SANITATION IN ITS BEARING UPON CERTAIN RAILWAY PROBLEMS.*

BY H. M. BRACKEN, M. D., SECRETARY AND EXECUTIVE OFFICER MINNESOTA STATE BOARD OF HEALTH.

A short time ago a sanitarian offered to perform certain sanitary duties for a prominent railway in the Northwest, at the same time stating that he was not seeking financial compensation for services rendered. The officials consulted (laymen) could not understand such a proposition and naturally asked of what advantage such action would be to the company and to the sanitarian. The latter replied that for himself, the opportunity thus offered for the study of sanitary problems connected with railway operations would be sufficient compensation. As for the company, it had nothing to lose and possibly something to gain through such an arrangement, as it could undoubtedly derive some benefit from the investigations and reports. Thereupon the sanitarian was turned over to the chief surgeon of the road. At the conference with this chief surgeon, certain lines, along which sanitary observations might be made to the advantage of both the company and the public, were suggested. To these suggestions the chief surgeon replied somewhat as follows:

"There is no need of special sanitary advice in connection with the railroad work, because:

"First, railway coaches are built along lines laid down. by the Builders' Union and the companies can do nothing tewards improving their construction. (No reference made to their care in this argument.)

"Second, sleeping cars are almost universally of the Pullman type and are modeled along the most approved sanitary lines. The railway companies cannot improve upon these plans.

"Third, depots are built under the same sanitary regulations (local) as those which govern the construction of other houses in villages and cities."

The person who made the above statements is, I believe, an excellent surgeon, but I have never heard him spoken of as a sanitarian. The answers quoted demonstrate sufficiently his opinion regarding the necessity for special sanitary knowledge. They will serve to some extent as the text for this paper.

Let me state that my intentions toward the railway companies in this matter are most kindly. Complaints are constantly coming to me, as a sanitary official, bearing upon railway sanitary problems. I have always found the railway officials in Minnesota ready to remove cause for complaint when their attention was drawn to the matter. I am under the impression that if railway officials are made familiar with railway conditions, which are likely to give rise to complaint, they will prefer correcting these conditions before a complaint is made, thus avoiding the friction which so often accompanies a complaint made by a local board of health, or by a village or city council.

In private life it is better to keep our houses and surroundings in such sanitary condition as not to annoy our neighbors. The same is true, I think, of railways and I have every reason to believe that the officials of such corporations appreciate this fact.

*Read before the ninth annual meeting of the American Academy of Railway Surgeons, held at Kansas City, October 2-3, 1902.

Let us now consider somewhat in order the most common causes of complaint:

Shipping pens: Of these, many complaints have been. made in the past to the sanitary authority of my state (Minnesota), but these complaints have grown less frequent during the past two or three years. The occasions for complaints in the past were due chiefly to one or all of the four following causes:

The danger of infection from communicable diseases of animals.

2. Improper construction of pens, especially as to the flooring.

3.

4.

Too long intervals without cleaning.

The constant use of the pens for feeding purposes by shippers.

5. The noise attendant upon the collecting and loading of stock at these pens.

My own experiences in dealing with these matters has Leen that railway officials have as a rule complied with any reasonable sanitary requirements bearing upon the first three points.

The fourth point is one that local health officers and shippers are often responsible for, rather than the railways. Shipping pens should not be used as constant feeding pens. The railways do not wish them to be used for such purpose; but often they cannot easily prohibit it without offending their customers. It is for the municipal sanitary authorities to regulate such matters. Gencrally the shipper is violating the rules of the railroad men when he uses their shipping pens as feeding pens, for often, if not invariably, the company's regulations state. that cattle, etc., must not be kept in the shipping pens over twenty-four hours.

The fifth point is often a difficult one to correct. It is apt to give cause for complaint in places where the pens have first been located at some unobjectionable point, around or near which buildings have been erected later. It sometimes even happens that a piece of property, lying contiguous to shipping pens and looked upon as undesirable because of its location, is bought at a low figure and thereupon the purchaser, with a wish to enhance its value, immediately sets about to complain that the shipping pens injure his property. If he can secure the support of the local sanitary or municipal authorities, he will undertake to force the railway authorities to remove the shipping pens to some other point, even though the expense of so doing may be considerable. This is in many instances an injustice to the railway. It happens at times that the growth of a place naturally encroaches upon shipping pens. Under such circumstances, it may become necessary to request or even demand the removal of the pens. But then it should not be a difficult matter to bring about the desired change, for the parties concerned should deal with this as a business proposition and should easily reach an amicable settlement.

