From this epidemic two facts stand out so as to demand attention and have been impressed upon municipal authorities all over the world; first, that beyond all question, water carries disease and secondly, that a well-constructed filter will remove all or a large part of these germs. Needless to say, after the epidemic, Hamburg put in a filtration system, and although the river water has, beyond doubt, been infected many times since with cholera, there has never been another epidemic, or any large number of cases.

We may consider that although water supplies purify themselves to a large extent and the most active agents are sedimentation and dilution assisted by oxidation, the action of light, air and marine life, yet it is not safe to drink polluted water without artificial purification.

Artificial Purification.

Now we come to the last phase of the subject of drinking water, the methods of purification and disinfection. There are many methods and the best for any particular town or city must be determined by the conditions. The character of the water differs greatly in different places, so that no general rules can be laid down. Sometimes a water will be very muddy but free from germs of dangerous character, so all that is necessary is to remove the mud. Again, a water sample may be perfectly satisfactory with regard to clearness and color and yet be very dangerous to drink because of pathogenic germs. In such a case all that would be necessary is a disinfecting process to kill the bacteria. Still other water supplies are both muddy and dangerous, or dangerous and highly colored and demand a combined treatment.

To briefly outline a few of the methods of water treatment:

Storage.

Some water supplies can be made safe to drink by pumping the water from the polluted lake or river into large storage reservoirs so situated that they cannot receive fresh pollution. Here the water is allowed to stand until the natural methods of purification have had an opportunity to exert their fullest effect. The method has been much used in England, but less here.

There are several problems which must be solved by the chemist in charge of a storage reservoir. The water may become stagnant, especially if the reservoir is very deep. Water is kept in motion by the action of the wind to a depth of 20-40 feet, but many reservoirs are much deeper than this, and below the 40-foot line the water may become stagnant, since the dissolved oxygen is exhausted and the organic matter becomes putrid and the water evil-tasting. This is most liable to happen where the bottom of the reservoir is covered with vegetable matter.

There are two occasions in the year known as "the fall and spring turnover" when the water in a reservoir is well mixed. The bottom water comes to the top. The reason of this movement is that in the summer the top becomes warmer than the bottom water and as winter comes on this relation is reversed, the top water becomes colder, hence denser and sinks to the bottom, stirring up the reservoir contents thoroughly. Like conditions arise in the spring, so we have two periods in the year when all the water in a pond is in motion for a few days, thus all becomes exposed to the air. This may explain why at certain times of the year for a few days the water of a supply tastes very badly, that which was stagnant has come to the top and is drawn off into the public mains.

Stripping the bottom of a reservoir of the top layer of soil prevents in great degree the growth of organic matter. This greatly improves the taste. It is, of course, impossible to empty large lakes and reservoirs for cleaning, so other methods of removing taste and smell must be used. One of the most practical methods is:

The Use of Copper Sulfate.

It has been found that copper sulfate is very poisonous to the organisms, both vegetable and animal, which give a bad taste to water. On the other hand, this chemical is very little dangerous to the human being, especially in great dilution. Bags of the salt are towed from a rowboat or launch across the storage pond and the results are very gratifying in improvement of the taste and odor of the water. The quantity of salt used is very small, one part to four million of water, and in some cases, one part to ten million. The copper seems to form a chemical compound with the organisms and both are precipitated.

Light and Dark Storage.

It is a curious fact that if water has been drawn from underground sources it is best to store it in the dark, i. e., in covered reservoirs, while that from surface sources is best stored in open reservoirs. There is one decided advantage in closed storage in the fact that the water does not become contaminated by the microorganisms which are floating about in the air, which although rarely dangerous to health may give a bad taste or odor to the water. Sedimentation.

This is merely a process of allowing water to stand quietly in large reservoirs or to flow slowly until the sediment has settled out. This is used as one phase in the procedure of many filter plants and in most cases very greatly improved the quality of the water. In some places where the water is merely muddy and not contaminated by disease germs, sedimentation is the only process. This is the case at Richmond, Va., and was the method

used at St. Louis until recently. Other filtration plants as at Omaha and Kansas City, have found that the process alone failed to make the water safe, so they have combined it with a treatment with chlorine, and now St. Louis has been obliged to follow the same method.

To discuss the sedimentation process further would not be of special interest, as it is a matter more for the engineer, but in conclusion let me say that the efficiency of the process depends upon three factors:

1. The rate of flow of the water.

2. The size of the surface on which the sediment settles.

3. The size of the particles to be removed. Thus the sedimentation is much more rapid with large particles than with small. Some of the particles found in water are so very small as to be almost in the colloidal condition and such settle very, very slowly.

