FILTH DISEASES IN RURAL DISTRICTS. 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 homœopathic 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; diarrhœal 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.