Next we may consider the railway stations and their appendages. That part of our text which bears upon these points would have it appear that stations are built under the same sanitary regulations (local) which govern the construction of other houses in the village or city.

In making this statement the fact was overlooked that only the larger cities have any supervision over the san

itary problems involved in house construction. In villages and small cities people build very much as their individual fancy may dictate. They may build with well, cess-pool and cistern all under the dwelling house, or under a common shed. Would any thinking individual take this as his model in the construction of railway stations?

The village resident who builds his house without regard to sanitary laws will probably not be molested so long as he does not endanger or annoy his neighbors. In fact, with a small family he may live for a considerable period without creating any marked unsanitary conditions. The conditions at a railway station are not parallel to the foregoing; the station is a place where many and careless people congregate; the home is for the few, and, we will hope, the cleanly. The station may become a public nuisance within a few days after its completion, while the private home constructed along similar unsanitary lines may never have such prominence. I have no doubt that many, if not all of you, have been in very decent looking depots where the conditions were almost, if not quite, unbearable, due, in the winter, to foul odors. from closets or urinals not properly separated from the waiting room; in the summer, to the flies attracted to this public place by these same foul conditions, which are not so noticeable to the waiting public because of the fact that natural ventilation can be carried out at this season of the year which is not practical during the winter.

Two points are open to consideration as pertaining to railway stations:

Proper care.

If a station is built without any regard to sanitary requirements, it will never be a decent place to wait in, even though the care of the place may be of the best. If a station is well built, but poorly cared for, it is an unattractive place. If it is well built and well cared for, much of the annoyance of waiting for trains is removed. In this, as in many other business affairs, it need cost no more to exercise a fair amount of intelligence in the construction and care of railway stations than it will to follow the reverse course.

Sleeping coaches may well receive attention at this point in our paper. The statement that these are almost universally of the Pullman type and are modeled along the most approved sanitary lines is not founded upon facts. I venture to say that there is nothing connected with railway travel which is as much in need of sanitary investigation at the present time as the ordinary sleeping car. I venture to say that as a sanitary problem there has been no improvement in the last twenty years so far as the Pullman sleeping car is concerned. True, there has been a slight improvement in construction, judging from the sanitary standpoint, but this change has been brought about chiefly through the esthetic, rather than sanitary, demands. There has been practically no change in the handling of berths. They are still closed up as quickly as possible after the occupant has risen and are not opened again until occasion demands for the next occupant. No ventilation of beds or bedding, no cleansing of blankets from day to day; and this is strikingly apparent when the

berths are prepared for night occupancy, for at this time. cach berth, as it is opened up, gives off the stale odors. left behind by its last occupant, until the general atmosphere in the car is markedly offensive. If you ask a porter how frequently the berths are aired, he will probably tell you—“at the end of each trip." He may even inform you that the blankets and bedding are taken out of the car and placed under a shed where they can be properly cleaned; that the car is then thoroughly cleaned; that everything is fresh and clean for the next trip. If you ask a sleeping car superintendent as to how the company's cars are cared for, he may give you an elaborate set of rules and regulations. In spite of these employe's words, your own sense of sight and smell will tell you that the porter has been lying, and a little investigation will prove to you that if the sleeping car company had any rules and regulations governing the proper care of cars, these are only meant for the credulous traveling public and are never enforced. If we investigate the toilet closet of the sleeping car, we will not find evidences of marked sanitary improvement. True, the pattern of the seat and Lowl has been changed, but the same stuffy room, the same lack of ventilation, the same foul odors, the same inconvenience at railway stations, are there. If sleeping cars were poorly paying institutions there might be some excuse for these conditions. But they are not. The traveler pays for the privilege of lying in an ill-smelling box an amount sufficient to secure for himself a wellventilated room with fresh bedding in a first-class hotel. The railroad companies pay for the privilege of hauling the sleeping cars and the sleeping car company waters its stock and pays its dividends. And these are what our friend, whom I have already quoted, calls sanitary cars! Unsanitary, say I, even to a greater extent than are the ordinary day coaches. ordinary day coaches. So far as the cars are concerned, there is actually more danger of infection from the furnishings of the sleeping car than of the day coach.

