better. It is especially desirable to avoid the necessity for long
horizontal waste-pipes from stationary waste-bowls and from bath-tubs.
5. Bell traps, D traps, bottle traps, and mechanical traps are
objectionable. The S trap is, upon the whole, the best, but it should
be provided with a vent-pipe to prevent siphonage.
6. The best kind of water-closet for general use is probably some form
of what are known as the wash-out closets. They are made in one piece
of earthenware, have no machinery inside them, have a quantity of
water in the basin into which the excreta drop, and do not require a
separate trap beneath them. Each closet must, however, be carefully
tested by itself: a very small warp or twist produced in the baking
may so interfere with the siphonage as to make it practically
worthless, and the basin cannot be altered or repaired. For use in
public places some of the hopper closets are very satisfactory, the
best which I have examined being the Rhoads Hopper and the Hellyer
Hoppers. Where there are no {192} children, and it is certain that the
fixtures will be used with reasonable care, valve closets may be used.
No form of pan closet can be considered as satisfactory, nor have I
found any form of plunger closet that I would specially recommend.
7. Water-closets should always be flushed from a special tank provided
for the purpose, and never direct from the main system of water-pipes.
The flush must be large and rapid, and this requires a large
supply-pipe, and for many forms of closets a flushing rim. Whatever be
the form of closet, it should not be encased in a wooden box or
closet, as is usually done, but it should stand freely exposed to
light and air. Sanitarians commonly advise that water-closets should
be located in outer walls and have an open window for ventilation.
Such a position is usually impossible, and is not specially desirable
in our climate. The open window acts as an inlet quite as often as it
does as an outlet, and the air of the closet is thus swept into the
house. The room should be ventilated in such a way that the tendency
of the air at the door shall always be from the house into it. This is
to be effected by a shaft passing through the room up and through the
roof; and it is well to have this shaft take its air-supply from just
behind the closet or from beneath the seat. It is best made of
galvanized iron, and at a convenient point should be expanded into a
lantern and have a gas-jet placed in it. The air-supply for the closet
is to be taken at the bottom of the door or through a transom or
louvres. Ventilating pipes from a water-closet should never be run
into a brick flue. While it is not so important as many writers seem
to think that a water-closet should be placed on an outer wall, it is
very important that it should be as light as possible, and the placing
it in a dark corner in the basement or under the stairs is very
objectionable.
8. No overflow-pipe from any cistern or tank, except the one used for
flushing water-closets, should be connected with the soil-pipe or
sewer. Trapping such an overflow-pipe does not prevent the danger. The
same rule applies to waste-pipes from refrigerators and to the
waste-pipes from the safes which are commonly placed beneath fixtures.
9. Grease-traps placed inside a house--for instance, beneath the
kitchen sink--are of very doubtful expediency, and if they cannot be
placed outside, they had better not be used at all.
In an unsewered city one of the first things to be considered in a
sanitary inspection is the manner in which the sewage of the premises
is disposed of. The question is, however, by no means superfluous in
many sewered cities, for cesspools and vaults are to be found in most
of them, and not only in yards, but beneath houses, and houses of the
better class. A privy-vault or cesspool beneath a dwelling or near its
cellar walls is always to be considered as very dangerous, for it is
practically impossible to prevent the passage of gases from it into
the interior of the house. A cesspit is a dangerous thing anywhere,
even in the country; but in a city it is so dangerous that its
existence should not be permitted.
If the water-supply of a house is derived from a well, and there is
reason to suspect that this may have been contaminated from a
neighboring privy-vault, the first test to be applied to the water is
that for the detection of chlorides. If none are present, the water is
not polluted. If they are present, the quantity is to be noted, and a
peck or two of common salt is then to be thrown into the suspected
vault. If repeated {193} examinations of the water show a marked
increase in the amount of chlorides present, it may be inferred that
the contents of the privy pass to the well. The fact that the water of
infected wells and springs is usually much liked and sought for is to
a considerable extent due to the presence of these chlorides. Wanklyn
recommends the addition of 50 grains of common salt per gallon to
drinking water to render it palatable. Popularity of a certain well is
therefore a reason for suspecting its purity.
This subject may be dismissed with one caution. Taking the
dwelling-houses of a city or town as they come, it will be found on
examination that over half of them would be described by a competent
inspector as being in a condition which might produce disease. It is
therefore more than an even chance that in any case of disease some
sanitary defect will be found about the premises quite irrespective of
any direct causal connection with the case. Let the physician
therefore be cautious in deciding as to such causal connection, and
not conclude that because a case of diphtheria or typhoid fever and a
leaky soil-pipe occur in the same house, therefore one is the cause of
the other. Such cases occur in houses whose sewerage is perfect and in
houses which have no sewerage, and it is folly to attribute them
exclusively or mainly to sewer gases.
