1922 The Lancet  
THE following case is of sufficient interest to merit record. The patient, an Egyptian baker, aged 40, was admitted to hospital for right inguinal hernia and hydrocele. At operation I found the ordinary indirect " oblique " or " external " hernial sac following the inguinal canal, the length of the sac being about 2 inches. Quite distinct from this sac I found another direct or internal hernial sac, about 1 inches long, the deep epigastric artery being to the outer side of the neck of the sac.
more » ... here was also a hydrocele on this side. I ligatured each sac separately, excised the hydrocele, and closed the abdominal wall by Bassini's operation. I have never previously met this condition, although I myself do about 100 hernia operations a year, nor have I heard of it at Kasr-el-Aini Hospital, where I was at one time registrar, and where about 300 hernia operations a year are performed. I should be interested to hear if the condition reported has been met with and described before. In his presidential address of last session Dr. Hamer had reviewed the evidence as to outbreaks of typhoid fever in the sixties and onwards, which had been attributed to water and to milk infections, and had urged that there was good reason for surmising that many of them were really due to sewage-contaminated fish or shell-fish. He had since made an analysis of the London prevalences of typhoid over the entire notification period-more than 30 years-and he considered that it amplified and confirmed this view. An earlier inquiry (1894)(1895)(1896)(1897)(1898)(1899)(1900)(1901)(1902) had shown that in 24 areas occupied by poor persons in widely scattered parts of London typhoid prevalences had been prone to occur, often affecting many of them simultaneously, and commonly happening in September and October. He suggested that these prevalences might be attributable to the fish which was brought under suspicion in his reports of 1900 and 1903-viz., that from the shallow " A3 area " in the North Sea, which included the estuary of the Elbe, and abounded with small flat fish. This hypothesis was strengthened by the fact that the London autumnal prevalences, after declining in 1907-12, had practically disappeared during the war; the change coinciding with the disuse of this particular area for trawling purposes. Dr. Hamer proceeded to review the recorded facts about the London outbreaks of cholera in the last century, with a view to showing the possibility of fish or shell-fish infection having played the part which had been so long ascribed to water infection as a result of the researches of Snow, Simon, Farr, Radcliffe, and others. He recalled that Pettenkofer had consistently held to the " localist " as opposed to the " water theorist " point of view in connexion with the Hamburg and Altona cholera of 1892, in the face of the conclusions of Koch as to river infection. The 1866 Outbreak of Cholera. This was an outbreak which had been attributed to water from the Old Ford reservoirs. Radcliffe, in his impartial report, dealt with the objections to the water thesis, and admitted the difficulties which they presented. Certain localities not supplied with Old Ford water were attacked. Certain sections of the population, localities, and institutions escaped, although they were supplied with it. T. Orton, M.O.H. for Limehouse, emphasised similar difficulties ; he mentioned that 19 out of 20 adults who perished were not water drinkers even occasionally, and referred to the escape of the 400 children in the Limehouse pauper institution who drank the water all day long and did not show even a single case of common diarrhoea. M. Corner, acting M.O.H. for Mile End Old Town, remarked on the want of simultaneity in the outbreaks, and affirmed that in 100 cases visited by him, not more than 5 per cent. had drunk of the water at all, and those only after it had been boiled. It seemed clear from Radcliffe's map that the areas specially attacked were limited to certain streets, courts, and alleys occupied by the very poor, and Dr. Hamer pointed out that a noteworthy feature was the focussing of the cholera mortality in the areas surrounding certain market streets, especially Salmonlane and Chrisp-street, then, as now, well-known coster fish markets. Simon, in his appended note to Radcliffe's report, alluded to the difficulty of conceiving that cholera should not have been carried indiscriminately wherever the water was drunk, if the drinking of it were an essential condition of the outbreak, and appeared to be inclined to the view that the water may have " operated on or through the soil of the territory." Dr. Hamer remarked that there was need of explanation not merely of variation of incidence " with difference of soil and altitude," but also with social differences, and in particular with concentration of fatal cases around coster fish markets. The 1854 Outbreak. This was attributed to the Southwark and VauxhaIl water. The case against the water rested on Snow's preliminary spade work and Simon's classical report. Simon adopted just as careful an attitude towards the water hypothesis as did Radcliffe 12 years later. He was strongly influenced by Snow's advocacy of the theory, though restrained by Pettenkofer's opposite views in relation to the Munich experience. Simon submitted that the population drinking the Southwark and Vauxhall water suffered three and a half times as much mortality as the population drinking the water supplied by the Lambeth company (and, even when they lived in the same streets, nearly three times as much) ; and that consumers of Lambeth water, which in 1849 was taken from the tidal portion of the Thames, suffered in the outbreak of that year more than three times as severely as in 1854, when the source of supply had been removed from Hungerford Bridge to Thames Ditton, well above the influence of London sewage. Dr. Hamer called attention to objections to thewater hypothesis similar to those he had advanced in connexion with the 1866 outbreak. The incidence was highly selective, and much was written at the time about the influence of altitude and the incidence. on people living near the river and in an insanitary environment. It was clear that limited groups of poor persons were especially liable to attack ; those, for instance, occupying certa,in courts or alleys, or housed in particular institutions, residential schools" prisons, workhouses, &c. Dr. Hamer did not consider it as being by any means conclusively shown that the difference between the one water-supply and the other was the deciding factor. Snow had evidently had difficulties in assigning the supply in many houses, and there was also evidence against the assumption that the consumers of the two water-supplies were otherwise on a. par. On the contrary, the districts supplied by the Lambeth water appeared to be on the whole less poor. It was difficult also to reconcile the water
doi:10.1016/s0140-6736(00)55193-9 fatcat:pgsxex2vb5b2nd3erojdkfzz7q