In speaking of sleeping cars, one must not overlook the compartment sleepers. These are a great improvement. in their general construction, over the ordinary sleeper. Sanitary requirements that might easily be met in these coaches are, however, overlooked.

A few words for the "parlor coach." From the sanitary standpoint, this has quite an advantage over its neighbor-the sleeping car. Still there is room for improvement. Too often the toilet closet is not well ventilated; too often it is located at the forward and when it should be at the rear end, or at least in the middle of the car; too often the odors from the closet are annoying to passengers occupying chairs in that section of the car nearest to them.

Of the day coach I shall say little. We all know that its toilet closet is avoided by all respectable people, even to the point of marked personal discomfort; we all know that such coaches have by no means an attractive appearance after a service of a few hours, for passengers are permitted and even encouraged, by the goods hawked through the cars, to cover the floor with the remnants of lunches and fruit, in a way that would never be permitted in a hotel or private residence. If one has a wish to learn how undesirable a day coach may become, speak

ing from a sanitary point of view, he has only to enter one about five o'clock in the morning after it has been in service all night and fairly well filled with passengers.

I shall not take time to speak of the drinking water supplied to cars from questionable sources, for the use of the traveling public, nor shall I discuss the questionable custom of depositing feces along the railway route, to be dried and scattered broadcast as dust, containing too often the infectious element of typhoid fever, tuberculosis, etc. Comparison between travel in this and foreign countries is often made as though we had the advantage in every respect; yet it can truthfully be said that the sanitary conditions at many of the stations in England are far in advance of those found in stations of cities and villages of a comparable size in this country; that with some of the inconveniences of travel in that country there is a restraint upon unsanitary practices which are indulged to the limit in this country. The man who "tips" the guard of a train in England, thus securing the half of a compartment where he may roll himself up in his own rug and sleep in his own clothes on a well-aired seat, has certain sanitary advantages over the American traveler who rests in a sleeper, with bedding that may have been used the previous night by some individual ill with tuberculosis, diphtheria or other equally infectious. disease.

I hope the spirit of this paper will be understood. It is to medical men I am speaking-to medical men who have an interest in railways and their success. It is to you rather than medical men who are interested in railways as travelers only, that I speak. As I intimated at the beginning of my paper, it is better for people to set their own affairs right than to be compelled by outsiders to maintain a respectable decency.

Possibly you may resent the reading of this paper, that has a bearing strictly upon sanitary questions, to a body of men recognized as specialists in surgery. My excuse for so doing comes from the spirit in which a "chief surgeon" received the proposition of a sanitarian. This is the day of specialization in medicine. The surgeon has long been recognized as a specialist. The sanitarian has been closely allied to both physician and surgeon. He should now be recognized as a specialist with an important field of usefulness.

There is a sanitary responsibility resting upon railway companies. Their advisors, to some extent at least, should be medical men who make sanitary problems their life work. The railway surgeon should be the first, not only to recognize this fact, but to urge its recognition upon the railway officials.

If railway surgeons are not willing to place the responsibility of dealing with sanitary problems upon the sanitarians, then they must assume such responsibility themselves. Railway sanitation must keep pace with general sanitation.

DISCUSSION.

Dr. M. Gardner of San Francisco, Cal.: I have listened with a great deal of pleasure to the paper just read, and I agree with the author in every particular. The ventilation of cars generally is imperfect, particularly in the day coaches that have been in use during the night. In coming to this city, I had occasion to go through the

train. There were three chair cars, filled largely by a poor class of people evidently, although some of them looked very respectable. But the air was almost unbearable. The closets were vile; every window and ventilator was closed. I remarked to the conductor, in passing through the train, that I did not envy him in his position, knowing that he had to submit to the air of these cars half a dozen times between Denver and Kansas City.

