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Olinical and other Notes 145 recommend removal of the head of the first phalanx alone in preference to amputation at the meta-tarso phalangeal joint. , However, the latter procedure is the one which I have several times lately seen carried out with excellent results. In performing this little operation, a most im­ portant point is to take care that the scar is well away from the sole, To show how little the loss of the second toes may weaken the foot, I would instance the case of one of our brother officers, a well known athlete. A frequent winner at the United Hospitals meeting he was so much troubled by hammer toes that he was advised to have them ampu­ tated. After this was done his times were better than ever. He could cover the half mile under two minutes, and was, I believe, second for the Amateur Championship at that distance. I have thought it worth mentioning [how good a foot may result from -the above operation as I see that the latest edition of Walsham's Surgery, in discussing the treatment of this common deformity, remarks that " amputation of the toes excludes admission to the Services." I have not the latest edition of Regulations at hand, and am ignorant whether, in such cases, anything is left to the judgment of medical officers. If the rule is hard and fast, it is only fair that an otherwise promising recruit,

who is anxious to have this defect remedied, should be advised to ask by copyright. for a conservative form of operation, lest the cure should disqualify him as iuuch as the disease.

A CASE OF BILHARZIA HlEl\fATOBIUM-CONTRACTED IN ENGLAND.

By E. C. FREEMAN. http://militaryhealth.bmj.com/ Royal Army Medical Corp8. CASES of bilharzia have been frequent among the troops returned from South Africa, but no case of the disease arising de novo in England has, as far as I know, been put on record. The following case is certainly one of bilharzia and the man's very positive statement that he has never left England, seems accurate and trustworthy. We have certain "knowledge of his movements for the last year and a half, and also that. he was not suffering from the disease in May, 1904, when he was under treatment 'for an injury in the Station Hospital. on September 24, 2021 by guest. Protected Private E. P., 2nd Norfolk Regiment, aged 24, was admitted to the Station Hospital, Colchester, on January 24th, 1905, complaining of passing blood with his urine and of occasional sharp pains in the region of the lower abdomen. History.-Patient was born in Birmingham, and' about the age of 15, got employment on a barge which plied between Birmingham and London. He was on the barge for six years. The barge carried bricks, J R Army Med Corps: first published as 10.1136/jramc-05-01-16 on 1 July 1905. Downloaded from

146 Clinical and othm' Notes tiles, &c., and only once or twice a refuse cargo. He left the barge and came to London and .worked on the Tube Railway for nearly two years, after this he did bricklaying and odd jobs, and also was employed at Bow on a bridge which was being built at the Docks. Later he went to in search of work and enlisted in the Norfolk and did one training at Norwich, he then enlisted from the Militia into the 2nd Battalion Norfolk Regiment. He was retained at the depot at Norwich three months, and then sent to join the battalion at Oolchester on December 24th, 1903, where he did ordinary duty, and was in the Station Hospital, Oolchester, for seventeen days in May, 1904, with a wound of the face. He proceeded to Borden Oamp on June 30th, with the regiment and while on manamvres there, had occasional attacks of sharp pain lasting a few seconds, " about the bottom of his stomach;" he did not notice that he passed any blood in his urine. He returned with his regiment to Oolchester and did not take part in the Essex manceuvres in September, but remained at Oolchester until he came into hospital. Present Illness.-Patient, who is somewhat debilitated in appearance, noticed that he was passing blood in his urine for a fortnight before he reported sick; he had never to his knowledge done so before. He now by copyright. passes blood and "thick stuff" in his water; the amount of blood varies on different days. He states that most of the blood is passed at noon and about 3 p.m., and he has occasional sharp pains, like those he had at Borden Oamp. On examination bilharzia ova with apical spine were found to be present in the urine with phosphates blood mucus. Possible Sotlrces of Infection-No cases of bilharzia hffimatobium or cystitis have been treated at Oolchester during the past year, but the 2nd http://militaryhealth.bmj.com/ Norfolk Regiment returned from South Africa in December, 1903, and about four men who served in South Africa have been sleeping in the patient's barrack-room (No. 8, Goojerat Barracks). One man newly arrived from Somaliland came to this barrack-room in October and remained six weeks, when he left for the depot. It is therefore quite possible that some one of these men may have been suffering from bilharzia infection. Goojerat Barracks are of the newest model, except that the old fashioned and obnoxious urine tubs are still in use. Urine from these tubs gets spilt on the landings and washed into the barrack-rooms, or the mops used for cleaning may bring the spilt urine into the barrack-rooms. on September 24, 2021 by guest. Protected It is quite possible that bilharzia ova might in this way be introduced and dry with the dust on the floor and so be inhaled or swallowed. Much the same may be said of possible infection in Borden Oamp. Men from South Africa were there, tents were more or less crowded, and soldiers urinate very carelessly in camp. Deductions to be drawn from this case, are, I think:- (1) That cases of h::ematuria, cystitis or vesical pain, should be care- J R Army Med Corps: first published as 10.1136/jramc-05-01-16 on 1 July 1905. Downloaded from

