ORIGINAL PAPERS.

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INVALIDS.

BY EDITH PECHEY, M.D.

IT not unfrequently becomes the duty of the physician to advise a patient to seek refuge from the cold dampness, and variable temperature of our English climate, in a land where clearer skies and more genial sunshine prevail during the winter months. But having delivered his opinion on this point, he is at once met by the query, Where ought I to go?' and this is by no means an easy question to answer for those who have no personal acquaintance with the various localities recommended as winter residences for invalids. And it is unhappily by no means an uncommon thing to hear complaints from invalids of having been sent to a place which has done them harm instead of good, and where they have been thoroughly wretched all the time of their stay. For my own part, I should always endeavour to find out, to some extent, the tastes and pursuits of the patient, after running over the different localities likely to suit his state of health. To recommend a winter in Luxor, for instance, to a person used to a London life, and unlikely to take any interest in Egyptian antiquities or architecture, would be very much like condemning him to solitary confinement for a period of four or five months. So that it seems to me it would even be better to choose the second best, rather than the best, if it appeared likely to fit in much more decidedly with the mental requirements of the individual.

Then as to climate. The chief characteristics for which we look are those which contrast most strongly with our own climate, viz.: dryness and equableness of temperature. With regard to these points, my impression of the climate of Egypt, though formed after the experience of one winter only in the country, may perhaps be of some service in enabling a fellow practitioner to form a correct estimate of its true value from a hygienic point of view. I must begin by stating that the past winter has been a most exceptionally severe one in Egypt, and up the Nile valley. All the residents to whom I spoke on the subject assured me that for twenty-five years past they had not experienced so cold a winter, and the unwonted severity of the season at Cairo and Alexandria was commented on in the London papers. We left Cairo on January 3rd, and for the first week or ten days it was certainly very cold without fires, so that we were glad of all available wraps, and it was not till we got above Luxor that the weather corresponded to our warm summer weather in England.

There can be no doubt as to the extreme dryness of the air in Egypt. Although it is not true that it never rains, we had but five or six showery days out of the ninety we spent on the Nile. Two of these were just at starting, in the neighbourhood of Cairo, and one was whilst our boat was detained in the cataracts or rapids, where a thorough Scotch mist prevailed the whole of one day. But when we landed at Alexandria on Christmas-day we were told it had rained incessantly for ten days, and rain is by no means unknown throughout Lower Egypt, although rare above Siout. Above the first cataract we had no rain at all. One soon has practical proofs of the dryness of the climate in a Nile voyage. One's hair gets very dry, one's nails grow very slowly and are

taken in case of surgical emergencies, was in a very short time reduced to a powder. The further one ascends the river the drier does the air become, and as dry heat is more easily borne than moist heat one experiences no discomfort from the increase of temperature as one approaches the tropics; in fact, one thoroughly enjoys there what in Lower Egypt would be found quite oppressive. The air is light and pure, and probably none but those who have tasted desert air can understand the exhilarating effects of the climate in Nubia, where the desert is only separated from the river by a narrow belt of cultivated land, and only a low range of hills breaks the course of the wind which sweeps across the Libyan desert.

With regard to variations of temperature, Egypt is not exempt from occasional sudden and great changes, as marked as those which we so often experience in England. Even during the winter months, or at least in March, the khamsin or sirocco may blow for two or three days, and this may be immediately followed by several days of unusual cold. For instance, on March 2nd-4th we had a very trying khamsin, on March 7th a sandstorm with a cold wind, and on the 10th the wind changed again, the temperature suddenly fell, and we had three or four days as chilly and with as keen and biting a wind as some of our March weather at home. Within four or five days there was a fall from something close upon 100° F. to about 50° F. Such changes are however rare in Egypt. That I have just mentioned is the only one recorded in our log-book during the whole winter. Of much greater importance is the daily variation, that is, the difference between the day and night temperatures; and to my mind the chief and almost only drawback in the dahabeeah voyage for invalids is that this difference is of course very marked in a wooden boat. In Lower Egypt the nights in winter are quite cold; the temperature falls suddenly at sunset for about half-an-hour, when there is a slight rise, followed by another depression just before sunrise, so that one is apt to wake in the morning feeling very chilly. In January, when some hundreds of miles from Cairo, and when the days were quite hot, we still felt the extreme chilliness of the nights, and on some few occasions there was a hoar frost on the deck in the morning. In Nubia, that is above the cataract, this diurnal variation was much less marked, and the nights were only pleasantly cool; but then only a small portion of the traveller's time is spent in Nubia, and the earlier part of the winter is passed in the region of chilly and dewy nights.

