By ALFRED L. CARROLL, M.D., NEW BRIGHTON, N. Y.
An editorial comment in _The Medical Record_ of April 14th, upon a
paper by Dr. Hamilton, of Philadelphia, may serve as an apology for
some remarks on a subject which ordinarily seems to possess scarcely
more interest for practicing physicians than for "practical" laymen;
both being wont to lay the finger of incredulity against the nose of
scorn when they turn their deafest ears to the voice of the sanitarian.
In the present very unsettled condition of professional opinion as to
the diagnosis of typhoid fever--passably good authorities in India,
on Western mountain peaks, and even nearer home, differing widely
thereanent--I shall not attempt here to discuss its etiology, or to
single out for reprobation any particular one of the several kinds of
bacteria which have been respectively described as its exclusive cause.
Suffice it merely to hint that there may be possible source of error
in statistical arguments touching its relative frequency in town or
country. But, waiving this, I am not aware that "professed sanitarians"
have ascribed to "sewer-gas" alone such pre-eminence over other
vehicles of filth or fungi as the article in question imputes. On the
contrary, I believe that the majority of cases of enteric fever which
have been traced accurately to their origin have been traced to other
and more tangible contaminations of food or water. Nevertheless there
is strong evidence, which has stood the test of much cross examination,
that the so-called "filth diseases" deserve their name in this respect:
that whatever be the specific _tertium quid_ which determines their
occurrence in the individual, filth-poisoning (_i. e._, the imbibition,
through some channel, of the products of organic decomposition) is an
essential factor in their genesis.
The first source of fallacy in the arguments referred to lies in the
misinterpretation of the term "sewer gas," connecting it with sewers in
particular instead of with sewage in general. Thus, I find it stated
that typhoid is "more prevalent in the suburbs and surrounding country
than in the cities subjected to the contamination of sewer gas;" that
diphtheria and scarlatina occur most fatally "in the country, where
sewer gas is wanting;" and that in Philadelphia the extension of the
sewage system into the rural sections has diminished the sickness
from fever. Now the facts on which most sanitarians lay great stress
are, that unsewered rural districts are more exposed to danger from
fermenting filth than cities, that the ineffable atrocities of leaching
cesspools and privy-vaults (those perversions of barbarism to which
the American rustic clings as to his most precious birthright) do
infinitely more to poison air, and soil, and water than all the
blunders of city engineers and plumbers combined; and that, granting
the worst that can be said of some city sewers which shall be nameless,
even a bad sewer is better than none at all--which is merely equivalent
to saying that it is better to carry away as much of one's sewage as
possible than to keep the whole of it on the premises to decompose
under one's nose. And the peril from this fount and origin of evil
is augmented a hundredfold where the mania for "modern improvements"
has invaded rural households. Long before sewers are thought of--even
before the importation of the agonizing pianoforte--the suburban
housewife insists on having a bath-room, including that sum and
substance of vileness, a pan water-closet on the bedchamber floor, and
a kitchen sink and "stationary tubs" down stairs; and these fixtures,
commonly constructed in the cheapest and nastiest manner, are connected
with an unventilated cesspool, serving as so many inlets to insure
the constant pollution of the house atmosphere with the gases of
decomposition. Then, in an uncemented basement a "portable furnace"
is arranged to transport to the upper rooms not only the cellar-air,
but the freely indrawn "ground atmosphere," laden with noxious vapors
from the soil-soakage of cesspools or privies. It is not saying too
much to affirm that for every one channel of filth-poisoning in a
paved and sewered city there are at least three in the average village
settlement, and if the evidence of insanitary conditions be found in
"not more than one house out of five," it is because, unfortunately,
very few physicians in this country have cared to learn how to look
for it--familiarity with the doses of drugs and the results of disease
being regarded in most of our medical schools as vastly more important
than _rerum cognoscere causas_.
