second case was one of gumma of the testicle. This had broken down and an abscess in the substance of the testicle was the result. Hernia testis occurred and resisted treatment. In the third case the diagnosis and treatment presented more difficulties. The patient, a corporal in the South Lancashire Regiment, gave the following history. Eleven months before his admission to Netley he was riding, and the horse stumbling he bruised his right testicle against the saddle. The testicle swelled up and he had to go to hospital, but returned to duty in about a fortnight. A few days after this the testicle again became swollen and he had to return to hospital. On several occasions the tunica vaginalis had been tapped and fluid removed, the testicle was found on these occasions to be enlarged and very painful. On his admission to the Royal Victoria Hospital the testicle on the right side was found to be much enlarged and very painful; a hydrocele existed; this was tapped and all the fluid drawn off. The testicle was then found to be enlarged, especially the epididymus, and painful. Both local and constitutional remedies were tried but without success. The patient's health became greatly deteriorated by constant pain and want of rest, and he begged that the organ might be removed. He was most anxious to remain in the service. As he had been in hospital nearly a year, and practically no improvement had taken place, but the contrary, and his general health had shown signs of failing, it was decided that removal of the organ held out the best prospects. On removal the testicle was found densely fibrous, especially the epididymus, and the tunica vaginalis was much thickened. The man speedily became convalescent and returned to duty.

In each case the cord was ligatured en masse " and the Staffordshire knot was used to tie the stump. In one case recurrent hæmorrhage occurred, not from the cord but from the surrounding parts; one or two bleeding spots were tied and the cavity packed with sponges to keep up even pressure.

This was a rather instructive case. Corporal T. D, of the Royal Sussex Abscess of bone Regiment, was admitted to hospital at Netley on April 4th, 1894. He was opened. invalided home for synovitis. He stated that for some weeks he had suffered acute pain in the right knee, and the joint had been very swollen and hot. On questioning, the man referred the pain to a small area, about the size of a shilling, situated on the inner side of the head of the tibia, three-quarters of an inch below the articular surface. This spot was intensely painful, and the parts over it were slightly edematous. As the symptoms pointed to an abscess in the head of the bone, an incision was made at this spot. A small abscess in the bone was found, and the contents evacuated. The abscess did not communicate with the knee-joint. The pain and swelling of the joint rapidly subsided, and the man made a rapid recovery.

Private W. M, Connaught Rangers, was admitted to the Royal Victoria Amputation of Hospital, Netley, on June 6th, 1894, with inflammation of the right ankle-joint. leg. At this time he had a sinus behind the outer malleolus, which led behind the ankle-joint. He was a good deal emaciated, and seemed broken down in general health. The ankle was stiff, and when moved pain was complained of. The discharge from the sinus was scanty, and the surface temperature over the right ankle-joint was not raised. No dead bone could be detected by the probe. The joint was kept at rest, but he continued to suffer from sleeplessness due to pain in the joint at night. About six weeks after admission the joint suddenly became much swollen, and acutely inflamed, the pain was intense, and suppuration occurred about the joint. On July 25th, free incisions were made on each side of the joint, and a drainage tube passed behind it. After this the swelling subsided, and the temperature fell. No dead bone could be felt, but the symptoms pointed strongly to this condition. Immobility of the joint was aimed at, with the hope that with efficient drainage and perfect rest, the disease might be arrested, and recovery take place at the expense of a stiff joint. Great pain and starting at night still, however, continued to be prominent symptoms, and the temperature also began to assume a slightly hectic character. It became evident that any further attempt to save the limb would imperil the patient's life, and it was therefore decided to explore the joint thoroughly under chloroform, and if the disease turned out to be extensive and of such nature as not likely to be sufficiently dealt with by partial operation, to remove the foot. The sinuses were therefore freely laid open, and the joint examined by the finger; it was found that the disease of the articular surfaces of the ankle-joint was very extensive, and that the internal malleolus was

Radical cure of hernia.