The same caution applies to investigations into the causes of a sudden
outbreak of disease in a community where a number of cases occur
almost simultaneously or in rapid succession. Such an outbreak may be
due to direct contagion, although sometimes very difficult to trace;
as, for example, an explosion of small-pox in a community largely
unprotected by vaccination, and where, owing to circumstances
connected with the first few cases, a large number of persons have
been exposed to the cause about the same time. The same applies to an
apparently sudden development of yellow fever throughout a city.
Another cause of such outbreaks is a polluted water-supply, as in some
epidemics of diarrhoeal disease or of typhoid fever. If the outbreaks
of these diseases are pretty sharply localized, and depend upon the
fouling of a well or wells, it will usually not be very difficult to
trace this cause. If, however, the town has water-supply by means of
pipes from a single source, while the outbreak of disease is limited
to a part of the town or to a single large building, it will probably
be almost impossible to establish any connection between the disease
and the drinking water. The possibility of the contamination of a part
only of a system of general water-supply by means of the drawing of
foul air into the temporarily empty pipes connected directly with a
water-closet flush should never be forgotten, for such a case has
actually occurred, and the account of its discovery is one of the best
pieces of sanitary detective work with which I am acquainted. If the
outbreak of typhoid fever cannot be traced directly to the
water-supply, the next point to be investigated is the milk, and after
that other possible modes of the conveyance of the contagium.
In cases of obscure disease characterized by fever of no definite
type, disorder of the digestive organs, headache, malaise, etc., and
which seem to be connected with residence in a particular house or in
one room in a house, the possibilities of arsenical poisoning from
wall-paper or hangings should be remembered, for much useless
medication and some real danger will be avoided if this cause be
promptly recognized. The effects {194} produced by arsenical dust are
very various, and simulate sometimes some of the specific fevers,
indigestions, or neuroses in a way that is very puzzling if the true
nature of the case is not suspected. The popular notion is that
arsenic is found only in greens (more especially in bright greens in
wall-papers), whereas in fact it is found not only in dull greens, but
in some browns, grays, and dull reds. The test for its presence in
quantity sufficient to be a cause of disease is an easy one, and is
fully given in any manual of chemistry or toxicology.
VI. OCCUPATION.--While the effects of occupation upon health are no
doubt great, they are in many cases so blended with those of condition
in life, including habitation, food, and intemperance, that it is very
difficult to distinguish them. In attempting to investigate these
effects by means of statistics, it is necessary to beware of a fallacy
which not unfrequently vitiates the conclusions drawn from otherwise
carefully prepared tables intended to show for different occupations
either the relative mortality or the average age at death. This
fallacy lies in the fact that the number of persons engaged in each
business is unknown; that, in this country at least, men often change
their occupations; and that certain trades or professions are chiefly
carried on by persons of certain ages. This last is perhaps best
illustrated by the remark of Dr. Farr, that the fact that the average
age at death of second lieutenants is much less than that of
major-generals proves nothing with regard to the comparative
healthfulness of the two grades. Statistics showing merely the number
of a particular class or grade dying in a given time are absolutely
worthless, unless the number of the same class or trade living at the
same time is also given.
It is also necessary to bear in mind the power of habit and the
effects of natural selection, especially when the effects of an
unhealthy occupation are immediate and marked upon those unfitted for
them. For example, young men, when first employed as scavengers or in
sewage-pumping works, usually suffer from disorders of the digestive
organs. A certain number find it necessary for their health and
comfort to soon leave the business; some acquire protection by passing
through an attack of fever; and by this process of selection a class
of men are obtained who seem to thrive in the midst of filth and
remain unaffected by effluvia which will promptly cause illness in
those unaccustomed to them. When men find that, to use a common
phrase, they "cannot stand" a particular kind of work, they are apt to
give it up and try something else, especially if the effects are
prompt and well marked.
Much attention has been given of late years in England, France, and
Germany to the means of protecting both the workmen and the
neighborhood from the ill effects of dangerous and offensive trades,
and the reports of the medical officer of the Privy Council and of the
Local Government Board are a mine of information on this subject. It
may be truthfully asserted that in those trades in which the special
danger is caused by dust of various kinds, or by gases, or by metallic
poisons--and these three include the greater number of the dangerous
occupations--it is almost always possible to so arrange the work as to
make it comparatively healthful and harmless. Overcrowded and
unventilated workrooms are responsible for much disease, and when to
these is added the risk of metallic poisoning, as is the case with
printers, artificial-flower {195} makers, etc., bad results are almost
sure to follow. It is curious that so comparatively little ill effect
seems to be produced by exposure to great heat, as in stokers,
foundry-men, glass-blowers, etc.; but further information is needed on
this point as to the real facts in the case. In some occupations the
chief evils arise from want of out-door exercise, a subject which will
be considered presently. The want of useful or interesting occupation
sometimes becomes indirectly the cause of disease among the wealthier
classes, and the giving a man or woman something to do is in such
cases the best prescription which can be made. This danger is
especially apt to occur in the case of an active, energetic man who
retires from business, intending to spend the rest of his life in
pleasure and in the enjoyment of the fruits of his industry: the
preventive or remedy is obvious.
