Part 37

States and municipalities often demand much more than this; as, for instance, that the medical man shall fill out the whole certificate, including age, nativity, nativity of parents, etc., and that he shall furnish the information to the registrar. In some cases it is provided that any physician having attended a person during his last illness shall furnish the certificate: this would apply to cases where the physician may not have seen the case for weeks before death.

While it is most convenient to have the certificate of cause of death upon the same form which contains the data necessary to identify the individual, the certificate should be distinct from the latter, and the duty of making the return to the registrar should devolve on the householder or undertaker, and not on the physician. On the other hand, it is easy for the physician to be hypercritical in these matters: his certificate is to be considered rather as a statement of opinion than as a statement of facts within his personal knowledge, precisely as he would certify as to his own age and birthplace.

The compulsory notification of infectious diseases to the health authorities is a matter presenting much greater difficulties than that of certificates as to causes of death. The state has no right to require such notification from the physician without giving some quid pro quo, and it is not expedient to make it compulsory, even with payment, except from physicians employed by the state or municipality, to furnish gratuitous medical attendance to the poor. The state has the right to require such information from the parent or householder, and it has also the right to require the physician to notify the parent or householder as soon as he recognizes the existence of such infectious disease. It is extremely desirable that the health authorities of a city should receive promptly, and direct from physicians, notification of the occurrence of such diseases, and there will usually be no difficulty in obtaining this if the health officer has tact and discretion and the city is prepared to do its duty. This duty is not confined to registering the information or placarding the house, nor will it be properly performed by merely removing the sick person to a hospital and disinfecting the premises. If the case occur in a family which can secure its proper isolation, and the attending physician certifies that it is so isolated and makes himself responsible for its management (for which responsibility he should be paid by the patient or his friends), the health officer should not interfere nor do more than furnish a competent person to secure disinfection if required. The employment of a trained nurse known by the health authorities to be competent and reliable would do away with most of the difficulties connected with such cases in the upper and middle classes of society; and such nurses should be registered just as physicians and midwives are.

Where the case cannot be thus isolated and properly cared for, it should be removed to a proper hospital. This presupposes that the city has such a hospital, and if it has not, and is not prepared for such cases, notification {211} is useless. When the city places a house in quarantine so as to interfere with business, it should be for the shortest possible time consistent with securing thorough disinfection of the premises, and the city should bear not only the cost of such disinfection, but the cost of caring for the persons in the house in an isolated place until no further danger is to be apprehended for them. When the city undertakes to pay all expenses for isolation and disinfection of such cases, it has the right to require that all such cases shall be so treated, leaving it to private parties to meet the cost in case they prefer not to use the buildings and apparatus provided by the city for that purpose. And when the city does its duty in this respect, it will be found that physicians and the people will do theirs, with rare exceptions.

When a city becomes very unhealthy the usual policy is to conceal the fact as much as possible, and to attribute the mortality to some other than the real cause. The influence of the mercantile part of the community is in such a case strongly exerted on the daily press and on the health authorities to produce such representations of the condition of things as will tend to allay apprehensions on the part of their customers. The healthfulness of a place is usually estimated from its mortality reports, but the reliability of these is by no means always what it should be. Yellow fever is called typho-malarial or pernicious fever, typhoid is reported as diarrhoea or malarial fever, etc. etc., and great stress is laid upon what is called the sanitary condition of the place, which is declared to be excellent.

Unfortunately, this phrase, "sanitary condition," means different things at different times. When the mortality is low, sanitary condition means the healthfulness of a place; when it is high, it means the cleanliness of a place. To a certain extent physicians are responsible for the truth of the statistical returns, not so much in relation to the number as to the causes of deaths; but none save those who have practised in a city liable to epidemics can realize the enormous pressure which is brought to bear on medical men to induce them to aid in or wink at concealing the true state of the case. Of course, this ostrich-like policy is in the long run an exceedingly unwise one, but neither the average householder nor community can be expected at present to pursue any other, except under pressure.