also considerably implicated. It seemed very doubtful if a Syme's amputation
would completely remove all the diseased bone. Under these circumstances
amputation was effected at the junction of the middle and lower two-thirds
by Teale's method. The wound pursued an aseptic course, and the patient
was allowed up on the 19th day, after three dressings, with the parts healed.
Three operations for the radical cure of hernia were performed during the
current year.
In each case the hernia was of the inguinal variety and
reducible. The period which the hernia had existed varied from two and a half
to one year. The method of operating by twisting the sac, and suturing the
conjoined tendon to Poupart's ligament was adopted in each instance. A
detailed account of the steps of this operation has been given in previous reports,
and it is therefore unnecessary to refer to this again. Perhaps the most im-
portant feature with regard to this operation is the strict attention which
should be given to the cleansing of the skin, and the packing with an anti-
septic solution of the field of operation. The ligatures used by us, also, for
this operation are most carefully prepared: the silk employed for ligaturing
vessels is boiled, and the silkworm gut used for the deep sutures, and the
horse hair employed for the superficial sutures, are well soaked in a 1-20
solution of carbolic acid. The danger of using ligatures which have been kept
in carbolic oil only has been so often pointed out that it is needless to refer at
greater length to this subject.

The results of the operation were most satisfactory; in each case recovery was rapid, two were discharged to duty, and one was invalided. The latter case complained of no pain or weakness till he went on leave, after his return from this, he stated the parts felt weak; in all respects the case seemed one of perfect recovery, and the probability is that during his leave he had found it more profitable to try and leave the service.

In connexion with permanency of the cure in this operation, it is interesting to note that only two cases of those operated on before entering the service have come under observation at Netley with a view to invaliding. One case

had to be discharged the service on account of neuralgia at the seat of operation, and in the second case the hernia reappeared after two years, the operation having been performed at a large metropolitan hospital before the enlistment of the man.

APPENDIX No. III.

REPORT ON THE EIGHTH INTERNATIONAL CONGRESS OF
HYGIENE AND DEMOGRAPHY HELD AT BUDA PESTH,
FROM SEPTEMBER 1ST TO SEPTEMBER 9TH, 1894, To WHICH IS
ADDED NOTES ON THE SEWAGE AND WATER SUPPLY OF HAMBURG,
FRANKFORT, HOMBURG, AND PARIS.

By Brigade-Surgeon-Lieut.-Colonel J. LANE NOTTER, M.A., M.D., Army
Medical Staff, Professor of Military Hygiene in the Army Medical
School, Netley.

Acting under instructions contained in War Office letter, No. 4,800/6/1,154, and dated August 13th, 1894, I left England on the 15th of August accompanied by Surgeon-General J. S. Billings of the United States Army.

The orders I received were that on my journey to Buda Pesth, as a delegate to represent the British Army, I should take the opportunity to visit the water and sewage works of those towns where large works had recently been erected with the view of reporting on them generally. I was also appointed to act as a member of the Committee on International Medical Statistics as representative of the British Army.

The first place we visited was Hamburg: the epidemic of cholera which Hamburg occurred in 1892 having been attributed to impure water, the authorities lost no time in endeavouring to secure a purer supply, and in a little over six months the present works were completed. The city obtained its new supply of water in May 1893.

The water is taken from the River Elbe, at a point much higher up the river than formerly, and further away from the sewer outfall, so as to avoid, as far as possible, any backwash bringing sewage with it. The distance from the old intake to where the present supply is obtained is one and half miles.

Formerly the water was pumped into tanks on the mainland close to the town, and after it had been allowed to settle for a short time was delivered to the houses in the city without undergoing any filtering process; that such water should have been contaminated by sewage being brought by the rising tide from the sewer outfalls was therefore most probable.

Now, the water of the Elbe taken at a greater distance from the town and its sewer outfalls is pumped on to an island in the river.