With regard to the ventilation of Pullman cars, it should be recognized by every railroad surgeon, because it has a bearing upon the spread of contagious diseases. I have no doubt whatever that on our lines the through cars from Chicago have more than once disseminated smallpox, diphtheria and scarlet fever in the city of Oakland. I have known diphtheria spread in the city of Los Angeles from cars occupied by diphtheria patients coming from St. Louis. I believe tuberculosis is sometimes disseminated in this way. I have no doubt that the day will come when railroad companies will have to provide cars especially for that class of people who are now seeking the West for their health.

So far as the means or measures that ought to be adopted to cleanse these cars are concerned, that matter has been canvassed largely by sanitarians, and it is a mooted question which is the best to resort to. We have been using on our lines formaldehyde gas under heavy pressure. It has done a great deal of good. I believe some Chicago firm advocates the use of chloro-naphthol. Personally, I know nothing about it, but I understand. that it is purely a deodorizer.

As to the ventilation of the berths, I look upon it as a specialty, essentially, and still it would be hardly convenient to leave the berths open after people have risen in the morning. People like to have their berths made up, and still, when the porter takes them down in the evening, odors are emitted which we all recognize as characteristic of those cars. The Oakland Board of Health of California has suggested to all railroad companies to sterilize all cars coming in from overland trips, whether day coaches or tourist cars, and I believe with beneficial effect. Smallpox, from off the Union Pacific and other railroads in this neighborhood, has spread in Nevada, Idaho and California, from patients who had smallpox and had occupied these cars. I have no doubt it is one of the prolific sources, particularly in the West, where we haul trains 2,000 or 3,000 miles, of spreading contagious and infectious diseases.

Dr. H. C. Fairbrother of East St. Louis, Ill. I desire to express my thanks for the paper we have just heard, and to express my view that as surgeons, and particularly as railroad surgeons, we believe in railway hygiene. Now, I would wish that every railroad company could have established the office of sanitarian, whose duty it should be to look after, first, the matter of contagious and infectious diseases affecting railroad companies, especially in the South; to have charge of the cleaning and disinfection of cars in which those who are affected with contagious or infectious diseases-smallpox, yellow fever, etc., travel; to have charge of the heating, ventilation, and water supply of all cars; to have oversight in regard to the shipment of all bodies of persons who have

died of infectious or contagious diseases throughout the railroad system.

Dr. R. W. Corwin of Pueblo, Colo.: I have only one comment to make, and it is this: It is easy for us to criticise; it is easy for us to ask questions, but I am only sorry that the essayist has not given us a remedy; that he has not pointed out in what way we shall practically do this work. It is easy enough for us to say, it shall be done, but it is an extremely difficult thing to do, that which we should like to have done economically.

Dr. Bracken (closing): I have but a few words to say. I did not suggest a remedy for two reasons: First, it is a difficult problem, and one cannot offhand suggest a remedy. I have heard many, many papers on car sanitation before medical societies, and there are a great many medical men who are not distinctly interested in railroad work. I have heard many papers that were impracticable, and the only way to get down to this problem is to study it as a body, and not leave it for any one individual to dictate. I dealt with the subject in a general way for the purpose of creating general interest and eliciting a discussion. Of course, these different problems will have to be studied out carefully. The question of car ventilation is one of the most difficult we have to deal with. House ventilation is simple, as compared with car ventilation. I am not yet ready to give a solution of the problem.

I was glad to hear one gentleman refer to the transportation of the dead. Of the different sanitary problems, this one has received more attention within the last eight years than any other one I know of in connection with railroads, and it received it largely from a selfish point of view, but more particularly from a sanitary point of view. The old way of carrying the dead became such an intolerable nuisance that something had to be done. The general baggage associations, the various state and provincial boards of health, the various undertakers' associations, both national and local, took hold of this matter, and a committee was appointed from each of these bodies, and after various conferences these committees drew up. rules governing the transportation of the dead, and those rules have been enforced by law in some states, by regulatrons in other states, and I think there has been a notable improvement in regard to transporting the dead. I hope other problems may be taken up and dealt with somewhat after the manner of this one.

EPISTAXIS.