There are many questions as to the best form of public health organization, and the powers and duties which should be conferred upon it, which can only be properly answered by taking into consideration the circumstances in each case. In a large city the health officers must have great powers if they are to be really efficient. They have to contend with ignorance, custom, and self-interest, and their action must in many cases be prompt and unrestricted if it is to be efficacious. They must sometimes be in conflict with wealthy and powerful corporations, whose interests are opposed to the reforms which they urge, and although their business is to protect the most important interest of the community at large--i.e. its health--against the interests of individuals, yet these last are much more immediately concerned, and are, naturally, so active that they are often, although few in number, able to defeat any attempt to interfere with their occupations.

It not unfrequently happens that a health board may have all the power {212} necessary, so far as the laws are concerned, and yet may be able to accomplish little for want of funds to pay the inspectors and other officials whose services are necessary. For a city, a health officer usually does better work than a board of health: his responsibility is more direct, and he has stronger motives to do good work, than a board. Of course, a poor health officer is less efficient than a good board of health, but the general rule is as above stated. The problems of hygiene require special knowledge, and the man who is to deal with them requires special training. The folly of treating diseases by their names with popular or patent remedies is not greater than that of the attempt to make a healthy house or city by men who are not architects or engineers or physicians, or who have only the information possessed by the average architect or engineer or physician. And, of all professional or educated men, the physician especially should recognize his own ignorance. When he is asked what one should take for dyspepsia or pneumonia his answer is, "Take the advice of a physician;" and so when he is asked how the plumbing of a house should be arranged, how a hospital should be ventilated, how a city should be sewered, how a marsh should be dealt with or a water-supply provided, he should reply, "Get expert advice and supervision, and be prepared to pay the amount necessary to secure it." It is the special duty of the physician to exert his influence to secure properly constituted sanitary authorities for his own locality, his State, and for the nation, and to support these against the hostility which they must inevitably arouse if they are efficient. And he should do this, not blindly and as a partisan, but intelligently and with due consideration of all the important interests involved.

The body of educated physicians in a community forms the tribunal by which the work of sanitary officials is to be judged, and they cannot judge wisely unless they appreciate the difficulties with which health officials have to contend. If a city has an incompetent or dishonest board of health, the medical profession of that city are to a certain extent responsible for it; if a competent, energetic, and faithful sanitary officer is crippled and harassed or forced out of office because he is on the wrong side of politics, or because in the legitimate and proper exercise of his functions he has come in conflict with the interests of powerful and wealthy individuals or corporations, it is the duty of medical men to support him, and to do this actively and promptly. And I take great pleasure in being able to say, as the result of somewhat extended observation, that, as a rule, the physicians of this country do cheerfully and promptly co-operate with the sanitary authorities where such exist, and are the first to try to have them properly organized and given the necessary means and powers to do effective work.

{213}

DRAINAGE AND SEWERAGE IN THEIR HYGIENIC RELATIONS.

BY GEO. E. WARING, JR.

For reasons, sometimes sound and sometimes fanciful, the drainage question often presents itself to the medical practitioner as an annoying if not as a serious one. It is not necessary for the physician to make himself an adept in the art of sanitary drainage, but he can properly meet neither the demands of nervous patients nor the exigencies of sometimes serious situations without having an intelligent general idea concerning it. Not only to prescribe improvement, but frequently to allay ill-grounded apprehension, he should be able to address himself, intelligently and promptly, at least to the few simple problems presented in connection with ordinary houses. I use the expression "ill-grounded apprehension," not because the drainage in and about houses is generally tolerably good, for it is not, but because the race seems to have so inured itself to certain grave defects in plumbing-work that one may reasonably hesitate, and look elsewhere for the occasion of diseases before accusing the imperfect sanitary appliances of an average house.

Anything like a treatise on the technical details of house-drainage would be quite out of place here. There are note-books easily accessible to such physicians as care to make a thorough study of the subject. It does seem worth while, however, to pass in careful review, in a work of this character, the various conditions of interior and exterior drainage upon which a physician is frequently called to pass judgment.

The perfect drainage of a house, like the perfect drainage of a town, implies the immediate and complete removal, to a point well beyond its limits, of all waste matters which are a proper subject of water-carriage; such a thorough ventilation of the channel which these matters have traversed as to reduce to a minimum the production of deleterious gases arising from the decomposition of the film with which they may have soiled the walls of their conduit; and adequate provision for the absolute and permanent exclusion from the atmosphere within the house of the air of the pipe or sewer. This is a brief and simple statement of the fundamental and absolute requirements of all good drainage. It is founded on the one grand object which governs all improvement of this character: the prevention of decomposition of refuse matters anywhere in house or town.