To remove very fine particles we use another process, partly chemical and partly mechanical, which we call

The Coagulation Process.

Chemists learned many years ago that when to a liquid containing many suspended particles, the particles being so fine that they will not settle, if a substance is added which will form a precipitate having large particles or, better still, large jellylike "flocks," the large particles will quickly entangle the small and the liquid will be easily and completely clarified. This process is applied on a large scale to water and works very well. Generally a crude sulfate of iron or aluminum is added to the water. If the water is slightly alkaline, as is usually the case, the hydroxide of iron or aluminum will be formed as a flocculent precipitate which on settling will carry down not only most of the sediment but a large number of the bacteria as well. This attraction of large particles for small we call "adsorption." In case the water is not sufficiently alkaline due to the presence in it of lime, some calcium hydroxide in solution is added. A mechanical dosing apparatus is used to add just the proper amount of each chemical, and the amount has been determined by laboratory tests. This method is now used along the Mississippi, especially at St. Louis and New Orleans, with the result that a beautifully clear and sparkling water is obtained.

This coagulation method has been known for a very long time, as years ago French troops in China found that the people of that country followed the custom of adding small amounts of alum to their drinking water, and when the soldiers did the same they suffered much less from fever and bowel troubles.

(To be continued.)

The Diagnosis and Treatment of Chaneroids.
By CHAS. H. J. BARNETT, M.D.,
812 South Fifteenth Street,
PHILADELPHIA, PA.

IF

F WE MAKE it a rule to examine every sore, regardless of what we might think it is, with the dark-field illuminator for the Spirocheta pallida we will never make the mistake of treating a sore for a chancroid and in six weeks find that our patient has developed secondary syphilis. In the textbooks we are told that chancroids are ulcerative processes coming on soon after intercourse; that the lesions are usually multiple; that they are irregular in outline and that they are not indurated at the base and that the base is purulent. That is, of course, a classical description of them. A great many chancroids are single, and even indurated and have edges that are clean and regular in outline, and it is these cases that tax the best of us in making a diagnosis; and it is my belief that a lesion of the penis in a man is of sufficient moment to both the doctor and the patient that he should know as soon as possible what he may have, and we should call to our aid every aid in the correct diagnosis. Repeated examination for the Spirocheta pallida should be made -two are usually sufficient. Make a Wassermann if necessary at the end of three weeks, if still in doubt. But if we take a small single or multiple sore, which is not indurated at the base, associated with an inguinal adenitis, which soon becomes suppurative and breaks down, there is very little doubt as to the correct diagnosis.

Treatment.

For this purpose it is well to divide the treatment into two parts, that is, for two different varieties of sores. The first, the ordinary small single or multiple chancroid, is best treated as follows: Clean the sore with ordinary salt solution; then apply one or two drops of a 1 per cent. betaeucaine, or novocaine or even cocaine, wait a few seconds for effect, then apply pure phenol, being sure that it does not touch the surrounding tissues; then apply pure nitric acid and allow the patient to sit down and rest for a few minutes until he becomes more comfortable; when he does become easy, apply a few crystals of argyrol upon the sore and tie the penis up with a 1:10,000 chlorazene solution, and I am sure that in no other way will we be able to obtain the brilliant results achieved from this combined treatment. I have seen sores which would not heal under the first part of the treatment heal very rapidly when the argyrol and chlorazene were added.

For the large chancroids, those that take in from one-fourth to one-half of the penis, the treatment is the same, except in addition, after cleaning the penis, place a 500-candle-power light over it and

allow the rays to fall upon the surface for varying periods of time, depending upon the size and depth of the ulcer, the large and deeper the greater amount of time should be allowed, and this process is best repeated twice daily until the ulceration begins to

T

diminish in size; then it can be reduced to once daily until cured. This treatment must be carried out with patience and persistency, otherwise failure will be the result. Try it out and let's have a report on your results.

By L. SEXTON, B.S., M.D.,
Room 506, Medical Building,
NEW ORLEANS, LA.

HREE PER CENT. of all hernias are of the umbilical variety. They are usually caused by intra-abdominal pressure in the adult; in infants from lack of closure of the abdominal ring, whooping cough, phimosis, straining at stool or urination, all increasing the intra-abdominal pressure in the child and thus preventing the closure of the umbilical ring. The congenital umbilical hernia is caused by lack of development of the abdominal muscles and the failure of the umbilical ring to close. The intestines may prolapse with the cord as a bulbous mass, which should always be reduced before the cord is ligated, lest a portion of the intestine be included in the ligature. The condition is rare, occurring about once in ten thousand infants. The umbilical hernia of the adult contains either omentum, small or large intestines, which have protruded through the abdominal ring and a split through the linea alba. Oft-repeated pregnancies and straining during delivery is the most common causes of umbilical hernia in the female. Females are twice as liable as are males to this form of hernia, which are usually irreducible.

