HYGIENE.
BY JOHN S. BILLINGS, M.D.
The purpose of this paper is to indicate some of the ways in which hygiene, both private and public, is connected with the duties of the general practitioner, and to give some information as to modern methods of investigation and work in preventive medicine.
While the business of the physician is more especially the care of the sick with reference to the cure of disease, or, where that is beyond his power, as is too frequently the case, to relieve suffering and secure temporary ease for his patient, he is nevertheless often called upon to answer questions as to the causes of disease, and the best means of avoiding or destroying these causes. Not only does diagnosis often turn upon considerations of etiology, but a very considerable part of the treatment of actual disease must be hygienic in the broader sense of the word. The prescription or the surgical operation must not only be supplemented by advice as to residence, clothing, food, exercise, etc., but must, in many cases, be merely supplementary to such advice, which indicates the really essential method of treatment; and the giving this advice then becomes the most important part of the physician's work, although not usually recognized as such by his patients. The chief value of the prescription is, in fact, often to methodize the mode of life of the patient and to remind him at frequently recurring intervals of the regimen which has been ordered with it.
The physician has also certain duties in relation to the public at large, as well as to his individual patients, and these duties become more numerous and important as the density of population increases, so that in the large cities of most civilized countries he finds himself, nolens volens, in almost daily contact with legally constituted authorities in the shape of registrars, health officers, coroners, etc., and is not infrequently summoned before the courts as a supposed expert in matters connected with the public health.
Moreover, the physician who has become eminent in his profession is, in many cases the adviser, and, so far as professional subjects are concerned, to a great extent the guide, of those who legislate for, or execute the laws of, not only his own city or county, but his state and the nation; and he must to a corresponding degree be held responsible for the position which he takes and the advice which he gives in regard to public health matters. This is true whether his attitude on these subjects be active or passive, for his silence will be taken to mean that there is no necessity for action or change.
The limits of this paper do not permit the presentation of proofs and illustrations of these somewhat dogmatic assertions, but it is believed that they will meet with general assent from medical men without formal and detailed argument, and that it is unnecessary here to urge the interest or importance of practical hygiene upon the medical profession, or to enlarge upon the desirability that the practitioner, as well as the professional sanitarian, should be familiar with the conclusions of modern science and technology with regard to it.
In the minds of many intelligent and thoughtful physicians there is, no doubt, a feeling of unformulated distrust as to the real possibilities or probabilities of improving the health and diminishing the mortality of the community at large; and this feeling is in part due to the exaggerated claims and emotional exhortations of some advocates of hygiene. A careful and unprejudiced survey of what has been accomplished by sanitary measures will, however, largely dissipate this distrust.
The natural term of the life of man is fixed by the physiologist at about one hundred years, which is nearly in accordance with the law indicated by Flourens, that the period of life of an animal is about five times that required to perfect the development of its skeleton and unite the epiphyses with the shafts of the long bones. The actual average duration of human life is less than half this, but there is satisfactory evidence that it has increased in civilized countries. The ancient estimate is expressed in David's declaration, that "the days of a man are threescore years and ten, and if by reason of strength they be fourscore years, yet is their strength labor and sorrow." Kolb, a cautious and learned statistician, concluded, from his studies, that while the maximum age reached by man has not materially changed for many centuries, the number of persons who now survive infancy and of those who reach a ripe old age has decidedly increased; and this opinion is sustained by Mr. Lewis, the secretary of the Chamber of Life Insurance of New York, who points out that while civilization largely interferes with the laws of evolution by survivorship, it aids by economizing the waste which occurs in its absence. "Under natural selection, when variations in capacity arise, thousands of them are wasted where one is secured, fixed, and transmitted. But human society economizes much of this waste, fastens upon and improves an immensely larger proportion of the capacities lavishly produced by Nature, and thus concentrates forces which would otherwise spread their operation over countless ages."1
1 "Influence of Civilization on the Duration of Life," Reports Am. Pub. Health Ass'n, N.Y., 1877, vol. iii. p. 173.
We have, however, no record of the duration of life in ancient Greece and Rome, and it is quite possible that it was greater than in Western Europe during the Middle Ages, which formed a period of retrogression in a sanitary point of view. The Jew, the Greek, and the Roman, prior to the Christian era, were probably cleaner in person and in dwellings than the people of the time when dirt became the odor of sanctity.