I am not sufficiently informed of the morbility statistics of African
cities to appreciate the full weight of reasonings based upon their
alleged comparative salubrity; the occasional scattered returns which
I have seen from a few of them show death-rates ranging from 30 to
over 40 per 1,000. But I am free to admit, on general principles, that
it is less dangerous to let organic matter decompose fully exposed to
atmospheric oxygen than to store it in unventilated receptacles to form
sulphureted and carbureted compounds, or to saturate an undrained soil
with it. It is to be remembered that few, if any, sewage substances
are suspected of pathogenic power while in their fresh solid or liquid
state: the products of their subsequent chemical changes are what we
have to fear; and if these products be liberated _al fresco_ as fast as
they are formed, they are diluted to homoeopathic insignificance by
the surrounding air. Of the two evils, therefore, the Africo-Hibernian
practice of throwing house refuse promiscuously upon the surface is
preferable to the American village method of fostering and festering it
in cumulative concentration.
As regards the allegation that "the young men at work in the fields
were more frequently attacked (by typhoid fever) than the females,
who were generally engaged in domestic duties in or about the house,"
it may be observed: First, that agricultural laborers do not spend
all their time in the fields, but sleep in rooms from which, as a
class, they carefully exclude all ventilation; second, that, for some
unexplained reason, enteric fever seems to have a selective affinity
for robust young males. It is an affair of common observation that,
under apparently precisely similar conditions, fragile women may resist
the infection to which strong men succumb.
Facts, however, are more forcible than words, and I therefore subjoin
a few examples of coincidences which have very much the air of causes
and consequences. I have excluded instances where water-pollution
could be supposed to bear a part, and also those where careful inquiry
did not seem to eliminate the possibility of immediate or mediate
importation of contagium from a pre-existing case. And let me, at the
outset, deprecate the Liebermeisterian criticism that if an adynamic
fever with peculiar temperature curve, abdominal symptoms, etc.,
be not directly traceable to a preceding patient, it is not true
typhoid, but only something otherwise indistinguishable from it; or
that, without evidence of contagion, a pseudo-membranous angina with
grave constitutional depression is not genuine diphtheria, though a
remarkably good imitation of the real article. Grant only that there
are diseases--call them what you will--which closely resemble the
regulation nosological types, that people sometimes die of them, and
that they are intimately associated with the eating, drinking, or
breathing of filth-products, and I shall, for the present, leave the
question of diagnosis to be begged by whosoever cares for it.
I. _Typhoid._--Large country house with numerous "conveniences."
Two "pan closets" on second floor; one in a small windowless
hall-apartment, the other in a bath-room adjoining a bed-chamber;
basin and bath-wastes led into trap of water-closet; leaden soil-pipe
not continued above the line of fixtures, communicating directly with
cesspool, and badly corroded at bends of closet-traps. Servants'
pan-closet in basement with foul and leaky "retainer;" kitchen
and laundry wastes on same horizontal branch, constantly liable
to siphonage. Frequent illnesses of minor grade prevailed in this
household until the whole plumbing system was reconstructed on a proper
plan, since when the inmates have enjoyed excellent health.
II. _Typhoid._--Small house in village street. Under the cellar runs
the ill-covered channel of a former brook, which receives the sewage of
several adjoining tenements. The house-refuse is discharged into this
foul trench through an open untrapped conduit in the basement.
III. _Typhoid._--Cottage of better class. No plumbing fixtures except
kitchen sink, which discharges untrapped into an obstructed and very
foul drain; leaching privy-pit on higher ground than the basement,
which, with the foundation walls, is uncemented, affording ingress to
ground-atmosphere.
IV. _Diphtheria._--Elegant mansion, regarded by owner and "practical
plumber" as a model of sanitary construction. Soil-pipe extended above
roof, but without ventilation at its foot. Materials and workmanship
good. On a lateral branch was a down-stairs water-closet into the
trap of which the kitchen waste discharged, and into the dip of the
running-trap of this horizontal soil-pipe, in the basement, and within
a few feet of the furnace, was inserted a servants' hopper-closet
without any flushing fixture; excremental matter being, of course, thus
retained in the trap a great part of the time, and its decomposition
favored by the admixture of hot water from the kitchen. When the water
from the boiler was set running, the steam arose freely from this
hopper.
