{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.
One other branch of this subject is worthy of attention. The
cleanliness and freedom from offence of the water-closet or of a
waste-pipe or drain is in proportion to the frequency with which it is
used and to the abundance of the discharge of water through it. A
dozen closets used by a dozen persons will be quite likely all to be
offensive. If the dozen persons all used only one closet--not a pan
closet--the frequency with which its trapping water is removed and the
frequency with which its walls are washed would secure its tolerable
condition, even if not of the best construction. In this case, as in
all others, simplicity should be the controlling principle.
(_b_) Dry conservancy next after water-carriage is the best and safest
system for the removal of human excreta. By dry conservancy is meant
the admixture of dry earth, ashes, or similar material with the
matters to be disinfected and absorbed. Theoretically, the effect of
such admixture is entirely satisfactory; under very careful and
intelligent regulation it is practically so. It has been proved,
however, by much experience that under ordinary circumstances--that
is, where no greater care is given than is ordinarily given to a
water-closet or to a common privy--the dry conservancy system is open
to serious objections, though always an improvement on the cruder
privy-vault. The theory of the effect of a sufficient admixture of
earth or ashes with urine and fecal matter is, that by the {219}
admission of air thus secured to every part of the material there is a
complete oxidation of their organic constituents, similar to, though
slower in its operation than, actual combustion in an active fire. In
isolated houses and in hospitals, factories, and other buildings not
provided with sewerage facilities, there is no question that the
earth-closet or the ash-closet affords the best available means for
disposal, if we except a system, to be described hereafter, for the
distribution of water-carried wastes over or under the surface of
suitable ground.
Incidentally--and this is of special interest to the physician--the
use of dry earth or of dry ashes in the close-stool of the sick
chamber effects not only an immediate and complete deodorization, but
without doubt a complete disinfection as well. A quart of dry earth at
the bottom of the vessel to receive the deposits, and rather more than
a quart with which immediately to cover them, constitutes a means of
relief always available and always efficient.
Where the house is provided only with an old-fashioned out-of-door
privy the greatest relief and the most complete security may be given
at little cost by filling the vault, and placing under the seat a
movable box to receive the mixture of fecal matter and of the
absorbent material, which, if it is desired to avoid the simple
patented appliances made for the purpose, may be kept in a box or
barrel in the apartment and thrown down after each use of the closet
with the hand-scoop. The objections to the common privy are so
obvious, so universal, and so well understood that the practical value
of such a means of relief should be appreciated without argument.