In the absence of reliable data for this country, it is impossible to speak with certainty of the results of attempts made here to prevent disease and death. Each sex, race, and age has its own rate of mortality, and until this rate is determined we can only guess as to whether good work is being done or not.
We can never hope to diminish the total number of deaths which will occur in long periods, say two hundred years, but we may rationally try to prolong the average duration of life, to diminish infant mortality, and to secure greater comfort and better health for individuals and for the community at large.
The reader must remember that only a mere outline of the subject can be presented here; the details would require several volumes, and the tendency to specialization in this, as in other branches, is so great that it is hardly to be expected that any one man shall have either the theoretical or the practical knowledge necessary for covering the entire field. There are certain things in relation to hygiene which every physician should know; there are many other things with regard to which it is sufficient if he knows where to find full and reliable information when he needs it. With this preface we will pass at once to our subject, which may be conveniently divided as follows:
| I. | Causes of disease, means of discovery, and prevention. |
| II. | Personal hygiene in its relations to the practice of medicine. |
| III. | Public hygiene in its relations to physicians. |
I. Causes of Disease, Means of Discovery, and Prevention.
Although the origin of disease has from the earliest times been the subject of study by medical men, the physician has not heretofore, usually, been called upon to investigate the causes of disease in particular localities, until the occurrence of sickness in that locality has called attention to the matter. The education of the public as to the importance of sanitary work has, however, recently made great progress, and it is now not unusual to ask the opinion of the family physician as to the healthfulness of a given locality or house. The question may be presented in three different ways: First. In a given case of disease, what is the probable cause? Second. Given the presence of a known or suspected cause of disease, what are the best means of avoiding or destroying it? Third. In the absence of cases of disease, to determine whether causes of disease are probably present, and if so, what causes.
The word "cause" is here used in its widest sense, including not only what are commonly called predisposing and exciting causes, but also those conditions which aggravate or continue the disease. These causes may be roughly classed as follows: Heredity; impure air; impure water; climate; habitations; occupation; food; intemperance of various kinds; clothing; errors in exercise; sexual errors; parasites; contagia; expectant attention and other mental causes, including worry, etc. In most cases two or more of these classes of causes are combined in action for the production of a given case or outbreak of disease, and when we refer any disease to a single factor, what is meant usually is, not that this is the sole and exclusive cause, but that it is the most prominent one.
Bearing this in mind, let us consider briefly some of the causes above mentioned.
I. HEREDITY.—That the child inherits from its parents its physical type, including color, stature, physiognomy, temperament, and certain peculiarities of structure or arrangement of internal organs, is well known. This hereditary influence is stronger from the immediate than from the remote ancestry, although the curious phenomena of atavism sometimes form exceptions to this rule. The hereditary causes of disease can be guarded against when known. Theoretically, by preventing generation on the part of persons who are unfit to produce offspring; practically, to a certain extent, by taking special precautions against these causes and their effects in the individual, particularly at those ages in which these influences seem to have their greatest force. The most important of these hereditary diseases are syphilis, consumption, scrofula, cancer, gout, certain skin diseases, insanity, and criminal tendencies of various kinds.
The physician's advice is rarely asked with regard to the propriety, from a sanitary point of view, of a proposed marriage, nor is it often taken when given, unless, indeed, it happens to correspond with the wishes of the recipient; nevertheless, he is occasionally in a position to exert influence in such a matter, and when this is the case the following general rules may be borne in mind: 1. No marriage should occur between persons having the same hereditary tendency to disease; and this is especially important in marriages between relatives. 2. A girl should not marry under the age of twenty. 3. A person affected with hereditary or well-marked constitutional syphilis, or having a strong consumptive taint, or tendency to mental unsoundness, should not marry at all.
The precautions to be taken in individual cases in which there is a known hereditary predisposition to certain diseases will probably be indicated in the articles upon those special diseases. The most important of these, from the sanitary point of view, are consumption and gout, partly because of their frequency, partly because of the undoubted power which a proper regimen, applied in time, has in controlling them. The pain in gout has often an excellent sanitary effect; it is an inducement to temperance much stronger than any amount of good advice.
The influence of heredity in producing abnormities of refraction and accommodation of the eye, and the importance of detecting these early and giving them proper treatment, have not hitherto received, from the general practitioner, the attention which they deserve. Children of parents affected with astigmatism, ametropia, etc. should be carefully examined before being placed at school, and if necessary fitted with proper glasses.
