Popular Science Monthly/Volume 63/June 1903/The Field of Municipal Hygiene

by Edwin Oakes Jordan

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THE FIELD OF MUNICIPAL HYGIENE.

By Professor EDWIN O. JORDAN,

UNIVERSITY OF CHICAGO.

THE modern disposition to revel in the general situation is met by those persons who are disinclined to take a consistently optimistic view of life with several sobering reflections. In regard to that conspicuous phenomenon of modern life, for example, the growth of large cities, attention has frequently been directed to the evil possibilities for the future of the race that are enwombed in city growth. Steady deterioration of mind and body, a tendency to movements of social unrest and disorder, increasingly unsanitary conditions of life are some of the elements in a widely-held belief that the massing or 'herding' of human beings in centers of population is a deplorable and distressing accompaniment of civilization.

It is often forgotten, however, both by those who lament the existence of great cities and by those who count with pride their tale of corn and oil and wine that in the last analysis not only the hope and salvation of the large city, but its growth and very existence depend upon the proper application of methods of municipal hygiene. We need hardly be reminded that many of the factors that make for a concentration of population have been operative in the past with quite as much force as they are to-day. The steady drift from the farm to the town is by no means a modern movement. In the course of the last three hundred years social philosophers have often had occasion to deplore the existence of a migration cityward and the so-called depopulation of the rural districts. In some countries, as in France in the eighteenth century, the chief danger in this movement was thought to lie in its evil effect upon the rural districts, and restrictive measures were advocated for the purpose of keeping a sufficient supply of labor upon the farms. In England the same current toward the cities was noticed, but different forebodings were aroused; the apprehension was expressed that the cities themselves might become unwieldy. Both Elizabeth and James I. issued proclamations forbidding migration into London because of the portentous dimensions that metropolis was thought to be assuming. In spite of the influx of immigrants, however, the actual growth of the large cities was slow if judged by modern standards. In the case of London there is reason to believe that the natural migration into the city was relatively greater two hundred and fifty years ago than it is to-day, and yet at that time its rate of increase was sluggish compared with the swift expansion of its population in the nineteenth century.

There can be no doubt that one reason why cities did not grow so rapidly in the seventeenth and eighteenth centuries as in the nineteenth is the excessively high death rate that prevailed during the earlier period. The flood of immigration, mighty as it was, did little more than make good the places of those citizens who fell victims to grievous sanitary conditions. From the facts that can be obtained it seems to have been universally true that almost up to the beginning of the nineteenth century the death rate of large cities exceeded the birth rate. This was not because the birth rate was abnormally low, but because the death rate was abnormally high. In the medieval city both birth rate and death rate were far higher than at present. Infant mortality must have mounted to a gruesome height. The uncleanliness and overcrowding of city dwellers, now largely relegated to the slums of our great cities, was the normal state of nearly all classes of society in the London and Paris of Louis and Elizabeth. Mr. Frederick Harrison has condensed into his own vigorous language the annals of many of the historians of the middle ages.

The old Greek and Roman religion of external cleanness was turned into a sin. The outward and visible sign of sanctity now was to be unclean. No one was clean, but the devout Christian was imutterably foul. The tone of the Middle Ages in the matter of dirt was a form of mental disease. Cooped up in castles and walled cities, with narrow courts and sunless alleys, they would pass day and night in the same clothes, within the same airless, gloomy, windowless, and pestiferous chambers; they would go to bed without night clothes, and sleep under uncleansed sheepskins and frieze rugs; they would wear the same leather, fur and woolen garments for a lifetime, and even for successive generations; they ate their meals without forks, and covered up the orts with rushes; they flung their refuse out of the window into the street or piled it up in the back-yard; the streets were narrow, unpaved, crooked lanes through which, under the very palace turrets, men and beasts tramped knee-deep in noisome mire. This was at intervals varied with fetid rivulets and open cesspools; every church was crammed with rotting corpses and surrounded with graveyards, sodden with cadaveric liquids, and strewn with disinterred bones. Round these charnel houses and pestiferous churches were piled old decaying wooden houses, their sole air being these deadly exlialations, and their sole water supply being these polluted streams or wells dug in this reeking soil. Even in the palaces and castles of the rich the same bestial habits prevailed. Prisoners rotted in noisome dungeons under the banqueting hall; corpses were buried under the floor of the private chapel; scores of soldiers and attendants slept in gangs for months together in the same hall or guard-room where they ate and drank, played and fought.

