night, when the wind is easterly or northerly. The nuisance may be lessened by insisting on the proprietor having the drain flushed by a continuous stream of water, by employing people to protect the drain from being broken down by cattle, and, lastly, by the free use of chloride of lime as a deodorising agent.

66

In laying before you the foregoing suggestions, I am aware that they are merely palliative. The proprietor has commenced sinking a pit, as a receptacle for the refuse liquor-in my opinion a measure not calculated to meet the emergency, as I consider the removal of the distillery to be the only thoroughly effectual measure. "I have the honour to be, Sir,

Your most obedient servant,
(Signed)

To the Officer Commanding at Lahore. T. G. SCOT, M.D. Strict attention is paid to the conservancy arrangements of the entire station. The mode in which they are carried out will be best understood by a perusal of the Brigade Orders on the subject, copies of which are annexed. The conservancy of barracks and hospitals is carried on under the supervision of the respective quartermasters.

One paid dust-cart, and one cart with a cask, for the removal of fluids, are allowed for the barracks of one regiment, and one of each for the hospitals of both regiments. At one time two were allowed, but one was withdrawn on account of the great expense to Government. A very short trial with the reduced establishment proved that it was absolutely necessary to entertain an extra cart with a cask, in order to get rid of the foul and waste water from the cook-houses.

Since writing the foregoing detail of sanitary arrangements and improvements proposed, a special committee have sent in a Report, recommending the immediate adoption for European barracks of sanitary arrangements similar to those in use in the Central Jail, Lahore; and I understand that the Executive Engineer has received instructions to do away with the cesspools attached to privies and urinaries, and to alter a privy belonging to each regiment to the dry principle plan as an experiment. I have delayed sending in this Report, in hopes of being able to add that the altering of every privy and urinary was authorised and actually being carried out, as the shutting-up of cesspools and the disuse of water in urinaries cannot now be looked upon as an experiment. We have the satisfaction of knowing, however, that the dry system is now recognised as the only one adapted for efficient conservancy.

SANATORIUM, CITTA VECCHIA, MALTA.

REPORT FOR THE YEAR 1861.

BY SURGEON-MAJOR T. P. MATTHEW.

THE Sanatorium is situated about six and a-half miles from Valetta, and within the fortifications of that part of Citta Vecchia called Notabile. It was opened as an hospital in June 1860.

The establishment consists of a large, irregular building, formerly a palace of the Grand Masters, and is stated to be 640 feet above the sea level (engineers' measurement); in other words, on almost the highest elevation of the island.

The large, crowded, and dirty town of Rabbato is entirely cut off from Notabile by the ancient fortifications of the latter, including a deep and wide ditch, and a carefully preserved glacis. Rabbato is also on a lower level, and only by its outskirts approaches Notabile on the south side. Notabile itself is very sparsely inhabited, being principally made up of the cathedral, several churches and conventual buildings, and houses of the better class, which last are for the most part untenanted.

The general configuration of the surface of the country slopes downwards from Notabile for some distance. On the south and west the land soon again rises, so that the Verdala, his Excellency the Governor's summer residence, about two miles distant, in a direction somewhat to the eastward of south, is

slightly more elevated than the Sanatorium, and the absolute highest point of the island lies to the south-west, about four miles distant. Neither of these points, however, are more than a few feet above the site of Notabile. Towards the north and east the ground falls at once, by a precipitous break in the tertiary limestone rock of which Malta is composed, some fifty or sixty feet, and afterwards descends by gentle slopes towards Valetta to the level of the sea.

Thus situated, and with this general configuration of the surface of the country, it is clear that the general aeration of the site is more favourable than can be usually obtained. Upon three points of the compass, the aspect is perfectly open to the country: on the west and south-west this is the almost bare limestone rock. The country north and east presents clay beds; but they are at such a very much lower level, that they can, I apprehend, in no way influence the sanitary condition of the place, and the general lie of the surface towards Valetta, in which direction the natural drainage tends, is such as effectually to prevent any lodgments of surface waters. The only point, then, whence we might expect deleterious influence is from due south, but Rabbato seems too far removed, and too completely shut off by several large and high conventual buildings, which face the aspect of that town towards Notabile, as well as by the clear and wide space of the glacis and ditch, to have any appreciable influence on the sanitary condition of this hospital, the more so as Rabbato is at a lower level than Notabile, and the wind very rarely indeed sets from the south.

The natural drainage of Rabbato is good, and flows wide to the east and west of Notabile; but I am unable to report upon the state of its artificial drainage-probably it is of a very imperfect nature. The natural drainage fall of Notabile could scarcely be better; but the artificial, or house drainage, is almost nil, and, where it exists, probably it is chiefly into cesspits, as is the custom throughout the island. The very small population, however, of Notabile, and the natural advantages of the spot, must go far to neutralise any evil which might, perhaps, otherwise arise from this source. The drainage of the hospital itself, I believe to be very good. A covered drain is led through an old sally-port passage into and beyond the ditch, some distance down the hill slope, where it terminates in a tank. This is emptied periodically by contract (the contents being considered valuable as manure), and during the summer months I found it expedient to require this service to be performed once a fortnight.