The heredity of idiosyncrasies as to certain articles of food or certain drugs must also be borne in mind by the physician, for, although implicit confidence is not always to be placed in the statement of a patient that he cannot take a certain medicine, yet a knowledge of the facts will occasionally save the prescriber from some awkward mistakes.
The importance of bearing in mind the family peculiarities is best appreciated by the old family doctor who has had two or three generations pass under his hands: he knows, for example, that in one family he may expect brain complications, in another lung troubles, and that what would be grave symptoms in one house are of comparatively small import in another. Unfortunately, the greater part of this kind of knowledge has not yet been formulated, and each physician has to acquire it for himself; but he will find the process of acquisition greatly facilitated if in all cases in a new family he makes it a rule to learn something of the medical history of the parents, and he will find intelligent laymen quick to appreciate his inquiries in this direction.
The importance of taking into account hereditary influences is well illustrated by the care which is taken to obtain information with regard to them in well-conducted life insurance companies. The medical examiners of such companies have their attention specially called to this matter, and the following extract from a manual of instructions shows how it is regarded from a business point of view: "If consumption is found to have occurred in the family of the applicant, he is to be regarded not insurable under the following circumstances, viz.:
| YEARS OF AGE. | |
| If in both parents, not insurable until | 40 |
| If in one parent, not insurable until (Except for ten-year endowments, then 20 years.) | 30 |
| If in two members (not parents) | 35 |
| If in one member (brother or sister) (Except for ten-year endowments, when peculiarly favorable.)" | 20 |
If apoplexy, paralysis, or heart disease is found to have occurred in any two members of the applicant's family, he is to be regarded as insurable only upon the endowment plan, the term of insurance to expire prior to his reaching the age of fifty years. If insanity shall have so occurred (in two members), a provisionary clause is essential, and is attached to the policy by the company.
II. IMPURE AIR.—The dangers of impure air, water, and food depend largely upon the fact that through these media may be introduced into the body particles of organic matter, living or dead, which tend to produce disease in the recipient. The parasites are types of this mode of disease-production, and these blend with the contagia of the specific diseases in such a way that it is not easy to draw the distinction in all cases. There are also certain poisonous gases and inorganic compounds which may occasionally be present in air or water to such an extent as to produce disease; but as a rule the gaseous impurities of the air are offensive to the smell rather than dangerous, as will be seen when we come to consider the effluvium nuisances.
The subject of ventilation, for the purpose of procuring an adequate supply of pure air, is one of so much importance, and one upon which the physician is so liable to be called for practical advice, that it seems proper to state briefly the general principles which should govern investigations into, or recommendations upon, this subject.
The impurities of air which are to be disposed of by ventilation are for the most part derived from the human body, chiefly from respiration, and these only will be considered here. In some cases it is necessary to make special provision for the products of combustion from gas, etc., but as a rule this is rather for the purpose of regulation of temperature than anything else. The impurities of air due to the presence of human beings consist mainly of carbonic acid, ammonia, sulphuretted hydrogen, and sulphide of ammonium, and of various organic compounds, mostly in the form of minute particles of organic matter of uncertain structure, but extremely prone to decomposition. It is usual to estimate the degree of impurity by the amount of carbonic acid present, and this leads many persons to suppose that the carbonic acid is in itself the chief and most dangerous impurity. This gas is, however, not perceptible to the senses, nor is it injurious to health, unless present in much greater proportion than that in which it will be found in the most crowded habitations or assembly-rooms. Its importance in questions of ventilation depends upon the fact that its increase in a room beyond the amount present in the outer air may usually be taken to be in direct proportion to the amount of the really dangerous and offensive impurities present, and that the amount of carbonic acid can be ascertained by chemical tests with comparative ease and rapidity; which is not the case with regard to the organic matter. The carbonic acid is therefore taken as the measure of the impurity, although it is not itself the impurity of which we are most anxious to be free.
To decide as to whether a room is well ventilated or not, some standard of permissible impurity must be fixed, and this standard is now usually taken to be, in a room occupied by human beings, that condition of air which produces in a person having a normal sense of smell, and who enters from the fresh air, a faint sensation of an odor very slightly musty and unpleasant. Upon testing the air of such a room, it will be found that the amount of carbonic acid impurity present—that is, the excess of this acid over the amount in the external air—will be between 2 and 3 parts in 10,000.