Practically, it is safe to say that these conditions are never complete, and that instances of perfect work are so exceptional as to need no {214} consideration here. We have to assume, substantially in every case that is presented, that we are dealing with defective work, ordinarily with work that is very seriously defective. Most houses have been built by contractors, and the plumbing is perhaps the item of the whole structure that it is considered easiest and safest to scamp or to neglect. Even where the motive of economy has had no controlling influence, the drainage has almost invariably been planned by a plumber who has learned his trade and conceived his ideas in the performance of work which was done at a time when no one realized the serious consequences of its being improperly done. The absence of interior ventilation, leaky joints, ill-arranged connections between the various plumbing appliances and the main outlet from the house, pipes and traps so large that an ordinary current is powerless to keep them clean, defects of form, defects of material, and defects of construction, are met with on every hand. This general statement is of itself sufficient to show how hopeless it is for the average physician to prescribe the manner in which the drainage of a house should be constructed or remodelled.

If we view the question solely with reference to its bearing on the causation of disease, we enter a field where neither the sanitarian nor the physician is ever sure of his footing. The precise relation between bad drainage and ill-health no man knows. Certain diseases are undoubtedly traceable to conditions of air or of drinking-water due to the improper disposal of organic wastes, but the extent and exact bearing of these influences are still greatly a matter of conjecture. It is, however, undoubtedly safe to assume--and the assumption is supported by ample general observation, if not by precisely ascertained facts--that whether we are considering serious diseases or the slighter ailments, every argument leads to the enforcement of the most strenuous requirements of cleanliness. Through all the ages no one has disputed, and no one has improved upon, the simple sanitary formula, "Pure air, pure water, and a pure soil." We may safely wait until the enthusiastic investigators now engaged with the subject shall have adduced the testimony of positive facts, if we will in the mean time adhere strictly to the requirements of Hippocrates' prescription. The physician will surely not go wrong if he treats all obvious defects of drainage as positive evils, and insists upon their complete reformation.

Not to confine ourselves to houses which are provided with the ordinary modern plumbing-works, but to include all collateral branches of the subject, we have to consider the following conditions:

I. THE REMOVAL OF HUMAN EXCREMENT: (a) By water-carriage in houses provided with modern plumbing; (b) By some form of dry conservancy; (c) By the fiendish privy-vault which prevails so generally, save in the larger cities. II. THE REMOVAL OF LIQUID HOUSEHOLD WASTES: (a) By delivery to public sewers; (b) By irrigation disposal; (c) By delivery into cesspools.

Incidentally to the above there must be considered the influences of the ultimate disposal of all household waste, whether by the public sewer or the private house-drain.

{215} I. THE REMOVAL OF HUMAN EXCREMENT.--We are too apt to judge of the power for mischief of any waste matter by its original offensiveness, and the world at large regards the solid and liquid exuviæ of the human body as the most dangerous material with which it has to deal. Doubtless it is so under certain exceptional circumstances. If impregnated with the infective principle of cholera or of typhoid fever, for example, its influence for evil may be widespread and active, but in the absence of such infection these substances offer a less serious problem, and, as their offensiveness causes them to be more carefully avoided, their evil influence is less, and is less widely disseminated, than is that of the comparatively inoffensive wastes of the kitchen-sink. This is a consideration important to be borne in mind. Nothing is more common than the expression of the opinion that the wastes of a population are offensive and dangerous in proportion to the degree to which excrementitious matter is allowed to flow away with its general drainage. The fact is, that the drainage from a house or from a town, if reasonably diluted with water, is very slightly offensive until it has passed through a considerable degree of decomposition. The outflow of a perfectly sewered town, where the whole community uses water-closets, is less offensive than the neglected back-yard drain of an average New England farm-house. The trouble begins with the condition of putridity. Fecal matter and urine are somewhat quicker than the other wastes of the house to enter into putrefaction, but the difference is only one of degree, and the latter rapidly overtakes the former in the foulness of its condition; so that where a house is provided with two cesspools, one for water-closet matter and the other for kitchen waste, it is quite impossible to determine from the character of their contents which is which; therefore examinations of the drainage of a house should by no means be confined to the manner in which its excrementitious matters are disposed of. Setting aside, in this connection, the peculiar liability of these matters to become the seat of specific infections, it is fair to assume that equally complete and cleanly arrangements are needed for all else that flows to waste, as for the discharges of the water-closet. The purpose of these remarks is of course not to belittle the importance of proper care in the disposal of human excreta, but to prevent the giving of an undue importance to this branch of the subject, with too light treatment of the very serious difficulties presented by the others.