The unsanitary conditions thus relentlessly portrayed must have had the same effect upon the health of all town inhabitants that similar conditions now exert upon the denizens of the 'crowded' and 'poor' wards of our modern cities.

So long as the city death rate exceeded the birth rate, the cities, in spite of the ceaseless thronging in of immigrants, could not grow as they have grown since. The economic equilibrium between town and country probably did not permit of any more considerable transfer of population than actually occurred, and this transfer merely sufficed to keep the city population at a fairly constant level. As soon, however, as the city death rate began to decline and even to fall below the birth rate, the city population increased with leaps and bounds. This change is comparatively modern. London did not show a natural increase, due to excess of births, until the beginning of the nineteenth century, and Berlin did not reach this point until 1810.^[1]

	Excess of Births.		Net	Total
	Number.	Percentage.	Immigration.	Increase.
1711-1815	—31,310	—0.2	1.4	1.2
1816-1837	23,505	0.5	1.3	1.8
1838-1858	55,513	0.7	1.6	2.3
1858-1875	95,460	0.8	3.2	4.0
1875-1895	189,240	1.1	1.6	2.7

 

It must not be forgotten, moreover, that simple excess of birth rate is not a fair measure of the decline that has occurred in the death rate. The birth rate itself has not remained constant, but in the last thirty years has materially diminished in nearly all civilized lands, so that in reality the decline in death rate is far greater than can be indicated by mere change in the absolute or proportional excess of births.

If the large cities have lost some of their former evil repute in the matter of healthfulness, the improvement must plainly be attributed to the development of the art of municipal hygiene. The dangers to health resulting from the massing of human beings within comparatively narrow limits are now fairly well known, but such knowledge has not always been available and is even now not always acted upon. The question of water supply affords a pregnant illustration. That some connection existed between outbreaks of disease and the character of drinking water was seen darkly all through the middle ages, but the groping speculations on the subject only led to the hypothesis, fraught with terrible consequences to an unhappy people, that 'the Jews had poisoned the wells.' It was not until about the middle of the last century (1854) that an explosion of cholera in London among the users of water from the 'Broad Street Pump' established definitely in the minds of physicians the truth that the specific poison of Asiatic cholera could be conveyed by means of infected drinking water. Some years later a similar conviction was reached regarding typhoid fever.

The medieval ignorance concerning the direct infectivity of drinking water and its importance as a factor in the spread of disease told heavily against the cities. In sparsely populated districts the likelihood that any particular well or spring would become infected was comparatively slight, and even if a single well did become accidentally polluted neighboring wells or springs used by other families might still remain entirely wholesome and incapable of spreading disease. The radius of infection was likely to be very circumscribed. In cities, on the other hand, where the persons resorting to a particular well might be very numerous,^[2] the contamination of a single source could lead to disease and death, not merely in one or two families but in scores of families. Again, the greater liability to contamination to which a well in a densely settled region was exposed was an added menace and enhanced the peril to the city dweller from this source. The introduction of general public water supplies lessened to a considerable extent the latter evil and placed the city resident in a more advantageous position. The public water supply of large towns became on the whole purer than the water formerly obtainable by the private citizen, and since the supply was often brought from some distance, it was not liable to increased pollution as a direct consequence of the increase in the density of the city population. But on the other hand, the introduction of the public supply increased the danger from diffusion. Far greater numbers of people were affected. If the public supply became infected with a specific disease germ, the germ was distributed among much wider circles, and the infection became a momentous matter to the whole community. This in turn had the natural result that the attention formerly directed by the more intelligent members of the community to the care of their own private water supplies was now turned towards the public supply, and the problems of expert selection, supervision and control of the public supply began to receive the attention they deserved. There remained in many municipalities, however, so much inertia that this obvious duty was neglected or abandoned to the tender mercies of greedy politicians.