As the amount of carbonic acid in normal air varies from 2 to 5 parts in 10,000 in different places, and in the same place at different times, it is better to look to the carbonic acid impurity as above defined rather than to the total amount of the acid found present, if strict accuracy is desired; but usually the statement of Dr. Parkes is correct, that the organic impurity of the air is not perceptible to the senses until the total carbonic acid rises to the proportion of 6 parts in 10,000 volumes. When the carbonic acid reaches 9 parts in 10,000 the air is close, and when it exceeds 1 part in 1000 the air is usually decidedly unpleasant. If we take 2 parts in 10,000 as the permissible maximum of carbonic acid impurity, it follows that the amount of fresh air which must be supplied and thoroughly distributed for each person per hour is 3000 cubic feet. If 3 parts per 10,000 be taken as the permissible maximum (which is the standard of Pettenkofer), the amount of air per head per hour must be 2000 cubic feet. While it is impossible, as Dr. Parkes remarks, to show by direct evidence that the impurity indicated by 7, 8, or even 10, parts of carbonic acid per 10,000 is injurious to health, it is advisable to accept his standard, because it is a simple one, and can be practically applied without special apparatus or technical skill, and because there is evidence of the injury to health which continued exposure to air impure, by this standard, ultimately produces.
Keeping this standard in view, the physician may be called on for an opinion as to whether the ventilation of a given building is satisfactory or as to the merits of a proposed plan for ventilation. The first is a question of fact: What are the effects produced upon the inmates? Are there unpleasant odors in the building or not? What percentage of carbonic impurity is present? What is the number of cubic feet of air per head that is introduced and removed per hour? And what is the character of the fresh-air supply as to purity? Does it come from the cellar, or from other rooms, or from a foul area? Air-currents can usually be best investigated by the fumes of nascent muriate of ammonia produced by exposing a cylinder of common blotting-paper, moistened with dilute hydrochloric acid, to the vapors coming from a crumpled fragment of the same paper moistened with common aqua ammonia and placed within the cylinder. The process for carbonic acid determination is simple, and can be learned in three hours in a laboratory under a skilful teacher. It does not seem worth while to describe it here. The determination of the amount of air passing through a given register, flue, or chimney in a given time is to be made by the use of an anemometer, an instrument which registers the velocity of the current of air passing through it.
In judging of the merits of a plan of ventilation the following points should be remembered: The defect in most plans for ventilation is in the air-supply. Many people suppose that they have made all necessary provision for ventilation if they have put in tubes or openings for the escape of foul air, forgetting that these outlets will have no effect if corresponding inlets are not provided. Examine, first of all, therefore, the ducts, flues, and openings proposed for the fresh-air supply, with reference to their size and position and the amount of air to be furnished by them. These will almost invariably be found to be too small. The proper size of flues and registers for a given room is ascertained by dividing the number of cubic feet of air to be supplied per second by the velocity in feet per second which the air is to have in the flue or opening, bearing in mind that it is much better that these flues and registers shall be too large than too small, since it is easy to reduce their capacity, but, in most cases, impossible to increase it. When the fresh-air register is so situated that the current of air from it is liable to strike upon the person of an occupant of the room, the velocity of this current should not exceed 1½ feet per second if unpleasant draughts are to be avoided; and it will usually be found best that the velocity of the air in the flue shall not exceed 6 feet per second, except in the case of very large flues, where the element of friction becomes of comparatively small importance. In the great majority of cases the amount of air to be supplied depends upon the number of persons, and not on the cubic space; but in exceptional instances, where the amount of cubic space is very large in proportion to the number of persons, and the heating is effected by warm air, it may require more air to keep the room at a comfortable temperature than is necessary for the supply of the occupants. The cubic space is also relatively much more important in rooms which are to be occupied but a short time continuously, and can then be thoroughly aired, than it is in rooms constantly occupied.
The methods of calculation can be best illustrated by one or two examples. What should be the number and size of flues and registers for fresh-air supply for a hospital ward to contain 24 beds, the ward being a rectangular pavilion with windows on opposite sides? In this case the room is constantly occupied, and the supply of air should be 1 cubic foot per head per second, or, in all, 24 cubic feet per second. The velocity of current at the registers should not exceed 3 feet per second—better only 2. This will require from 8 to 12 square feet of clear opening in the registers. If we allow four on each side of the room, each register must have at least 1 square foot of clear opening. The velocity of the air in the flues supplying these registers should not exceed 4 feet per second, and therefore the area of each flue should be about 9 by 12 inches. Suppose the same question be asked with regard to a school-room to contain 48 pupils. In this case the room will not be occupied more than two hours at a time. The air-supply desirable may be put down at 35 cubic feet per head per minute, or 28 cubic feet per second for the whole. The velocity in the flues may be put, as before, at 4 feet per second; hence we need 7 square feet area of flue, or seven flues, each having 1 square foot of area. It is safe to say that there are not twenty school-houses in the United States which have fresh-air flues of sufficient area; the deficiency is made up, for the most part, by leakage of the outer air through cracks around windows and directly through the wall, and also by the passage of air from the central hall into the room, this last air coming from the cellar or basement.