I carefully inspected this part of the river. It is extremely doubtful if the present source of supply is a safe one; the water is very dark, contains much sedimentary matter, and, if not contaminated during ordinary tides by sewage from the town outfalls, it is certainly not free from this danger during exceptional states of the river. There is also always the liability to pollution from a river like the Elbe, which carries a large traffic in merchandise and a constant floating population; although a notice board is placed close to the intake directing the attention of barge owners to the regulations which orders no boat to anchor within 160 yards, this distance is not sufficient to afford sufficient protection.

The water taken from the Elbe is stored in newly constructed tanks, where the suspended matters are allowed to subside by mechanical action. The water as received from the river into these tanks is very impure; the time allowed for the suspended matters to settle is from 24 to 36 hours, after which the water is drawn off for the purpose of passing it through the sand filter beds.

Ordinary sand filters are used. The total filtering area measures nearly 34 acres, and filtering at the rate of 2.74 feet per square yard of surface in the 24 hours.

Eppendorf
Hospital.

One serious drawback to these filters is their size. In winter, exposed as these filter beds must be to the severe frosts which are frequent and prolonged, the surface of the filter must inevitably be frozen over in part, if not on its entire surface; if in part, then the movement of the water through the unfrozen portion of the surface must take place at a rapidity in inverse proportion to the smallness of the permeable area. Again, if one of these large filter beds requires cleaning the greater the superficial area of a filter the more difficult will it be to prevent the formation of ice upon it, and therefore to clean it. Further, if water ceases to pass through one or more filter beds from this cause, it will naturally throw extra work on any others which remain unaffected. The future must show whether it is possible to keep filters of such dimensions free from ice, and to cleanse them so rapidly that the sand surface does not freeze.

There is no rule as to cleansing and recommencement of filtration, as the process of filtration is regularly tested by bacteriological examination daily—a special laboratory building, with an adequate staff and amply supplied with apparatus being placed in the grounds and close to the filtering areas. The moment a water is found to be insufficiently filtered the filtering material is removed. Each filtrate is examined once daily, and frequently oftener. The sample of water is taken in a specially constructed bottle which has been carefully washed and rendered sterile; it is dropped by a chain to about 3 feet below the surface and withdrawn and immediately sealed by a gas flame. Within a few minutes the water is submitted to bacteriological examination, and from personal observation I can testify to the fact that the water I saw was quite sterile. A chemical examination is also made daily in a separate laboratory in the same building as that in which the bacteriological work is carried on. The water is raised as formerly into a water tower, and thence reaches the houses by force of gravitation.

One cannot help seeing the danger underlying such a source of supply as has been selected for Hamburg. It is not even now certain that the intake is not within the limits which may receive the backwash from the sewer outfalls, and, however carefully watched, open filters in such a climate are liable to a breakdown.

A better source of supply would have obviated the expense which it entailed in endeavouring to obtain a tolerably pure drinking water from a sewage contaminated river. It is very well to lay down a standard of purity for filtered water; but the difficulty arises when engineers have to construct works which will deliver a constant supply at that standard. A far safer plan would have been to select a source less liable to contamination.

The sewers in Hamburg are very old. They are not impervious, and are intended to drain away some of the sub-soil waters; but they also contaminate those waters by permitting the sewage to escape into the surrounding ground. The sewers are ventilated by the rain-water pipes. This, of course, is most undesirable, especially as the storm-water overflows open directly into a lake, the Aussen Alster, which is in the middle of the city, and contaminate it. The sewer outlets open direct into the river and harbour; in fact, the whole system is bad, and urgently requires reorganisation.

When at Hamburg we visited the Eppendorf Hospital. This hospital was begun in 1885 and completed in 1889. The site covers 45 acres. The buildings are 82 in number, 10 of which were erected to meet the demands on the hospital during the epidemic of cholera in 1892; the remaining 72 are built of brick and are substantial buildings.

