most mammals. Here the hepatic duct joins the cystic duct to form the common bile-duct, which enters the duodenum by passing obliquely through the intestinal wall. Fig. 2 shows a form occurring in certain mammals and some fishes, where instead of one hepatic duct, two or more hepatic

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