The velocity of the air at the foul-air registers and in the foul-air ducts may be greater than in the fresh-air flues, since there is no danger of its causing draughts, and hence there is no truth in the common notion that the outlets should be larger than the inlets to allow for the expansion of heated air. It is important that the velocity of the current in the outlet shaft or chimney should be at least 8 feet per second at the point where it escapes into the outer air; and if the outlets be too large for the inlets, the result may be that some of the foul-air flues will work backward and become inlets. The plan of making everything a little larger than is necessary is not a safe one as regards chimney-flues and outlet shafts.
The merits of a plan of ventilation depend not only on the amount of air introduced, but on its distribution. The test for distribution is chemical analysis of samples taken in different parts of the room and at different levels. A very good idea of the direction taken by the incoming air can also be obtained by the use of fumes of nascent muriate of ammonia, as above described. In considering the distribution which will probably take place in a given plan, care should be taken not to fall into the common error of supposing that because pure carbonic acid gas is heavier than air, therefore the carbonic acid derived from respiration sinks to the floor, and that special provision should be made to remove it at that point. The law of the diffusion of gases effectually prevents this separation and sinking of the carbonic acid from the mixture of gases expired, and it will be found to be present in about equal proportions in all parts of an inhabited room.
The methods of introducing and distributing fresh air depend to a great extent upon the methods of heating employed; and it is necessary to remember that while good ventilation is a very desirable thing, satisfactory heating is, in cold weather, still more desirable, and must be attained even if the ventilation is interfered with for that purpose. The principal difficulty in the way of securing good ventilation is its cost. In a cold climate satisfactory heating, good ventilation, and cheapness are not compatible; it is comparatively easy to obtain any two of them, but impossible to have the three together. This fact should be fully understood and realized by the physician, for its comprehension will save much time in considering the merits of various patent ventilators and ventilating appliances, which, according to their inventors, produce good ventilation at no expense beyond that of the original cost of the apparatus; which is practically about the same as a claim to have discovered perpetual motion. Patent ventilators are usually cowls to be placed upon the top of outlet flues. I know of none which are superior to the common Emerson Ventilator, on which there is now no patent. In cold weather the air must be warmed to secure comfort; it must be changed to secure ventilation. The changing of the air carries off heat, the loss of which must be supplied by fuel, which fuel costs money. The greater the ventilation, the more rapid the change and the more heat required. It is therefore quite possible to judge somewhat of the merits of a heating and ventilating apparatus—for example, of a school-house—from the amount of fuel consumed; but the conclusion will be precisely the reverse of that drawn by the average trustee, since it will be, that within certain limits the less fuel required the less satisfactory the apparatus.
The evil effects of insufficient ventilation, although very certain and very serious, are not immediate, or such as to attract attention at first, except in very aggravated cases with excessive over-crowding. The power of the organism to adjust itself to surrounding circumstances is very great, and perhaps as great in regard to the endurance of foul air as anything else. Yet this power is greater in seeming than in reality, for at last such air produces disease and shortens life. Its effects are manifested in diseases of the respiratory organs, acute and chronic, and it is now generally admitted that the undue prevalence of phthisis in troops is due to the foul air of the barrack-rooms.
Some persons are much more susceptible than others to the effects of impure air, and will suffer from headache, languor, loss of appetite, etc. where others would experience little inconvenience. Children thus susceptible dread the school-room as ordinarily constructed and ventilated, and their discomfort should be taken into account and guarded against.