Of course in a steamer the distance is more rapidly traversed, and in a fortnight or three weeks one is very near the tropics. But this mode of locomotion, under existing arrangements on the Nile, should certainly never be recommended to invalids. The choice must always lie between the dahabeeah trip and spending the winter in one place. The drawbacks of the life on a dahabeeah are the slight protection afforded from the changes in temperature by the wooden walls of the boat, the necessary smallness of the cabins and saloon, the distance from friends and from medical assistance, and lastly, if the party has not been judiciously chosen, the danger of finding one's self with uncongenial companions. On the other hand, the life is a very enjoyable one; there are few days which may not be spent by the

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greatest invalid on deck, whence a constant variety of scenery presents itself, all the surroundings are novel and interesting, the food and cooking are generally excellent, if a good dragoman has been secured, and one is as much master as in one's own house; the boat may be stopped when and where one pleases, and kindness and affability secure the ready services of a willing and happy household. For cases of overwork nothing could be devised more calculated to restore and strengthen the intellectual powers than the Nile trip, and here no physician need hesitate for a moment. There is perfect rest, no railway bustle or jar, the variety of travelling in fact without the fatigue, with the constant enjoyment of sunshine and fresh air. Phthisical and rheumatic patients, too, will derive immense benefit from the voyage if care is taken to impress upon them most distinctly the imperative necessity of going below deck directly the sun sets, and of remaining pretty late in bed in the morning until the weather gets quite warm. All the way up to Luxor the mornings are very cold till near ten o'clock, and as there is no possibility of getting a fire, the only way of keeping warm is to stay in bed. This ought not to be considered a hardship, as such an arrangement still leaves nearly eight hours to be spent on deck in the sunshine, and with congenial companions the evening may be spent very pleasantly in the saloon. It is a good plan to have dinner at the hour of sunset, and then invalids should not go again on deck.

There are two places to select from for a stationary residence-Cairo and Luxor. In Cairo there is plenty to interest the European in the bazaars, and in watching the novelties of Eastern life; and in the Hotel du Nil one can secure the comforts so

necessary to an invalid. A house, too, ensures greater protection from the rapid radiation at night, and the temperature rarely falls uncomfortably low after a warm day. On the other hand, the winter temperature is of course considerably lower there than in Upper Egypt or Nubia, and there are occasional spells of comparatively cold weather, whilst the rooms are without any appliances for warming. This is the case in almost all Cairo houses, with the exception, I believe, of a few rooms in the New Hotel. Luxor does not seem to me to present advantages over Cairo in the matter of climate sufficient to compensate for the extreme dulness of the life there, and the inferiority of the hotel accommodation to that to be had in Cairo. What is wanted is a really good Sanatorium, with a competent doctor, established above the first cataract, beyond the reach of sudden changes and night chills, in the delicious Nubian air, which the invalid might reach by steamer in about a fortnight from Cairo. At present no such undertaking has been attempted, and of course the charges must necessarily be high to repay the trouble and expense attending such an enterprise; but I feel certain that few, if any, spots on the whole globe would offer such a chance of recovery to phthisical and rheumatic patients, and that a winter spent there would be the means of restoring many a one to health to whom the English climate offers only a few miserable months of life.

STRUCTURAL SANITARY WORK, ITS DESIGN AND EXECUTION.