Solution Adrenalin Chloride has been used to control nasal hemorrhage with great satisfaction.

Gordon King, M. D., professor of diseases of the car, nose and throat in the New Orleans Polyclinic (New Orleans Medical and Surgical Journal, April, 1902), says that a few drops of Adrenalin Chloride Solution will check any capillary bleeding from the mucous membrane, when sprayed into the nasal fossæ or applied by means of a cotton tampon. In his hospital practice it is relied upon to control, temporarily, at least, all forms of nasal hemorrhage. The author's plan is to check the flow of blood and clear the field of vision in the nose by the application of Adrenalin Solution, when the seat of hemorrhage is located and cauterized.

HOSPITAL CONSTRUCTION.*

BY R. W. CORWIN, M. D., OF PUEBLO, COLO., CHIEF SURGEON COLORADO FUEL & IRON COMPANY.

We shall not attempt to give a complete description of the hospital, but call your attention to a few points of interest, and refer to others, leaving most of our time, should the subject prove of interest, for discussion and asking and answering questions.

In way of preface, let it be stated that Minnequa Hospital, of which we are to speak, is a private hospital erected by the Colorado Fuel & Iron Company for its fifteen or sixteen thousand employes; that the company has steel works, coal and iron mines, coke ovens, quarries and railroads-in all forty-nine camps and places of busiThey extend over Colorado, New Mexico and Wyoming, and their extremes are more than one thousand miles apart. To visit all the camps it requires 3,600 miles of travel and seven weeks' time, if one day be spent at each place.

ness.

The plan we have adopted for the hospital admits of expansion without interfering with the general arrange

ment.

EXTERIOR.

Verandas have been omitted because upon them convalescents congregate, often to the annoyance of the patients occupying adjoining rooms, where they make suggestions to the sick and frequently advise the change of physicians, nurses and food, secure for the inmates forbidden eatables and liquids and recall the recollection of friends who were sick and finally became associated with the undertaker.

It was the desire of the management to construct the hospital without stairways or elevators, and to use inclines instead. An embarrassment was at once met when the architect illustrated "to have an incline of easy grade, a long hall or corridor was necessary," which would be objectionable. This was overcome, however, by suggesting that the approach on the outside of the building be made by an incline half the height of the first story, and from the inside to reach either the first floor or the second floor the descent or ascent would be but half a story. This arrangement has proved very satisfactory, but could only be employed in a two-story building. A scheme, however, could easily be devised by which an incline might be used for any number of stories. An incline necessarily occupies more room than stairs or elevators, but it is of infinitely greater service. It is easier for patients and help and gives opportunity for better ventilation, and is far less dangerous in case of fire. An elevator is a fire draft trap and stairways a slow means of exit.

INTERIOR.

Another very important thing is the arrangement of plumbing, which has been placed far enough from the wall to admit of its being easily gotten at from all sides. There is no boxing in-splashboards or metallic wall protectors, where dirt and insects may rest in security-but, on the contrary, everything may be reached by the housemaid and thoroughly cleaned.

*Read before the Academy of Railway Surgeons, Kansas City, Mo., October 2-3, 1902,

The doors are panelless and easily cleaned. No transoms to admit foul air from the hall and create a wide dust-catching sheif, rarely observed.

Window and door trims small and beveled.

All corners rounded and floors made so they may be flooded.

Wainscoting of cement and hall corners protected by

metal.

Showers and rubbing slabs take the place of bathtubs. It is difficult to teach a patient not to bathe his feet first and his face last, and in the same water. With showers and slabs one can never use the same water twice. If the overhead shower be found objectionable to ladies, who do not wish to have their hair wet, the side and foot sprays may be used, or the head protected by a rubber or silk cap.

The housemaid ward closet is furnished with metallic soiled linen receiver, instead of a chute in the wall, and metallic dust receiver, and immovable urine and bed pan metallic rack, all of which may be easily sterilized.

In the diet kitchen there are no cupbords, but all pans and other utensils are hung from hooks where they may be under constant observation, and not kept out of sight in a dark closet.

The icebox, home-made of plain wood and movable zinc inside, which may be scalded as readily as a milk pan, is far superior to a fancy tile, glass, marble or paneled wood icechest, which is impossible to wash and always generates odors.