V. _Diphtheria._--Handsome country-seat. Plumbing work recently
overhauled and declared perfect by the plumber. Three foul pan closets
and numerous other "conveniences," all leading to unventilated
cesspool. In the bedroom occupied by the patient the "safe-waste" from
a stationary basin was carried into the soil-pipe, constituting a
direct inlet from the cesspool.
VI. _Diphtheria._--Presumably "first class" residence. Kitchen and
laundry wastes carried from basement into privy-vault, which was filled
to above the level of the pipes.
VII. _Typhoid?_ (two irregular cases).--Cottage in good neighborhood.
Bath and basin wastes discharging into trap of foul pan-closet with
"putty-joints." Two inch tin pipe inserted, with leaky slip-joint, into
bend of water closet trap, and carried with several angles to roof; no
other ventilation of soil-pipe, which connects with leaching cesspool.
Cellar riddled with rat-burrows (indicating probable connection with
some old drain), and airbox of furnace made of loosely jointed boards,
so as to convey the cellar air to upper part of house.
VIII. _Typhoid?_ (continued fever)--Cottage on high ground. Offensive
pan-closet on bedroom floor. Soil-pipe relieved by angular galvanized
vent. But carried without other ventilation or trapping to cesspool on
lower ground. Kitchen and laundry wastes untrapped and led to a row of
buried barrels which were filled with a most malodorous mess, the water
being allowed to soak into the soil as best it might.
IX. _Diphtheria._--House without plumbing fixtures. Cellar loosely
paved with bricks, and saturated with soakage from several privy-vaults
on much higher ground and close in the rear; the fæcal-smelling
semi-liquid filth actually oozing up between the bricks when they were
stepped upon.
X. _Diphtheria._--Cottage alleged by the owner, and innocently believed
by the tenant, to be "one of the best plumbed houses in the county."
Pan closet in a decadent and offensive condition, with untrapped bath
waste and insufficiently trapped basin waste led into its seal. Short
vent from bend of closet trap to outside of wall, with orifice closed
during winter "to prevent water pipes from freezing;" soil-pipe thus
without ventilation at top or bottom. Butler's pantry sink connected
by tin pipe with earthenware drain, which was badly laid and composed
of different sized pipes. Some distance beyond the junction of the
soil pipe and wastes, this drain was tapped by a "ventilating" pipe
carried into a chimney flue, with an occasional down-draught. Kitchen
waste opening directly into an unventilated cesspool. All lead pipes of
poorest quality.
XI. _Diphtheria._--Country farm-house. No plumbing. Uncemented cellar;
living room in wing built directly upon the earth. Overflowing
privy-vault within twenty feet and on higher ground, the soakage and
surface washing from which had permeated the soil around and under the
building.
XII. _Diphtheria._--Large and handsome house. Sanitary arrangements
satisfactory to plumber. Pan-closet with insufficient flush. Two-inch
tin vent from bend of soil-pipe carried with various angles into
cold chimney flue. Running under the whole length of the basement
was an eight inch earthenware drain receiving the soil-pipe and the
wastes from different fixtures; its large caliber and slight grade
precluded proper flushing, and it was thickly coated with refuse and
chilled grease. Into its upper end was inserted the overflow from a
tightly covered cistern, so that the only ventilation of the entire
house-drainage system was through the rain-water leader, close to a
"mansard" bedroom window.
XIII. _Typhoid?_--Two small houses of the poorer class, situated on a
road at the foot of a steep declivity. No plumbing. Two privy-vaults, a
pig-pen, and an indescribably filthy cow stable just behind and above
them, from which the washings were traceable into their cellars.