The Anatomy.

The anatomical parts of umbilical hernia are the same as in others, constituting neck, sac, and body; but the sac is not so well defined in umbilical as in other hernias because the peritoneum forming it is often not distinguishable from adhesions with other tissue. The skin over the top of the hernia becomes thinner and attenuated with the age and pressure of the hernia. The tumor may be round, smooth or lobulated. In older persons there is no such tendency for the rings to close as in children from the fact that increasing fat, hard labor, atrophy of the tissue from pressure, straining and the further fact of the omentum becoming adherent to the abdominal ring.

Complications.

In long standing cases incarceration and strangulation is a frequent complication. There is heavy dragging weight connected with the tumor, with colicky pains if there is any twisting or strangulation of the bowels. This strangulation may be intrasaccular by the intestines being twisted or caught in the inflammatory process.

Preparatory Treatment.

The only permanent means of relieving these acute abdominal symptoms is by an operative procedure. When patients will not submit to an operation, trusses, pads, suitable abdominal bandages, rest in bed and purgation may temporize, until the consent of the patient can be gained for the radical cure of the case. The average intelligent patient will not hesitate long in coming to a conclusion if the merits of the operation are properly presented. Increased obesity from sedentary habits, with constant dragging pains from omental adhesions, are great inducements to the patient to be relieved of the hernia. It is the irony of fate that nearly all umbilical hernias occur in obese patients, and to correct this condition and avoid operating in the bottom of a well of fat, in some cases four inches deep, it is therefore advisable, if the case is not strangulated or suffering severe pain, to use a month or two in reduction of fat and other preparatory treatment before the operation is undertaken. From twenty to forty pounds can be taken off of the largest patient, who is willing to assist the doctor in reducing his or her avoirdupois, and getting into proper shape for an operation by avoiding rich soups, fresh and salt fish, pork, veal, hashes, fats, potatoes, macaroni, oat meal, hominy, rice, beets, carrots, turnips, puddings, pastries, cakes, sugar, sweets, milk, cream, malt or spirituous liquor, sweet wines and champagne and in fact reduction of all diet by onehalf, with light exercise and daily purgation by such foods as dates, apples, prunes, raisins with pulverized senna, milk of magnesia, agar, or other purges, which tend to the absorption of gases and non-irritation of the bowels.

Much of the outer layer of fat can be absorbed by wearing a tight bandage around the abdomen. By this reduction of food and by purgation, the bloodpressure will be reduced, kidneys and liver relieved of an overworked condition and the operative chance of the patient much improved.

Treatment.

In infancy the tendency of all unnatural openings is to close up. If the child is circumcised for phimosis, the constipation regulated by diet or medicine, cough relieved and intra-abdominal pressure reduced, many cases in children may be relieved by the use of abdominal bandages and support and by the proper application of wide Z. O. strips so applied

as to assist in the closure of abdominal rings and the reduction of intra-abdominal pressure. All of these methods, if given a fair chance for a year or even more, with the intelligent assistance of the parents or nurse, will cure many cases. Others will need operative procedure, the same as in the adult. Before any operation the patient should be kept in bed on a very spare diet, thoroughly purged, with an abdominal supporter pressing upon the hernia to try and reduce as much of the mass as possible before operating. This reduction of the hernia may sometimes be helped by elevating the foot of the bed and the application of ice bags, relieving the tumor of as much blood as possible.

Operation.

After the usual antiseptic precautions, a transverse elliptical incision is made around the hernial tumor to the base, pushing back the surrounding tissue for two inches from the hernial sac, exposing the aponeurosis of the recti and opening the sac. The neck of the sac on the side is incised by a circular cut over the finger, exposing the contents of the sac and reducing any intestines after separating from all adhesions with the omentum. The omentum is then ligated in segments in order to insure hemostasis. The edges of the sac should be clamped to prevent its receding into the abdomen; and the omental mass is then cut away. The more common adhesions of the omentum are at the upper margin of the tumor and around the hernial ring, hence the sac should be opened at the side of the tumor, thus with less risk of danger to the patient. The adhesions can be broken up by the insertion of a finger around the ring and sweeping it gently from one side to the other. As a matter of course, any intestines which may be abraded by this separation should have the raw surfaces covered over by Lembert-Czerny sutures before returning them into the abdomen.