During the summer, at which time the establishinent may be considered to be of more utility than during the cool season of the year, probably no better site for a sanatorium could be found in the island (if indeed so good), and it has the advantage (besides the previous existence of a suitable building in possession of Government), of being about the nearest point to Valetta at which the heights of the Bengemmi hills are reached, also of a good road the whole way, and the precipitous elevation of the site, and the main aspect of the building, prevent in very great measure the evil effects of the surface sunreflection usually so much complained of in Malta. During the winter months, however, I am of opinion that the situation may be almost characterised as bleak, being much exposed to the high winds which are then apt to prevail, and consequently during this period of the year (short, however, in Malta), Í conceive that cases, more especially of lung affections, should be sent here with great caution.

The main aspect of the building is nearly east, and it looks out on to the open country in the direction of Valetta, and forms part of the main wall of the old fortifications, which have a sheer fall at this spot of between 40 and 50 feet.

The building itself is of stone, and mainly arranged round a central quadrangular court, although there are two small subordinate courts. This mode of building, common, nay almost universal along both shores of the Mediterranean, and certainly as old as the time of the Romans, seems to have been adopted with the twofold object of excluding the sun, and at the same time encouraging ventilation.

The lowest story is entirely taken up with stores, kitchens, bath room, ablution room, dead room, &c., &c., and also comprises a large dining hall for convalescent patients, which is, besides, used as a chapel.

A very elaborate description of the building having been forwarded last year, I shall pass over all the offices on the ground floor, simply contenting myself with stating that they afford ample accommodation for the purposes indicated.

The wards in occupation by patients are all on the second or (where such exists) third story. The greater part of them are spacious and lofty, and leave little to be desired in this respect. All the floors are throughout of stone, as is almost always the case in Malta. To meet the objection of exposing a patient's naked feet to the stones on first getting out of bed, each is furnished with a smooth deal plank, which is placed alongside the cot.

The following tabular statement shows the number and appropriation of the several wards, with the estimated clear cubic space per bed, but without calculating space to a greater height than twelve feet from the floor, and without reckoning the embayments of the windows and other recesses and offsets, where such exist. Wards 1 to 10 inclusive, however, are in fact 30 feet high, or thereabouts. Ward 12 is about 15 feet, and the wards situated on the third story, viz. Nos. 13 to 18 inclusive, are 12 feet 2 inches, up to the beams of the

roof.

Total Number of Beds, 86: Average Cubic Space, 1,460 feet.

It usually happens that, where there is more than one door in a ward, the supplemental doors open into other wards; but in every ward, without exception, there is a door opening into the external corridors. This arrangement affords in the summer months the means of very freest ventilation throughout the building, although defective in some respects.

It thus appears that the cubic space allotted is most ample and unusually large, while the means of ventilation during the warm months is also almost as perfect as if the building had been specially designed for an hospital. Many and somewhat important improvements, however, in the original state of the building, were added at the suggestion of the last Inspector-General of Hospitals, before its conversion into a sanatorium; but a few minor improvements in this direction remain to be completed.

The warming of the building (supposing it to be fully occupied during the winter months, which I imagine will rarely be the case) I think should be

* Converted into a Reading-room.

improved. It will be seen on reference to the Table, that only five of the wards are provided with the means of effecting this. By a careful apportionment of patients, however, it is hoped no disadvantage in this regard has hitherto accrued, although it has necessitated to some extent the mixing of various kinds of maladies (more especially eye affections) with others, which, in some instances, the military authorities have thought objectionable, although his Excellency the General Commanding has expressed his full concurrence with and approbation of the proceedings of the medical officers in this respect.

Wards 4, 5, 6, 7, and 8 open on to a cheerful and wide terrace, with a lookout towards Valetta, one of the finest views in Malta. It has been proposed to place a light wooden verandah over this terrace, which will have a double advantage, first in screening the before-named wards (the best in the establishment, accommodating between them thirty-six patients) from the morning sun; and, secondly, it will also allow the terrace to become a sort of open-air dayroom for the summer.

Free access to one of the angle bastions of the fortifications, which comprises a considerable plot of ground, is also open to the patients. In this spot, but in this only, smoking is allowed, under regulations specially sanctioned by his Excellency the Lieutenant-General Commanding.

The water-closets of the establishment are as follows:

1. At one end of the terrace above mentioned, and in the open air, is one which comprises three seats; these it is necessary at present to flush by hand, which is carefully done by the two Maltese labourers attached to the establishment for this and other cleansing purposes. At this spot also are located several urinals. Both these last and the waterclosets, I conceive, are nearer to Ward No. 4 (which opens on to the terrace by galvanized windows in the closest proximity) than should be for the comfort of the patients inhabiting that ward, although I do not think, with an efficiently carried out system of flushing, they can prove injurious to health.

2. Opening out of Wards 8 and 9 there is a small wash-room, and from it open a set of water-closets having five seats, which flush from the tank on the roof of the building.