The conditions in many parts of the United States at the present day testify eloquently to the existence of this transition stage. In those sections, however, where it is the rule for proper care to be taken of the public water supplies the city death rate from typhoid fever is low, often lower in fact than in the surrounding country districts. In the year 1900, for instance, the typhoid fever death rate in the thickly populated 'Maritime District' of New York State, comprising chiefly the territory of Greater New York, with a population density of 1,535 per square mile, was only 2.0 per 10,000 inhabitants, while in the sparsely settled 'Adirondacks and Northern' district, with a population per square mile of 26, the reported death rate from typhoid fever was almost twice as great (3.9).

Theoretically, at least, the city ought to possess a decided advantage over the country in the matter of water supply. It ought to be possible for a large city to place its public supply under expert and specialized control, thus averting from the ignorant and careless members of the community the consequences that would otherwise follow their ignorance and neglect. In other words, the quality of a public water supply ought easily to be better than the average water supply that would be obtained by the average citizen for himself under rural conditions. If the real situation is sometimes otherwise it is not because impure water is one of the necessary and inevitable accompaniments of city life, but because the city has failed to avail itself of the superior resources at its disposal.

The matter of water supply is not the only respect in which the city should possess a practical advantage. The opportunities for speedy and efficient treatment of many acute diseases are greater in a large and compact community than in one sparsely settled. Well-equipped hospitals and dispensaries, the most expert surgeons, the best trained nurses are all most likely to be found in the centers of population. Many city families have experienced the increased anxiety and danger that accompany a case of serious illness occurring when the family is away for the summer in a little country town. The careful nursing and the timely and expert treatment which even those in moderate circumstances can command in a large city are quite out of the reach of the majority of rural dwellers.

In addition to the advantages that accrue to the city dweller from opportunities for a particularly efficient treatment of disease in general, there are certain specific instances where early diagnosis and prompt treatment of a particular malady may suffice to turn the scale in favor of the patient. A notable example is presented in the case of diphtheria. All the larger cities and most of the smaller ones have in recent years provided themselves with well-equipped municipal laboratories in which microscopical and cultural examinations are freely made at the request of any physician. By the utilization in this way of the best modern appliances and methods and of experienced and specially qualified service, it is possible in the majority of cases for the physician to discover within twenty-four hours whether his patient is infected with the virulent diphtheria bacillus or is merely suffering from an ordinary and only remotely dangerous sore throat. The importance of an early diagnosis in the case of diphtheria is supreme for the reason that the administration of the diphtheria antitoxin is most likely to prove successful in the early stages of the disease. The antitoxin can not repair any damage that may have been done to the tissues of the body, ]jut can only neutralize and render harmless the diphtheritic poison that is circulating in the blood. If the presence of a true diphtheritic infection is not recognized until late in the course of the disease the injection of the antitoxin may have little influence upon the outcome, since the heart and other organs may have suffered irreparable injury before the nature of the disease becomes understood. It is of the utmost importance, therefore, for the physician to recognize the existence of diphtheria and to be in a position to employ without delay the specific remedy. In this respect the city physician is at a distinct advantage in treating diphtheria as compared with his brother in the country districts, although the latter may be often his equal, perhaps his superior in individual ability. Both as regards the early diagnosis of diphtheria and the speedy procuring of reliable antitoxin the city practitioner occupies a position of vantage. Whether the city physician always avails himself of his superior opportunities is another matter. The opportunities certainly exist, and with the development sure to take place in the efficiency of municipal laboratories, the perfection of telephone and messenger service and the establishment of stations for the delivery of antitoxin, the balance is likely to turn even more in his favor. Individual ability and special training in the use of the microscope will sometimes enable a country physician to obtain the necessary information for himself, but in accordance with the laws of specialization, such tasks in the larger towns will devolve more and more upon the expert who devotes his whole time to the work.