(a) Modern conveniences may fairly be said to be the bane of modern society, or at least of such of its members as have the questionable good fortune to be housed within the same four walls with every device that a misguided talent for invention has led the American mechanic to provide for the comfort and convenience of the occupant. Properly regulated, there is no element of modern house-building more conducive to health than such a system of plumbing as brings within reasonable limits the labor of supplying abundant water at every point in the house, and obviates the need for exposure and removes the temptation to neglect and postponement attending the use of out-of-door houses of convenience. The spigot and the water-closet are the two essential sanitary agents which the plumber offers to us. The bath may be replaced by the sponge, the stationary wash-basin may be, and generally should be, replaced by the bowl and pitcher of our fathers, but there is no sufficient {216} substitute for an ample supply of water on each floor of the house and for a cleanly water-closet placed within doors. The evil that the plumber has inflicted upon the race is due very largely to his not having held his hand when he had fairly provided for our reasonable requirements. When he fills our bedrooms with stationary basins, connects our refrigerators with the sewer, provides twenty outlets for water which had better reach the drain through less than half that number, and incidentally underlays all our floors with pipes, every foot of which is a possible source of danger, he turns what ought to be a blessing into what is too often an unmitigated curse.

It will not be easy to convert persons who have become accustomed to the universal diffusion of plumbing-works throughout the house to a belief that their best sanitary interest, and, perhaps hardly less, the best requirements of refinement, point to the abandonment of what is practically superfluous in the way of wash-bowls, bidets, foot-baths, sitz-baths, urinals, etc.; but one who has given careful attention to the subject cannot hesitate to recommend that in a house which is "strictly first class" it would be the part of wisdom to reduce by at least three-fourths the openings which lead to the soil-pipe and drain and sewer, and to concentrate upon the remaining fourth the flushing effect of wastes which are now so widely distributed. Strenuous effort is being made, not only by those who write and talk in the interest of the plumber and manufacturer, but by many who honestly believe that the good the plumber has to give us cannot be given with too free a hand, to prove that so long as they are properly constructed and properly arranged we may use plumbing appliances at every point in the house with the utmost freedom and with a minimum of danger. The minimum of danger, and often more than the minimum, does, however, exist. It exists, perhaps, in a constantly increasing degree with every extension of the work, and it can only be the part of wisdom to insist, so far as advice can have influence, on the reduction of all these appliances to the least requirements of reasonable comfort and economy of labor. My own advice would be, in all cases, to permit the use of no wash-bowl or bath or other vessel at a greater distance than a few feet from a vertical soil-pipe, and not to permit their use in any case in bedrooms or in closets opening only into bedrooms.

At the risk of seeming extravagant, I would say that the stationary wash-bowl as ordinarily used is one of the most uncleanly of modern household appliances. Long experience in the inspection of houses and in the examination of waste- and drain-pipes has led me to the belief that servants, by no means rarely, use these vessels as the most convenient means of voiding and cleansing chamber utensils. Their overflow-pipes are coated with soap and with the exuviæ of the skin to a degree which makes them usually the seat of an offensive decomposition. Their plugs and chains are almost invariably foul, and those devices which provide for closing the outlets by valves or plugs, somewhat removed from the strainers at the bottom of the bowl, bring the water in which the face is washed into an interchanging communication with a considerable length of foul and uncleanable waste-pipe--a communication that is made active by the bubbling of the contained air as the pipe fills with water. The labor of filling pitchers from a spigot on the same {217} floor, and the labor of emptying chamber-slops into a water-closet on the same floor, are not to be considered as compared with the greater cleanliness and the greater sanitary security that such an arrangement ensures. There is no serious objection to the placing of wash-basins and baths in the same apartment with the water-closet, or elsewhere immediately adjoining the soil-pipe; but it certainly cannot be disputed that the extension of the drainage system by horizontal lead pipes to remote points is altogether and wholly to be condemned.

