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A Historical Review Of The Toilet And Its Contribution To International Sanitation Efforts

November 19 is International Toilet Day. That may sound funny, but it is a serious event. It is a day to contemplate what we have and others don’t. As we sit in privacy on our comfortable flush toilets today, it is hard to imagine that a scant two hundred years ago sewage disposal meant emptying chamber pots into the nearest convenient place, which was often the street.

If you were out for a walk in Britain in the 18th century and heard the cry “gardy-loo,” you had better scamper across the street because the contents of a chamber pot were set to be hurled your way from a window. The expression derives from the French “regardez l’eau” and was commonly heard as chambermaids carried out their duties. Some even suggest that the custom of a gentleman walking on the outside when accompanying a lady can be traced to the desire to protect the fair sex from the trajectory of the chamber pot’s contents.

What may be even harder to imagine than the sidestepping of flying fecal matter is that roughly a third of the world’s population today cannot easily sidestep the problems associated with exposure to untreated sewage because of a lack of access to a toilet. As a consequence, diarrheal disease is rampant, killing more children than AIDS, malaria and measles combined. In developing countries a child dies every twenty seconds as a result of poor hygiene. Mahatma Gandhi recognized the problem when he proclaimed in 1925 that “sanitation is more important than independence.”

The invention of the flush toilet and the introduction of plumbing for sewage disposal mark two of the most significant advances in history. Let’s get one of the toilet myths out of the way right away. Contrary to numerous popular accounts, Thomas Crapper did not invent the flush toilet! It is easy to see how connecting his name with the invention would make for a compelling tale, but what we actually have here is a prime example of the classic journalistic foible, “a story that is too good to check.”

Almost all accounts of the Crapper saga claim that a 1969 book by Wallace Reyburn, cleverly titled “Flushed with Pride-The Story of Thomas Crapper” establishes Crapper as the inventor of the flush toilet. Reyburn actually says no such thing. The book is an entertaining celebration of the life and times of Crapper, the man who “revolutionized the nations’ water closets.” Indeed, that he did do. But flush toilets were around long before Thomas Crapper ever got into the game in the 19th century.

The first flush toilet appeared as early as 1700 B.C. The Palace of Knossos on the island of Crete, built around that time featured a toilet with an overhanging cistern that dispensed water when a plug was removed. Curiously it would take another three thousand years until the next step in flushing technology was taken by Sir John Harrington, godson of Queen Elizabeth I. In 1596 Harrington installed a “water closet” in the Royal Palace that featured a pipe fitted with a valve connected to a raised water tank. Opening the valve released the water that would carry waste into a cesspool. Apparently the Queen was not overly pleased with the invention because odours from the cesspool wafted up into the Royal powder room. It would take another couple of centuries before this problem was addressed.

The first patent for a flushing toilet designed to keep sewer gases from seeping back was issued to Alexander Cummings in 1775. Cummings designed a system that allowed some water to remain in the bowl after each flush, preventing the backflow of odours. Joseph Bramah attempted to improve upon this system with a sophisticated valve that was supposed to seal the waste pipe after each flush. While it didn’t work perfectly, Bramah’s toilet was introduced at just the right time because London was beginning to install sewage systems. Some 6000 Bramah toilets soon dotted the city’s landscape. And then about a hundred years later, along came Thomas Crapper.

In 1861 the Thomas Crapper plumbing company opened for business in London. The time was ripe for the sale of plumbing supplies because the need for proper sanitation was being firmly established. A public report issued in the city of Leeds claimed a significantly higher death rate among children who lived in “dirty” streets where sewage flowed openly. And in 1854 physician John Snow had pinpointed the homes in London where someone had contracted cholera during an epidemic and traced the problem to water contaminated with sewage being dispensed from a pump in Broad Street. The need to flush away problems associated with sewage was becoming clear.

There is no question that Crapper made significant improvements in toilet technology. He invented a pull-chain system for flushing, and an air tight seal between the toilet and the floor. Crapper was also responsible for installing plumbing at Westminster Abbey where to this day visitors can view the manhole covers clearly displaying the name “Thomas Crapper Co.” What he was not responsible for was the introduction of the word “crap” into our vocabulary. That term meaning “refuse” predates Crapper by several centuries.

It is virtually impossible to attribute the numerous improvements in toilet technology since Crapper’s time to individuals. There are patents galore for eliminating overflow, reducing water usage, curbing noise, improving waste removal from the side of the bowl, devices to alert night time users if the seat is up and gimmicks to encourage men to aim properly. And the future may belong to toilets equipped with biosensors that automatically monitor urine and feces for health indicators such as sugar and blood. But for now, just think of the amazing technology that allows for the removal of the roughly 200 grams of poo we deposit per person per day. That’s a stunning 600,000 kilos in a city of three million!

So on November 19, as we get comfy on our high tech toilets, ready to flush away the remnants of a scrumptious meal, a roll of soft toilet paper and fragrant soap by our side, let’s give a thought to how we can help those unlucky enough to have been born in a place where “gardy-loo” still rings true.

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Joe Schwarcz, Ph.D., is the Director of McGill University’s Office for Science and Society and teaches a variety of courses in McGill’s Chemistry Department and in the Faculty of Medicine with emphasis on health issues, including aspects of “Alternative Medicine”.  He is well known for his informative and entertaining public lectures on topics ranging from the chemistry of love to the science of aging.  Using stage magic to make scientific points is one of his specialties.


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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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