The same tendency is at work in other directions. The scope of municipal laboratory work is evidently broadening with the advance of scientific medicine, and. new fields of activity are continually opening before it. In the diagnosis of malarial fever and typhoid fever and in the early recognition of consumption it is already rendering valuable aid to the busy city practitioner. The actual degree of usefulness of the municipal laboratory to the community is still made the shuttlecock of local political conditions, but this stage can last only so long as the city dweller continues to close his eyes to the part that might ]ye played by the laboratory in securing and safeguarding the public health.

There are at least two particulars in which the city is still at a conspicuous disadvantage as compared with the country. These are, first, the high infant mortality, and second, the greater prevalence of various infectious diseases.

As regards the first of these, it is well known that there is a clearly established relation between infant mortality and city milk supply. The richness of milk in those very substances that render it valuable as a food is a source of danger. Not only children but microbes find milk an exceptionally nutritious food. It is not surprising that milk that is at the start carelessly collected and carelessly handled and then carried a long distance should often swarm with countless microorganisms by the time it is delivered to the consumer. In hot weather the growth of bacteria in milk is especially rapid, and much of the milk that is distributed in cities during the summer season is far advanced in the process of decomposition. The high death rate among bottle-fed infants during the summer months, and the traditional popular dread of the 'second summer' as a critical period in infant development are directly traceable to the use of stale milk. The evil is by no means irremediable. Many enterprising milk dealers have already demonstrated the enormous improvement that can be brought about in the quality of milk by attention to simple details of collection and transportation. A high authority says of the present New York City milk supply: "There is an inexcusable lack of cleanliness in the methods of procuring milk and of care in sufficiently cooling and keeping it during its transportation. Even in the matter of sending milk to the railroad many farmers take twenty-four hours more than is necessary, keeping back one half of their milk in order to save the trouble and expense of making more than one trip each day to the station."^[3]

In addition to the dangers and disadvantages arising from the entrance into milk of the bacteria of decomposition, there is reason to believe that the germs of disease also sometimes find their way into milk. Outbreaks of specific diseases like diphtheria and typhoid fever have been traced to infection of the milk supply, and evidence is accumulating that cases of disease from this source are more numerous than formerly supposed. There is good ground for believing that the indiscriminate use of raw milk is one of the most serious sanitary indiscretions committed by the average city dweller. The practical difficulties in the way of exercising an adequate supervision and control over the milk supply are often over-estimated by city health authorities. A large amount of time and energy is now devoted to the detection of chemical adulteration and of dilution or 'extension' of the milk, but little or nothing is attempted in regard to the vastly more important matter of protecting the general character of the supply. Much good might be accomplished by the systematic official cooperation of the health authorities with the various associations of milk dealers who are in a position to apply effective pressure to slovenly or wilfully careless producers. The milk dealers and producers as a class are rapidly awakening to the importance of scientific method, and will respond readily to any attempt made to bring the results of scientific investigation to bear upon their work. In individual instances that have come to the writer's notice, milk dealers, in their eagerness to do the right thing, are actually committing grave sanitary mistakes, and their customers receive no benefit from the dealers' endeavors, because the dealers themselves are not properly guided. Certainly the municipal authorities in some places are not performing their whole duty in this regard.