3. A water-closet with two seats looks on to one of the secondary courts, and flushes from above.

4. And one with one seat is attached to the Ward Master's quarters, which also flushes from above.

These four are all situated on the middle, or main story, of the building. 5. On the upper story there is only one (comprising two seats) which flushes.

6. On the ground floor there are two, comprising three seats, which require to be flushed by hand.

It is thus seen that all the water-closets (except that opening on to the secondary court) are somewhat objectionably placed. The first named cannot be reached without opening one of the doors which lead to the open aspect of the building, of one or other of wards from Nos. 4 to 8. The second can only be arrived at by passing through either Ward 8 or 9. The fourth is reserved for non-commissioned officers and their wives. The fifth can only be reached by passing through Ward No. 13, which occasionally is required as a prison ward, and when thus employed there are no water-closets available on the upper floor. The two on the ground floor are too far removed to be generally available for the patients. The objection against opening ward doors having an outside aspect, at night, during the high winds which frequently prevail here during the winter months, must be personally felt to be fully appreciated. The proceeding is likely to be injurious both to the man seeking an outlet through a ward, and also to any weakly patient occupying a bed in the ward. I conceive that suitable additional accommodation might be easily provided within the shelter of the walls of the courts, which could be reached without the necessity of passing through a ward.

All the latrines have been kept daily flushed and cleansed, and quicklime applied.

Off Ward No. 2 there is a small room told off as an orderlies' room, with two beds, which, on exigency, might be made available for patients. This might

be the more easily effected, as we have seldom had our full complement of orderlies attending on the sick (at the regulation rate of one to ten), on the plea that the Army Hospital Corps has been short handed; and, as many of the patients were convalescent, a large number of orderlies was not considered necessary, and could not be allowed. I am of opinion that the orderlies should sleep in the ward, whenever a sufficient number are not allowed to permit an arrangement being made whereby every ward shall at all times have an orderly in or about it, in case his services should be suddenly wanted by one of the sick.

The Water Supply is obtained from a large tank which occupies the entire of the main central quadrangular court, the water being collected from the roof of the building. The greatest care is exercised to keep the roofs clean, and patients are not allowed access to them. The quality of the water is consequently good, and no filtration or other process is necessary to fit it for use. In case of an additional supply being needed, a communication exists with one of the sources of the main aqueduct which supplies Valetta with water, from which an almost illimitable supply is obtainable by means of a force-pump, and from this source a large iron tank on the roof of the building (from which the various water-closets are flushed) is filled.

Food. The supplies furnished by the purveyor's contractor have generally been of good quality, and not open to serious objection. The bread, however, which I conceive in an hospital should be of first-rate quality, has sometimes been very indifferent, being ill-baked, and apparently made from second or third rate flour, leavened, and not yeast made, as I have been given to understand the contract provides it should be. After a troublesome correspondence, entailing a reference to the General Commanding, this has in a measure been rectified. Potatoes could not be supplied during nearly the whole of December, and were only issued some four or five times during that month, on account of the old crop having become so much deteriorated as to render them unfit for issue, and the new crop not being sufficiently advanced to be available. During the above-named period bread was issued as a substitute. How far, however, it may be advisable to limit the patients to potatoes solely as vegetable food, I think questionable, seeing that the island affords abundance of cauliflower, cabbages, pumpkins, and many other vegetables, at very low prices. I think that a modicum of the cruciferous vegetables, at all events, might with great advantage be occasionally added to the food of the convalescent, not only in this, but also in the regimental hospital. Indeed, in some instances I have felt myself fully justified in ordering lemons, on account of what has appeared to me to be a scorbutic tendency on the part of patients admitted under

treatment.

Cooking. This has been efficiently, and, on the whole, well performed; but the cooking of small delicacies for patients very ill has been, and I suppose always will be in a large hospital, indifferently performed. If the female nurses are ever to become an established institution of the service, it seems to me that this hospital is one where the superintendance of a suitable female nurse is specially likely to prove beneficial, especially in the particular just adverted to.

Clothing. This has been the regulated hospital clothing for the Command— suitable and convenient enough. The supply of clean clothes, wanted on an emergency, has sometimes been scanty, owing, I believe, mainly to a delay in transmitting the washed clothes from Valetta. This, however, has been represented, and I hope rectified for the future.

Bedding. The supply has been good and ample. The bedsteads, however, which have been in use have not been regulation hospital bedsteads, but cots, with iron-barred bottoms, on which the mattress rested. This, in cases of patients whose diseases have presented profuse diaphoresis, has had a twofold evil resultthe under surface of the mattress gets saturated with moisture, if it is turned, the patient very properly complains that the new surface is damp, or even wet; if it be left unturned, the iron bars in a very short time destroy the ticking, and a re-making of the mattress and a new ticking become necessary; and unless a sufficient number of beds are disposable to allow of one patient occupying (in such cases) two beds, shifting from one to the other, the very greatest care cannot prevent, in frequent instances, one or other of these results.