Each floor has private rooms and wards; the wards have but four beds each, and are supplied with pictures, rugs and curtains. The pictures are hung from hooks made behind the frame so they may be easily removed, dusted and replaced. The rugs are of cotton and washable. The curtains of denim, suspended from rods readily removed, and also washable. We find this form of window fixture far superior to the dust-collecting spring rolling shade, which is never clean.

Shelves, both in the diet kitchen and linen closets, are stacked in the middle of the room, so they may be approached from all sides and cleaned through and through, thus avoiding corners and a back against the wall.

In place of bureaus or chiffoniers a chest of shelves and hooks, of home-made construction, is used, opening on both sides, and made to be cleaned like the linen shelves just mentioned.

The operating building, which is connected with the rest. of the building by a corridor, contains an anesthetizing room, instrument room, instrument-cleaning room, surgeons' disrobing room, surgeons' bathroom, surgeons' preparation room, operating room, sterilizing room and minor operating and dressing room.

Possibly special attention need only be called to the operating room, which is a novel and decided innovation, as it is lined throughout with sheet lead. On the floor lead weighing twelve pounds to the square foot has been used; on the sides and ceiling the lead is six pounds to the square foot. The lead is laid upon the floor, specially prepared to keep it smooth, otherwise the lead would soon become uneven on account of its so readily seeking any indentations or cracks. The sides are nailed to wood backs and soldered. The ceiling is hung by copper and tin strips

soldered to the upper surface and attached to beams; this leaves a continuous and smooth surface in the operatin room. The ceiling is sloping to carry any condensation of moisture to the sides, so that there may be no dripping into the field of operation. The room is sterilized with live steam. The floor drained into an open receiver, which receiver connects with the sewer, but there is no connection between sewer and operating room. Ventilation is obtained by forcing air through moistened screens an exhausting the air from the room by electric fans. Light is admitted through a window facing the north; there are no cross lights or reflected light, which is a very great advantage to the operator. The walls are dark, but this is also a relief to the operator, and there is no objection on account of lack of light. Artificial light is obtained from side lights and extension cords, and not by overhanging chandeliers, which are often covered with dust.

It is far superior to any operating room I have seen. The objection to painted walls is that paint leaves innumerable cracks; tile cannot be joined so that cracks do not form sooner or later. The same objection is raised to glass, and marble and mosaic are porous. Lead overcomes all of these objections; it is not porous, there are no cracks, it can be readily repaired if punctured, and easily cleaned, is noiseless and not slippery-in other words, making simply an ideal room, except from an esthetic standpoint. This, however, is no objection, because the patient is usually oblivious to operating room surroundings, and the physician who places esthetics above asepsis has missed his calling.

DISCUSSION.

Dr. M. Gardner of San Francisco, Cal.: I am very much interested in Dr. Corwin's paper. I would like to ask him what system of ventilation is used?

Dr. Corwin: The indirect in all of the buildings; the direct system in the corridors.

Dr. Gardner: How do you dispose of your foul air? Dr. Corwin: By means of a fan in the roof, which draws the air out from the bottom of the room.

Dr. Gardner: I am very much interested in that part of the paper pertaining to the operating room. I have never seen an operating room furnished in the manner spoken of by the essayist. In our operating rooms the company with which I am connected has not resorted to the plan described. Our operating rooms are laid with Zanesville (Ohio) tiling, octagon in shape. Our walls, from eight feet up to the ceiling, are coated with the paint that comes from Baltimore and used largely by the Johns Hopkins Hospital. We sterilize our operating room after operations with formaldehyde gas under a pressure of twenty pounds to the square inch. It gives us better light and I believe it is equally as sterile as the operating room of Dr. Corwin, which is covered with lead. I would like to see the operating room of which he speaks. We have our operating room separated from the main building by a corridor, and have side rooms, six or seven in all. Our dressing rooms for outdoor patients are not in the main building; they are in a separate department. Take a man with a suppurating arm or foot; the injury may have occurred some time before we get him. Such cases are dressed in the outside rooms in order to save the operating room from being sterilized as often as might be neces