Olinicctl and otlter Notes 147 fully'looked for among troops from abroad, examined for bilharzia, and brought under treatment at once to prevent possible spread of infection. (2) That this case affords yet another reason for the abolition of urine tubs in barracks and shows another possible uauger from polluted soil in camps. (3) That there is a possibility, heretofore unrecognised, that bilharzia hffimatobium may become endemic in Great Britain, having been intro­ duced on a somewhat large scale of late years. (4) That, therefore, every effort should be made to destroy the parasite before the patient is discharged hospital, and that disinfection of the urine of these cases shonld be practised and urotropine given internally. My thanks are due to -Colonel Robinson,R.A.M.C., for permission to publish the case, and to Civil-Surgeon Scott for bringing the man under my notice. Lieutenant-Colonel Leishman, R.A.M.C., has very kindly examined a specimen from this case for me and reports as follows :- "Bilharzia ova were found in the sediment of this urine, it was noticed, however, that they were somewhat more slender than usual and the terminal spine was less pronounced. The contained embryos

presented the usual characters but were not viable." by copyright.

POSTSCRIPT TO THE CASE OF BILHARZIA ARISING AT COLCHESTER.

Since writing the above case, I have been making fu~ther investiga­ tions as to the source from which the man, E. P., contracted the disease, and, thanks to the kindness of Major Elkington, R.A.M.C., the Adjutant,

Norfolk Regiment Depot, and others, I am in possession of the following http://militaryhealth.bmj.com/ facts :- (1) There have been no cases of bilharzia among the men of the 2nd Battalion Norfolk Regiment since their return to England from South Africa. (2) There have been no cases of bilharzia among the twenty-five men of the Norfolk Regiment who returned from Nigeria. All had good health. (3) Six cases of bilharzia hffimatobia were admitted to the Cambridge Hospital between July and December, 1904, from Aldershot.

(4) No cases of bilharzia were admitted from Borden Camp into the on September 24, 2021 by guest. Protected Princess Louise Hospital, Alton (where the sick from Borden are treated), between July and December, 1904, but the Medical Officer in charge informs me that they have now four or five cases from the Argyll and Sutherland Highlanders who had heen stationed in Rustenberg. E. P. remembers passing this battalion once on the march, but his regiment was never brigaded with them. It is, however, quite possible that the Norfolks might have followed on the same camping ground on some occasion. J R Army Med Corps: first published as 10.1136/jramc-05-01-16 on 1 July 1905. Downloaded from

148 Olinical and other Notes

Acknowledging that we have very little knowledge of the conditions necessary for the spread of bilharzia, except that infection is probably through the medium of water, and that some cases escape diagnosis, I think the circumstances in this case point to infection having occurred while at Borden Camp and not in barracks at Colchester. It would also seem probable that it is only the careful protection of the water supplies, a~d the rigorous sanitation at Alder'shot which prevents the disease becoming possibly endemic among the troops . by copyright.

• http://militaryhealth.bmj.com/ on September 24, 2021 by guest. Protected