BY JOHN S. HODGSON, C.E.

THE SANITARY RECORD of May 15th, in again directing public attention to the question of 'Wholesome Houses', puts forward some highly pertinent remarks upon the faulty manner in which private drainage work is almost universally performed. Those who have had opportunities of becoming familiar with the subject will be able to bear testimony to the glaring apathy which characterises local authorities generally in their consideration of such an important branch of sanitation, and will readily agree that a decided change is needed. The appointment of skilled officials to supervise the design and execution of such works, as suggested in the article under consideration, would go far to produce the desired amendment; but it would be idle to disguise the fact that the fulfilment of this essential requirement seems to be as remote as ever. Sanitary legislation, in its present stage, fails to insist upon any standard for executive officials, and the experience now available nearly all goes to show that Local Sanitary Authorities, so far from regarding their work in an enlightened spirit, only too readily avail themselves of this serious omission. Such, at least, is the deduction to be drawn from the absence of engineering officials from all but the larger and more important areas, such as boroughs, a state of things which prejudicially affects not only the efficiency of the private drainage but every other branch of sanitary work in addition. While yielding to no one in my advocacy of correct principles, careful design, and superior workmanship in the execution of private drainage work, I cannot but think that the defects existing in the public sewers of towns and villages, not only in old works, but in the systems now being carried out, are too readily passed over, even by those who would not knowingly condone such faults. It seems to be assumed that work of this public character, involving the outlay of considerable sums of money, must necessarily be undertaken only with a full sense of the responsibilities attaching thereto; and that every precaution is consequently adopted to ensure success in each essential particular. One reason for this easy confidence may be found in the fact that whenever loans are required for the carrying of such schemes into effect, the supposed guarantee of a Local Government inquiry, by an engineering inspector of undoubted ability and experience, is always secured. This is no doubt true, so far as the holding of the inquiry is concerned; but to those who are in a position to note the steps consequent upon the inquiry, the hollowness of the guarantee becomes in many instances only too painfully apparent. Not many days ago, for instance, I had an opportunity of inspecting the execution of extensive sewerage works for an important district in the county of Durham. An inquiry had been duly held, at which plans, sections, and details would doubtless be laid before the Inspector, upon whose report the expenditure of the large sum required could alone be sanctioned by the Local Government Board. It might, therefore, have been thought that such matters as the direction

manholes, and the provision of flushing and ventilating arrangements, would have received a befitting amount of attention, and that, if modern requirements in these respects had not been sufficiently borne in mind in the preparation of the scheme,

necessary modifications therein would have been relentlessly enforced; say, for instance, upon the excellent basis of the printed 'Suggestions issued by the chief engineer of the Local Government Board. It may be, possibly, that this course was followed in the instance under review, but, as a matter of fact, my own inspection of the actual work only showed that the scheme was being carried out in defiance of the most elementary sanitary principles. To begin with, pipe sewers were being laid in whatever might happen to be the direction of the street or road, instead of in absolutely straight lines with shafts or chambers at the angles. It will be apparent that with pipes of such large diameters as eighteen and twenty-one inches (these being the sizes I saw), a wide gaping space must be left at one side of each joint wherever laid in such disjointed curves as those to which I refer, while, in addition, the amount of puddle used was totally inadequate, even for pipes truly butted together, as in straight lines. Other advantages accruing from the adoption of the straight line system (which is surely no novelty in the present year of grace), such as easy permanent inspection and simplicity in the registration and finding of junctions for branch drains, were evidently regarded as of no moment whatever. The negligence as regards levels was, however, a still worse feature than the above; the sole apology for sight-rails being mere shapeless cross-battens, nailed to a single upright plank, the latter depending for its support upon a sewer pipe, standing at side of trench. The cross-battens were fixed by the workmen themselves as the work proceeded, it being thus quite impossible that the sections are being adhered to with any degree of accuracy, or that any uniformity of gradient can exist in the finished work. manholes were of very inferior construction and workmanship, and the value of the open ventilating gratings was greatly reduced by the absence of any provision for intercepting road-dirt and preventing its admission to the sewer. Moreover, the bottoms of the manholes were flat throughout their whole area, instead of being channelled for the conveyance of sewage. One result of this must be that putrefying matter will accumulate in the manholes, giving off, especially in hot weather, a delightful variety of the foulest odours imaginable by means of the otherwise beneficial open gratings. The number and distance apart of the gratings were not arranged upon any discoverable system, and, to conclude this dreary catalogue, no attempt to provide flushing appliances was anywhere discernible.