Be exceedingly careful that all bleeding is stopped before dropping the omental stump back into the abdomen. A flap-splitting incision is made through the aponeurotic and peritoneal structure for from one to two inches, according to the size of the umbilical opening, the peritoneum being separated from the surfaces of the flap. Chromacised mattress cat-gut sutures are inserted two inches above the upper edge of the umbilical ring; the same suture firmly grasping the lower margin of the flaps. The lower flap is then drawn up by this suture from one to two inches, according to the size of the patient, making a double covering for the ring, and taking the slack out of the peritoneum. The upper flap of the aponeurosis is then drawn down and sutured by cat-gut to the aponeurosis of the ring below. In inserting the mattress suture a large bite should be included in the loop, so as not to cut out from pressure in the inflammation which follows. The

lateral muscles and aponeurosis are closed in the same way by sliding one side above the other when it is possible, thus covering the opening with four layers of tissue.

The less the tissue is handled in any operation the better for the patient, but especially is this true in an operation where any subsequent infection means the return of the hernia. Hemorrhage from small vessels should be controlled by clamping torsion, using as few ligatures as possible. It must be remembered, however, that hematoma will become infected just as likely as the ligature, so all bleeding must be stopped before the wound is closed up.

After the operation is finished, before closing up the incision, we usually wipe it out thoroughly with half-and-half tincture of iodine and alcohol to prevent sepsis. We think that the overlapping of the muscles and aponeurosis from the sides, when it can be done, reinforces the peritoneal flap very much and renders the return of the hernia less probable. It is more important to approximate the aponeurosis than the body of the muscle in order to prevent the recurrence of the hernia.

After the muscles and sheath have been sutured, the adiposed tissue and skin should be brought in close apposition by deep cat-gut sutures. A small drain may be left in the corner of the incision for a short time if there is enough effusion to justify it.

After-Care.

A suitable dressing, with an abdominal bandage, is then applied and the patient confined to bed for three weeks or a month as the further treatment of the case. For some time after the operation the patient should eat no gas-producing foods, such as hot bread, potatoes, peanuts, starches and sweets, but should keep the bowels moderately open with alkaline gas-absorbing laxatives. We have recently operated and relieved two large umbilical hernias in women who have borne many children. They were treated and operated upon the above plan and were relieved of the embarrassing and uncomfortable hernias. The technic of the operation was very similar to what one sees in the Ochsner and Mayo clinics.

Openings in Medical Corps of the Army.

There are 650 vacancies in the Medical Corps of the U. S. Army. Examinations are being held at various points monthly. If open for such an appointment-this is not the Medical Reserve-write the Surgeon General, U. S. Army, Washington, D. C.

United States citizens between 22 and 32 years of age who are graduates in medicine and have had one year's post-graduate hospital interneship are eligible for the examination. Chemistry and physics have been eliminated from the army examination.

A

By WILLARD CONNELY, U.S.N.R.F., MINNEAPOLIS, MINN.

WAR EXPEDIENT which would add to the lasting honor of all great American medical colleges if they took part in it has been initiated at the University of Minnesota. Professors of medicine and surgery are giving special instruction to sailors, who are trained for the purpose of nursing the sick and wounded aboard our dreadnaughts, our hospital ships, or at naval hospitals. The immense advantages attendant upon bluejackets becoming familiarized with the broad range of therapeutic methods at a leading medical school are at once obvious to physicians. The very atmosphere of a college impresses enlisted men with

a sense of their gilt-edge opportunity. They declare an exultant desire to be "doctors"; eventually many of these sailors will realize that wish.

Surgeon-General William C. Braisted, of the Navy, and Ensign Colby Dodge, U. S. Navy, of the Minneapolis Naval Training Detachment, originated the measure during the course of one of Ensign Dodge's official trips to Washington. Upon immediate acceptance of the proposal by Dean Elias Lyon, of the University Medical School, one hundred hospital apprentices were detailed from the far West. They came from Mare Island, Seattle, Bremerton, and sixty of them from the Naval Hospital under the direction of Rear Admiral George H. Barber, Medical Director at Las

2. A quiz in the operating room, Elliott Memorial Hospital. These ear and throat irrigations will be criticized technically by the men in the background, alert to detect maladroitness.

sity medical faculty. When professors of the various departments and head nurses of the hospital staff were invited to volunteer extra hours for Uncle Sam they jumped, they cheered, at the chance. The day after the disentrainment of the sailors their schooling began.

The class was divided into twenty sections of five men each, on the sound principle that only in small groups at the clinics and for certain parts of the hospital work could the sailors obtain the best appreciation of the subjects taught, through continuous individual attention by instructors. The morning lectures of course were given before the entire battalion. The only morning work at which the class split up was in dissecting and in the laboratory of bacteriology.