VII. FOOD.--The comfort, energy, usefulness, and moral character of a
man depend largely upon his digestion, and this in turn depends
largely on what it has to act upon--viz. food. There are, it is true,
many men who boast that they can digest anything, and who are really
comparatively indifferent as to the kind, or mode of preparation, of
the food set before them, so that the quantity be sufficient; but were
it not that habit and heredity--which is the family habit--combine
with natural selection to adapt men to their food, it is probable that
the frying-pan, the pie, and soda-bread would depopulate large
portions of this country. As it is, there can be no doubt that fried
food swimming in grease, leathery, sodden pie-crust, and heavy bread
tend to make life short and the reverse of merry; and when the effect
of these is combined, as it often is, with those of malaria, damp
soil, and a free use of whiskey, the result is plenty of work for the
doctor and very little to pay him with. This state of things is being
gradually improved, but in all classes of society and in almost all
parts of the country the rule is, that while the raw materials of food
are abundant and of excellent quality, the cooking is bad. This is
due, in part, to an idea that it is to a certain extent discreditable
to a person that he should give much attention to his food, at least
so far as its appearance and taste are concerned, and that a man who
can plan a good dinner must be more or less of a sensualist and a
glutton.
Another popular error is, that a large amount of disease is due to
overeating, and that abstemiousness in diet is either certain to
secure health, or is, at all events, indispensable for this purpose.
Upon this point the reader should consult a capital paper by Dr.
Austin Flint on "Food in its relations to personal and public health,"
which will be found in vol. iii. _Reports American Public Health
Association_, N.Y., 1877. After remarking that many of the popular
errors about food and diet are relics of old and abandoned medical
theories, one of which is embodied in the not uncommon advice that one
should always stop eating before the appetite is fully satisfied, and
that food should only be taken at regular fixed periods, no matter how
hungry one may be, he says: "Physiology, experience, and common sense
are alike opposed to these popular notions relating to food.
Conditions for perfect health are, first, a sufficient appetite;
second, the gratification of normal appetite before the want of food
reaches the abnormal degree expressed by hunger; third, the
satisfaction of appetite by an adequate quantity of food. These
conditions of health are fulfilled by compliance with instructive
provisions for {196} alimentation. But, it will be asked, is appetite
infallible as a guide in dietetics? Following it as a guide, is food
never taken beyond the requirements of health? I answer, It is a
reliable guide under normal circumstances. The inevitable
circumstances of life are often not altogether normal, although
producing no distinct morbid affection. Experience teaches, for
example, that in a state of fatigue or exhaustion (which is not a
normal state) inconvenience may arise from the full gratification of
appetite; that if unusual exertions, mental or physical, are to
follow, a hearty meal may occasion disturbance; and other examples
might be added. Irrespective of abnormal or disturbing influences, if
appetite be not infallible, it is, at all events, more reliable than a
rule based on theoretical ideas, popular notions, or on purely
physiological data. Moreover, it was evidently not intended that the
quantity of food should be accurately adjusted to the needs of the
economy. To do this is impossible, and therefore it is necessary to
elect between the risk of taking either more or less food than is
actually required. Which is to be preferred? Undoubtedly, it is vastly
better to incur the risk of taking too much than that of taking too
little. Nature provides for a redundancy, but there is no provision
against a persistent deficiency. Ex nihilo nihil fit. An ample supply
of alimentary principles is indispensable to nutrition; and inasmuch
as the supply cannot be made to contain precisely the needed amount of
the different alimentary principles, we may say that a superabundance
of food is a requirement for health.
"As in appetite we have a guide in respect of the times of taking food
and the quantity to be taken, so taste is a guide in respect of the
kinds of food required. The discrimination of food with reference to
the wants of the system is the evident purpose of the sense of taste,
and the enjoyment connected with this sense was designed to afford a
security, in addition to appetite, for adequate alimentation.
"Among professional men and those who live sedentary lives the mistake
is not uncommon of paying too much attention to the sensations after a
meal, and deciding therefrom whether certain articles of food are
unhealthy or not. If the man who does this is not already dyspeptic,
he will pretty surely become so. The remedies in this case are
exercise and attracting the attention to something else."