I could extend the list by scores of illustrations of rural
house-defects: soil-pipes disjointed from their outlet drains and
discharging their sewage under basement floors; cesspools "backing-up"
into kitchen sinks or laundry tubs, or pouring a reflux tide through
"overflow" pipes into drinking water cisterns; ingenious devices of
every sort to deprive the gases from pent-up filth of any escape, save
into the dwelling. And these among the "wealthier residents," whose
surroundings are commonly supposed to be above suspicion. As regards
the unplumbed poor, their chances of inhaling filth-polluted air or
imbibing filth contaminated water are often enhanced by inadequate
cubic space and faulty construction within doors, and ignorant neglect
of the very rudiments of hygiene in the environment; their cellars
and wells being sunk in soil saturated with putrescent refuse. In
the intermediate agricultural or mechanic class similar conditions
frequently exist, their potency for evil depending chiefly upon the
porous or retentive character of the soil; precautions to exclude the
ground atmosphere from cellars or basements are seldom found; cesspools
and privy-vaults are close at hand; and it is a common thing for a
couple of adults and two or three children to sleep in a "stuffy"
unventilated room with not more than 1,000 or 1,500 cubic feet among
them.
From a sanitary point of view it matters little whether the gases from
decomposing sewage escape from sodden soil or from a foul sewer; their
nature is alike in either case, and the aggregate dose may be even
larger in the former instance. But when, and why, and how, they, or any
of them, exert their most deleterious influences, are questions which
it is impossible to answer in the present state of our knowledge. It
is an indisputable fact that people may for a long while be exposed to
them without pronounced manifestations of "filth disease"--although
such people, in my experience, are seldom thoroughly well, even if not
specifically ill. But sooner or later an apparent qualitative change
may take place, and an acute zymosis declare itself. I have elsewhere
suggested the part that may be borne in this complicated problem by a
"personal factor," or temporarily altered individual susceptibility;[7]
but it seems necessary also to assume an alteration in the external
conditions; and such alteration is explained by many etiologists on
the hypothesis of the importation or evolution of specific pathogenic
micro-organisms. That certain varieties of schizophytes are associated
with some of the acute infections is beyond doubt; that in a few, such
"microdemes" are the conveyers,[8] if not the causes, of the infection
seems proved; but it must be remembered that in the diseases chiefly
under consideration no characteristic bacteroidal forms have been
defined. In typhoid fever, Klebs describes a bacillus where Letzerich
finds only micrococci; according to Wood and Formad, the micrococcus
of diphtheria is just like that of the ordinary buccal mucus; indeed,
nearly all of the acutest infectious diseases are attributed to these
ubiquitous micrococci, indistinguishable from each other in most
instances, and divided into species solely on the score of their
assumed physiological effects. Admitting all that the most ardent
advocates of the germ theory can claim for it, there are at least three
possible ways in which filth and fungi may be connected.
1. Taking the view of Naegeli and others as regards the mutability
of the bacteria, it is conceivable that the common "scavenger"
microphytes may acquire pathogenic properties by successive generations
of development amid the products of certain decomposing substances.
In favor of this conception may be cited the seemingly gradual
intensification of "filth poisoning" in numerous instances; sore
throats of a less septic type forerunning outbreaks of diphtheria;
diarrhoeal derangements preceding enteric fever; and, furthermore,
Koch has found both bacillus-spores and micrococci in surface soils,
the latter organisms preponderating where the earth is subjected to
excremental soakage.
2. Or, accepting the specific classification of the schizomycetes,
it may be supposed that some pathogenic germs obtain favorable
intermediate conditions for their development and multiplication in
these products of decomposition; a supposition almost necessary if the
specific-germ theory be applied to enteric or choleraic discharges.
3. Finally, if it be conceded that desiccated spores may retain their
specific vitality indefinitely, and be air-wafted almost unboundedly,
the predisposing action of our filth emanations maybe imagined to be
cumulative, slowly undermining the individual powers of resistance, or
rendering certain cell groups an easier prey to the intruding organisms
in the struggle for existence.
Which of these hypotheses, if either of them, will ultimately prevail
is a question only to be decided by experimental investigations which
are beset by a multitude of difficulties and sources of error.--_Med.
Record_.
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