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I have enumerated at some length the many defects found to exist in this particular instance, not from any desire to give it excessive or undeserved prominence, but because it shows more clearly than any theoretical dissertation could do that the Local Government Board's control over the structural sanitary work of the country, as at present exercised, is of extremely small value in preventing the perpetration of huge and costly blunders, even where the intervention of that Board is obligatory. As an example of what may happen where this intervention can be dispensed with by a Local Authority of insanitary and cheeseparing tendencies, I may cite the case of the town from which I write, where works for securing an increased amount of drainage-area for water-supply have been carried out in such a manner as to call forth an energetic, but unheeded, protest from the Medical Officer of Health, on the ground of sewage-contamination. No plans for this work have ever been prepared, and

the whole has been conceived and executed as if the experience of the last thirty years in the yield of water and in the causation and propagation of disease had never been accumulated. The Local Government Board, as the central Health Authority, has no official cognisance of this work, excepting such as may have been derived from their copy of the protest above referred to, upon which, however, no action has been taken at the time I write. And yet it is eight years since the Public Health Act was passed, and no less than thirty-two years since the establishment of a General Board of Health for the whole country. Cui bono? it may surely be asked!

In the face of such statements as those I have made (and I have no reason to believe that they refer to extreme or isolated cases, though occurring in two adjoining counties), it will be admitted that much more than a mere reform of private drainage work is required. How, for instance, can efficient bye-laws for this work be enforced in such districts as those alluded to, in which the first principles of sanitation are ruthlessly ignored by the Local Authority in their own expenditure of public funds? The officials in charge are clearly not qualified for such work, and, even if they were, property owners would have some amount of justification on their side in declining to carry out stipulations, in private work, which are not made to apply to the equally important undertakings of the controlling authority. The force of a good example is not a power to be despised in such a matter, neither can the dangerous influence of a bad lead be safely ignored.

The article which has called forth the present remarks closes with the suggestion that the assistance of the engineering element in sanitary work is as necessary as that of the medical profession. I cannot but regard this as the key-note to a solution of the problem under discussion. It is, at any rate, a consideration the force of which has hitherto not been sufficiently estimated, either by the Local Authorities or by the framers of existing legislation as to the work of these bodies, for while the qualifications of the Medical Officer of Health are clearly defined there is no condition of ability attached to the holding of the office of Surveyor, and in rural sanitary districts not even the existence of an official passing under this designation is required. The supposed financial difficulty or pecuniary hardship involved in the appointment of really efficient engineers over sanitary districts can be entirely obviated by the system of combined areas, but, so far from attaching any weight to any cry of this sort, I am satisfied that the unwise objection of Local Authorities to submitting themselves to technical advisers is the_real obstacle which has to be contended with. Even Medical Officers of Health, appointed in virtue of an established law against which all objections are futile, do not fail to experience this deeply-rooted antipathy to the behests of skilled and zealous officials on the part of their nominal employers. In like manner, the conditions which would be laid down by competent engineering officials in such matters as the design, construction, and management of necessary sanitary works would be sure to meet with uncompromising opposition, based partly upon real ignorance as to their utility and partly on the additional outlay which their observance would necessitate over the cost of cruder and less efficient ideas. evident, therefore, that whenever the long-delayed introduction of the engineering element into the details and routine of sanitary work is to be effected,

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