A physician ought to understand something of cooking, and a short
course of practical instruction in what might be dignified as the
culinary laboratory would be of more real value to him than some of
the branches which are now considered indispensable in the medical
curriculum. He should know why oysters are the best thing with which
to begin a dinner, and why a cocktail is one of the worst; how to make
a salad, or a cup of good coffee, or a perfect consommé; and a number
of other things pertaining to gastronomy of which most people are
woefully ignorant.
It is not within the scope of this paper to give details with regard
to the diet of either the sick or the well, but it seems proper to
remark with regard to the feeding of infants, more especially in our
large cities in the summer months, that all the various patent
preparations for infants' food are more or less pernicious, and should
be discountenanced by all medical men. The proper food of an infant is
milk--human milk if it can be had, cow's milk if it cannot. If it be
remembered that an infant suffers {197} from thirst as well as hunger,
and care be taken to give it enough pure cool water to quench this
thirst, it will be found that in most cases it will thrive on pure
cow's milk.
With regard to adulterations of food, the only form of such
adulteration found in this country, which has any special interest
from the sanitary point of view, pertains to milk. This adulteration
is in most cases the dilution of the milk by water, and this is very
common in large cities. The danger from the use of such milk is by no
means confined to infants, and it is probable that a larger proportion
of the typhoid fever, diphtheria, scarlet fever, cholera infantum, and
diarrhoeal diseases in our cities is due either directly or indirectly
to the milk-supply than is now even suspected. The possibility of this
mode of origin should always be borne in mind in investigating the
causation of such affections.
A very large amount of food is now furnished preserved in tin cans,
and it is almost invariably of excellent quality. There is a
possibility of the contamination of such food by the salts of lead or
tin, but such contamination to an extent which is injurious to health
must be so extremely rare as to be hardly worth considering. The
danger from the entrance of parasites, such as trichinæ, etc., in the
food is also extremely small--in fact, is nothing where the food is
properly cooked.
Milk has so often been the cause of disease, and is so universally
used, that it seems worth while to refer to it again. The special
aptitude of milk for absorption of odors has long been known, and of
late years it has been clearly proven in a number of instances that
milk has been the means of conveying the cause of typhoid fever and of
scarlatina. Diphtheria, yellow fever, and intermittent fever have also
been supposed to be conveyed by milk. The variety of nutritive
principles contained in milk, which makes it so valuable as a food,
also gives it the power of sustaining many different sorts of minute
organisms, and it perhaps comes as near being a universal
culture-fluid as anything yet devised for that purpose. The
possibilities of the contamination of milk are so numerous, and
especially in the case of that furnished from small establishments,
that, in the case of outbreaks of typhoid or diarrhoeal diseases in a
town, investigations into causation should always include the milk- as
well as the water-supply. Milk from diseased animals is no doubt often
used without producing bad results, but its effects in conveying to
man the disease known as milk-sickness are well established, and it
has also been known to produce symptoms of the contagious aphthæ, or
foot-and-mouth disease, in man, when derived from an animal affected
with that disease. The only danger in the use of the milk of animals
fed upon sewage-grown grass appears to be in the possible
contamination of the milk, after it is drawn, by particles of dust in
the stable, derived from the food or litter of the animal or from
uncleanliness of the exterior of the udder, etc.
VIII. INTEMPERANCE.--Every one knows that alcoholic drinks are the
cause of a vast amount of disease, crime, and misery in all civilized
countries. No one knows how this is to be prevented, for no one knows
how to make the great mass of the people wise and contented. The
effects produced by excessive use of alcohol are well known to all
physicians, and the remedy is self-evident. I see no use in adding to
the heap of useless rubbish which exists in the shape of the great
mass of existing {198} popular literature on this subject, and
therefore leave the subject to the reader, who is quite sure to know
all that is really important on this subject.
IX. CLOTHING.--The hygiene of clothing is also a subject which may be
treated summarily in this paper. People wear what they can afford,
made according to the prevailing style. Diseases due to insufficient,
excessive, or badly-fitting clothing occur most frequently in women
and children, and the use of such clothing is for the most part due to
poverty or fashion, either of which is beyond the power of the
physician to successfully cope with. Here and there, in individual and
exceptional cases, he may be able to do a little good by advising
against tight lacing, high-heeled shoes, insufficient covering for the
chest or legs, etc., and he will find that a knowledge of the
peculiarities of the various styles of modern under-clothing will
sometimes be very useful. Men are, as a rule, comfortably and sensibly
dressed to suit their business and surroundings, and require no advice
on this subject.
X. EXERCISE.--The ease and completeness with which the functions of an
organ or of an organism are performed depend to a great extent upon
the frequency and regularity with which such functions are exercised.
Hence comes the importance of bodily exercise for the preservation of
health, and every physician meets cases of disease due largely to want
of work.