The greater general prevalence of infectious diseases among city dwellers as compared with the rural population is a second important respect in which present city conditions are strikingly disadvantageous. The more abundant opportunities for infection that are afforded, indeed made necessary, by the nature of city life and occupation can not be easily avoided, but at least their exact character can be made known and the grosser possibilities in some measure controlled. The enforcement of greater cleanliness in public buildings and conveyances, a better system for the notification and control of cases of infectious disease—a matter in which American municipalities are notoriously lax—provision of adequate hospital facilities for the reception and care of patients suffering from infectious disease are among the measures which would unquestionably reduce the city death rate from the infectious diseases. Above all, a thoroughgoing system of medical inspection of schools should be introduced. Nearly all the infectious diseases are most prevalent and most fatal among children of school age, and it would seem as if this were a highly important field in which the energies of municipal health authorities should be exercised. In some cities, as in Boston and Chicago, school inspection has been introduced with successful results, but lack of funds for the purpose has prevented a general and thorough adoption of the system. It would seem as if no reasonable expenditure should be allowed to stand in the way of this important public health measure. If money is available for safeguarding the public health in any way, it ought to be available for this purpose. If necessary the school year should be shortened to secure the funds needed. The saving to the community of the expense of caring for cases of even the minor and less dangerous infectious diseases should constitute an effective financial argument for the general adoption of school inspection. It is perhaps significant that the growing unwillingness on the part of many of the most intelligent and public-spirited members of the community to send their children to the public schools is based on the great liability of the children to contract infections under existing conditions. The removal of this grave drawback to the public school system would in itself seem an object worth striving after.

If a small fraction of the money now expended under compulsion for over-elaborate and unnecessarily complex systems of plumbing were devoted to measures better calculated to prevent the spread of contagion, the city death rate from infectious diseases would be materially lessened and would not so largely exceed the country death rate from the same causes, as is at present the case. The campaign against infectious disease in cities should not be conducted, with antiquated methods and along lines not countenanced by recent investigation, but should take advantage of the most recent scientific discoveries and above all should be carried on with a full understanding of the nature and degree of success that may reasonably be expected from the methods it is applying.

Municipal hygiene, then, to be worthy of the name should not confine itself to combating only the most dreaded or most dramatic forms of disease, but after a scientific study of the whole problem of city life should enter upon a carefully planned and systematic endeavor to remove or lessen some of the causes of excessive disease. There does not seem to be any sign that the desire of modern man to build himself cities and to live in them is weakening. So far ahead as any one can see, cities will continue to crowd to the edge of the stream of human life in 'a blacker, incessanter line.' Unknown forces will doubtless arise in the future which will ameliorate the conditions of city life in the way that the trolley has already done, but there will always exist certain problems peculiarly urban and created by what some curiously term the artificial conditions of city life. It should be the task of a well-conceived, far-seeing art of municipal hygiene to deal with the sanitary aspect of these problems. It does not by any means follow because some of the conditions of city life at present are distinctly inimical to human welfare that they should always remain so. And it should be recognized, furthermore, that the city possesses, within and because of its own structure, certain hygienic advantages, of which to be sure it does not always avail itself, but which in the long run will count heavily in its favor. There are already indications that these factors are becoming operative. The approximation of the urban to the rural death rate shown by the last census to have occurred in several states is not in all probability to be accounted for by a sudden shifting of the age and sex distribution of the population, but marks a real improvement in the sanitary conditions surrounding city life.

Excess of Urban Over Rural Death Rate.

Registration State.	1890.	1900.
Connecticut	3.9	.1
Massachusetts	2.7	.8
New Hampshire	1.0	1.3
New Jersey	7.9	3.3
New York	9.3	4.0
Rhode Island	1.1	.4
Vermont	3.0	.7

Since it is not true that urban life necessarily and inherently entails a higher death rate than rural life, it would seem time to dismiss the gloomy forebodings sometimes expressed that the cities are destined to become 'the graveyard of the human race,' that an inevitable physical degeneration is bound to attend life in the great centers of population, and that density of population is in itself a deplorable accompaniment of modern industrial development. Rather do the signs point to an increasing consciousness on the part of the city dweller of the hygienic advantages bestowed upon him by his position, to a deliberate and intelligent attempt on his part to master the forces that make for the excessive prevalence of disease in crowded centers, and especially to a growing realization of the necessity for a careful study and appreciation of the hygienic possibilities of his environment.

1. A table is given by Kuczynski which shows the relative shares of immigration and excess of birth rate in producing the growth of Berlin.
2. At least 137 persons were known to have drunk water from the Broad Street pump shortly before the outbreak of cholera in 1854.
3. W. H. Park, Journal of Hygiene, July, 1901.