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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.

Leeches As Medical Devices: A Sordid History

What did the jockey who never lost a race whisper into the horse’s ear? “Roses are red, violets are blue, Horses that lose are made into glue!” OK, so it’s a groaner. But until the advent of polyvinyl acetate (PVA) and other synthetic glues in the twentieth century, the destiny of aging horses was indeed the glue factory. The collagen extracted from their hides, connective tissues and hooves made for an ideal wood adhesive. Our word “collagen” for the group of proteins found in these tissues actually derives from the Greek “kolla” for “glue.”

Not all aging horses were dispatched to the glue factory after their plow-pulling days came to an end. Some farmers found they could squeeze a little more profit out of the animals by assigning them another duty. They would become leech collectors! The elderly horses were driven into swampy waters only to emerge coated with the little bloodsucking worms. It seems the creatures found horses to be a particularly tasty treat! Since for many people suffering from various ailments, the little parasites were just what the doctor ordered, the harvesting of leeches made for a lucrative business.

Leeches have actually been used in medicine since they were first introduced around 1500 BC by the Indian sage Sushruta, one of the founders of the Hindu system of traditional medicine known as “Ayurveda.” That translates from the Sanskrit as “knowledge of life.” Sushruta recommended that leeches be used for skin diseases and for various musculoskeletal pains. Ancient Egyptian doctors extended the indications, treating headaches, ear infections and even hemorrhoids in this peculiar fashion. Galen, the famous Roman physician, used leeches to balance the four “humors,” namely blood, phlegm, black bile and yellow bile. Swollen, red skin, for example, was thought to be due to too much blood in the body and the answer was to have leeches slurp the excess.

Curiously, despite having no evidence for efficacy, bloodletting, either with leeches or by making an incision with a “lancet,” became part of standard medical practice for more than 2500 years! Monks, priests and barbers got into the act along with physicians. In 1799 George Washington had more than half his blood drained in ten hours, certainly hastening his demise.

Many British doctors preferred leeches, especially in areas around the mouth, ears and eyes where lancing was a tricky procedure. They even learned how to encourage a leech to bite by stimulating its appetite with sugar or alcohol. But the creatures were in short supply, and had to be imported by the millions from France, Germany, Poland and Australia where they were often caught in nets using liver as bait. Sometimes poor children earned a little extra money by wading into infested waters to emerge, like the horses, with leeches attached to their legs. A gentle tug or a pass with a flame then relaxed the bloodsucker’s grip before much damage ensued. Good thing, because leeches can be pretty nasty once they latch on. Remember Humphrey Bogart flailing about in African Queen while trying to rid himself of the little vampires?

The lack of leeches caused some physicians to explore recycling techniques. Usually a single leech becomes satiated after filling up on about 15 milliliters of blood and then falls off. But then if it is plunked into salt water, it will disgorge the blood and is soon ready for another round. A German physician even developed a technique to encourage continued sucking by making an incision in the leech’s abdomen allowing for the ingested blood to drain out as fast as it came in. It seems the leech wasn’t much bothered by this affront to its belly and would go on sucking for hours. Amazingly, leeches were sometimes used internally. To treat swollen tonsils, a leech with a silk thread passed through its body would be lowered down the throat and withdrawn when it had finished its meal. Sometimes the creatures were even introduced into the vagina to treat various “female complaints.” The literature is vague about how this was done but one account suggests that the technique required a clever nurse.

While bloodletting as a general treatment for ailments has been drained out of the modern medicine chest, there is still work for leeches. That’s because their saliva is a complex chemical mix of pain killers and anticoagulants. Hirudin, for example, is the protein that keeps the blood flowing steadily after the initial bite is made, and is so effective that the blood will not coagulate for quite some time even after the leech falls off. Indeed, these bloodsucking aquatic worms have received approval from the U.S. Food and Drug Agency as a “medical device.”

Surgeons have been known to use leeches after reattaching ears, eyelids or fingers that have been severed, as well as after skin grafts. This has to do with the fact that arteries are easy to reconnect but veins are not. Eventually new capillaries do form to reconnect veins, but in the meantime the finger or ear fills with blood which then clots and causes problems with circulation. A leech will drain the excess blood at just the right rate and can prevent blood clot formation by injecting hirudin. This is such a potent anticoagulant that it holds hope for dissolving blood clots after a heart attack or stroke. Unfortunately hirudin is too difficult to extract from leeches but can potentially be produced through genetic engineering techniques.

Where do physicians get leeches today? No need for horses. They can order them directly from the French firm Ricarimpex. One would think that after helping to save a finger or an ear the useful little critters would be rewarded. But their destiny is death in a bucket of bleach. Not any better than ending up in a glue factory.

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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.

Looking Ahead: Considering What Medical Breakthroughs We’ll See In The Future

A Little History:
It’s 1958 and Ensign Thomas Eggleston is giving an inservice to US Navy Nurses LT. Frances Hogan, LCDR Magie Ziskovsky, and LCDR Edna Schnips about the Van Der Graaff teletherapy machine. The nurses were participating in the Nuclear Nursing Course at the National Naval Medical Center, Bethesda, MD. This machine was considered a medical breakthrough in its day. It looks antiquated now doesn’t it? I can only imagine what these Navy nurses were thinking while they stood next to this medical wonder.

Things have changed since I became a nurse. There were no CAT Scans or MRI machines when I graduated from school. There were no IV pumps either. We ran our IVs by counting drops that flowed into a drip chamber, and we monitored the hourly flow rate by glancing at a strip of medical tape that we marked off in CCs and ran down the side of each IV bottle. The nursing text books were different back then, too. There was no mention of AIDS and a diagnosis of Read more »

*This blog post was originally published at Nurse Ratched's Place*

Experience In Medicine Has Its Downsides

You have probably read that experience makes for better doctors.

And of course this would be true–in the obvious ways, like with the hand-eye coordination required to do complex procedures, or more importantly, with the judgment of when to do them.

There’s no news here: everyone knows you want a doctor that’s been out of training awhile, but not so long that they have become weary, close-minded or physically diminished. Just the right amount of experience please.

But there’s also potential downsides and struggles that come with experience. Tonight I would like to dwell on three ways in which experience is causing me angst.

But first, as background…

It was the very esteemed physician-turned-authors, Dr. Groopman and his wife, Dr. Hartzland, who wrote this thought-provoking WSJ essay–on how hidden influences may sway our medical decisions–that got me thinking about how I have evolved as a doctor. They were writing from the perspective of the patient. But in the exam room, there are two parties: patient and doctor.

# 1) The sobering view that experience brings: Read more »

*This blog post was originally published at Dr John M*

Advancement In Medicine: Are Physicians Losing Their Clinical Heritage

“There is already plenty of evidence to show that we are in danger of losing our clinical heritage and of pinning too much faith in figures thrown up by machines. Medicine must suffer if this tendency is not checked.”

- Paul Wood, MD   January 1950

These words from Dr. Paul Wood are interesting. Wood was a mid-twentieth century master cardiologist out of the UK.  His story is remarkable if you like those playing strong supporting roles in modern medical history. He’s the guy to the left posing with the cigarette.

I like the quote because it captures the insecurity doctors feel with change. It also supports Read more »

*This blog post was originally published at 33 Charts*

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