In the centre in front and opening on the Martin Strasse is the main administrative building, having behind it, and at a short distance from it, the Governor's house. The wards, which are all of single storey, and built on the pavilion plan, are arranged behind the administrative block in parallel rows, the men's side being to the east, and the women's to the west of the road which leads in a straight line from the centre of the front block. There are also two small isolation pavilions, male and female; on the west side is a building for lunatics, and to the north of this the mortuary. Other buildings, such as kitchen, stores, laundry, boiler-house, ice-house, officers' quarters, &c., are conveniently situated.

The whole of the buildings are entirely detached, there being no covered communication of any kind. This hospital is capable of accommodating

1,500 patients. The large ward pavilions are one storey high. They are raised about 18 inches above the ground, and, except at the end, have no basements. In the large wards are 30 beds placed very close together; the floor space is only 78 feet. The cubic space per bed is 1,280 feet, but this is obtained by raising the roof to the height of 16 feet 3 inches. The proportions of these wards certainly do not comply with the usually accepted conditions of area and cubic space in due relation to each other. At the further end of the ward is a day room with doors opening out into the garden.

The partitions enclosing the waterclosets, three in number, which open off the day room, do not reach to the ceiling or down to the floor, and are not separated by a ventilated lobby, in fact these waterclosets are directly ventilated into the day room. On the other side of this room are the ward, scullery, and bath room.

The walls are plastered and coloured, a painted cement dado being carried round the ward to a height of about 5 feet.

The roof is made of "wood cement," and is almost flat; this form is said to afford the best protection against extremes of heat and cold.

The floor is laid with "terrazzo"; under this flooring are a series of channels 2 feet 6 inches wide, in each of which runs a steam pipe, supported on iron rails. The steam is supplied by a boiler, each pavilion being provided with its own boiler. In addition in each ward are two steam radiators which are connected by tubes with the outer air.

The ventilation of the wards is provided for by windows, and by a ridge ventilator on the roof.

The system of heating the floor of wards is very generally adopted now on the Continent; it is claimed for this principle the following advantages:(1) that it renders possible the use of an impervious material for the floor surface; (2) that the greatest warmth is at the part needed, that is, nearest the feet; and (3) that the air being constantly circulating the system materially assists ventilation.

The operation theatre is a two-storied building having cellars underneath. There are two operation rooms each with a large semi-octagonal bay, with windows forming each side. On the same floor are two waiting rooms and an instrument room. There is also a special bath room for the surgeon's use. On the upper floor is a large room for the preparation of bandages and dressings. The other buildings consist of the mortuary, waiting rooms, chapel, bacteriological rooms, &c., which do not require any particular mention.

Leaving Hamburg, we went direct to Frankfort, where we were fortunate Frankfort-onenough to meet with Mr. Lindley, the consulting engineer to the City of Maine. Frankfort, and the engineer of several large works connected with sewerage and water supplies on the Continent. He took an immensity of trouble to show us everything in connexion with his department, and personally conducted us over the works at Frankfort.

Water Supply-One of the most interesting and instructive sights was the new water supply. The old supply was taken from a small river and springs which have their origin in the mountainous range of hills about 14 miles distant. This supply not being sufficient new works had to be constructed and a new source of supply sought for. On this same range of hills, but at a long distance away from the original intake, Mr. Lindley noticed that several small streams at the foot of the hills sunk into the gravel and disappeared. The whole area of ground between the hills and the City of Frankfort is Crown preservation lands and covered with very fine timber. Mapping out by trial borings the contour lines, Mr. Lindley was able to intercept the water which passed through the gravel on its flow towards the river. This bed of gravel is about 100 feet in thickness and rests on blue clay. Trial borings showed that the water level was a constant one, never fluctuating very much, and remained at a depth of 50 feet from the surface.

Just above the level of this ground water, and for a distance of 12 miles, Mr. Lindley constructed a tunnel in the form of an egg-shaped sewer, the greater diameter forming the invert; this is lined all through with white glazed tiles, making a perfectly dry, clean, and impervious subway at a distance of 50 feet below the surface. This subway is about 7 feet 6 inches high and about 4 feet wide at its greatest diameter. The direction this subway follows is in the line of the contour lines. At either end is an entrance