However, the question more immediately at hand is that of the disposal of human excreta by the use of water-closets; and it is the water-closet that first attracts the attention of one who is called upon to examine the sanitary condition of the work. There are several radical defects in water-closets, which are so widespread and which have become so familiar to the world at large as to attract less attention than they deserve. For example, it is a radical defect of a water-closet to be tightly encased in carpentry. Nearly all the water-closets now in use have a somewhat complicated mechanism about their bowls. They consist in part of earthenware and in part of iron, generally with an unstable connection between the two. More often than not they overflow or drip or leak, and whatever may escape from them, whether foul air or foul water, is confined within an unventilated space, but a space which is still not absolutely excluded from the atmosphere of the house. The removal of the "riser" or vertical board under the front of the seat will usually disclose at once a condition that suggests at least the need for thorough ventilation. It also discloses in some cases a complication of machinery and pipes and levers and chains which makes a thorough dusting and cleansing of the space difficult, even were it accessible. There are water-closets which are essentially good in their construction and working, which it is important to protect by a "riser," but this "riser" should never be of close work. It should at least be freely perforated with large holes, or, better still, be made with slats or blinds, so that there may be the freest possible circulation of air under the seat. If there is an entire absence of machinery, so that the whole space may be left open, being well finished with tiles or hard wood or other suitable material, it is better that it should be unenclosed and that the seat should be hung on hinges, so that it may be turned back, exposing the whole space to easy cleansing. It is better too, in all cases, that the ventilation should not even be interfered with by a cover over the seat, the freest possible exposure to the air being of great importance.

A very large majority of the water-closets in use throughout the world are either very imperfectly flushed "hoppers," which are generally foul and which are often defective in their traps, or that worst of all forms, known as the "pan" closet, where a slight depth of water is held in the bowl by a hinged pan closing over its outlet. This pan swings in an iron chamber under the bowl, which is entirely cut off from ventilation, which is generally foul with adhering fecal matter, and which as an abomination has no equal in the whole range of plumbing appliances. The closet of which it forms a part has everything to condemn it, and only its cheapness and its apparent cleanliness, and the habit of the world in its use, to commend it. If flushed, as it usually is, by a valve on the supply-pipe, it is rarely flushed adequately, and its use not seldom leads to an indraft {218} of foul air (or worse) into the main water-supply system of the house. Such closets may be easily inspected as to their condition by shutting off the water-supply, opening the pan, and lowering a candle into the container below. Such an inspection will almost invariably disclose an extremely and dangerously filthy condition. Yet the worst part of the container, that which never receives an adequate flush, is even then concealed from view by the pan being thrown back against it. The nose will here be a good adjunct to the eye, and the odor escaping from this filthy interior chamber will generally afford convincing testimony of the impropriety of allowing such a vessel to remain in use.

It is a rule almost without exception that closets, except perhaps on the first floor of the house, which are flushed by valves connected with the bowls, are to be condemned. However good or however bad the state of a closet thus supplied with water, its condition will always be improved by giving it a copious flush from an elevated cistern delivering never less than two and a half gallons of water at each use, and delivering it through a pipe so large and so direct as to secure a thorough cleansing at every discharge.

It would be out of place here to enter into a detailed description of the various closets which are and which are not to be recommended for use. So far as the physician's inspection is concerned, it is perhaps sufficient to say that wherever an odor, however slight, can be perceived, and wherever a fouling of the interior surfaces of the closets or of the spaces under the seat can be detected by the eye, radical reformation is necessary. The only safety with a water-closet, as with any other vessel connected with the drainage of the house, is to secure an immediate and complete washing away of all foul matter of every kind. Where this result is not attained, it should be insisted upon. This much lies within the province of the medical attendant; the manner in which it shall be secured is not necessarily for him to decide.