Thus far, reference has been made only to those impurities of air due to respiration and lights; in other words, the necessary impurities found in human habitations. The impurities due to sewer gases will be referred to hereafter; they should be prevented absolutely, and not provided for by ventilation. One of the most difficult problems presented to the physician is to determine whether the effluvia from a given locality are injurious to health, and if so, to what extent. These effluvia may be due to certain occupations or manufactures, or they may result from the disposal of excreta, from obstructed drainage giving rise to swamps and the collection of decaying organic matter, and in other ways. The best definition of the term "injurious to health" in this connection is perhaps that suggested by Dr. Ballard—i.e. that exposure to the offensive effluvia causes bodily discomfort or other functional disturbance, continuing or recurring as the exposure continues or recurs, and tending by continuance or repetition to create an appreciable impairment of general health and strength, to render those exposed more liable than others to attacks of disease, and more apt to suffer severely when attacked, and, in the more serious forms, to the direct production of the disease and the shortening of life.
The group of symptoms due to offensive effluvia is, as Dr. Ballard remarks, a tolerably constant one, and consists of loss of appetite, nausea, headache, giddiness, faintness, and a general sense of depression, with, in some cases, vomiting and diarrhoea. But it is usually impossible to prove by statistics that these phenomena are due to a given effluvium complained of, for those who suffer from it are usually exposed to other causes of ill-health, such as poverty, overcrowding, collection of filth, etc.; and, on the other hand, many of those exposed to the effluvium seem to suffer very little, if at all, from their surroundings. And so true is this, that in the carefully prepared report upon effluvium nuisances recently issued by Dr. Ballard,2 it will be found that as a rule no attempt is made to prove that the effluvia from any particular branch of industry are injurious to health; the test practically applied is that they produce offensive odors.
2 Report in respect of the Inquiry as to Effluvium Nuisances arising in connection with various Manufacturing and other branches of Industry. By Dr. Ballard, London. Her Majesty's Stationery Office, 1882, 8vo.
The legal view of this subject is given in the various decisions as to what should be considered a nuisance, the essence of which is the use of one's own property in such a way as to inflict damage upon, and injure the rights of, another. If a man collects on his own premises, for his own use, any material, such as water or filth, he is bound to retain it within his own premises or to let none of it escape in such a way as to damage others; and this holds good as regards gases, vapors, and odors. The decision of Mansfield, in the case of Rex vs. White, is often quoted approvingly by jurists, viz.: "It is not necessary that the smell be unwholesome; it is enough if it renders the enjoyment of life uncomfortable." But, practically, the question as to whether the discomfort produced is sufficient to produce ill-health will be the one upon which the physician is called to give evidence, and the one also upon which he will find it most difficult to obtain data sufficient to enable him to form a positive opinion.
III. IMPURE WATER.—Of all the various preventable or removable causes of disease to which the attention of the physician engaged in practice in the small towns and rural districts is directed, it will usually be found that the water-supply is the most important, because it is in these localities that it is most liable to become contaminated in such a way as to produce sickness.
All water used for drinking purposes is impure in the chemical sense, since it contains some inorganic matters or salts, and in most cases organic matter also. It is difficult to define precisely what should be considered an impure water in a sanitary sense, and the best we can do is to indicate probabilities in the absence of positive evidence of the production of disease by the suspected water. So far as inorganic impurities are concerned, the most important, from the sanitary point of view, are the salts of lead, magnesia, and lime, but in this country these are so rarely the cause of disease that they hardly require special notice. The physician should, however, bear in mind possibilities of lead-poisoning in some obscure cases which he will meet.
The diseases due to impure water are certain specific fevers, diarrhoeal diseases, and some affections due to parasites which find entrance to the body through this medium. The water-supply is to be suspected in case of prevalence of diarrhoeal disease in a community, and especially if the outbreak be sudden and affect a number of persons and families. Sudden outbreaks of cholera, typhoid fever, or malarial fever, confined to a limited locality, should lead to careful examination of the water-supply. The impurity in water which causes these diseases is supposed to be either organic or the product of organic life, and at present the prevailing opinion is that the really dangerous impurities consist of minute living organisms or germs. It is usual to estimate the impurity of water by the amount of organic matter present, but it is evident that this alone can give no positive information, since by this standard milk and soup would be very dangerous. Much depends upon the character of the organic matter, whether it is derived from the animal or vegetable kingdom—whether it is in a state of fermentation or putrefaction, etc. etc.; but the presence of specific germs in it is the most important part of all, and at the same time the most difficult to ascertain. Nitrogenous organic matter in a state of decomposition is dangerous, yet it does not always produce disease, even when ingested in comparatively large quantity, as in case of "high" game or tainted meat; and it is easy to find instances where water strongly polluted with sewage has been used for a considerable period without producing marked ill effects. It is, however, so extremely probable as to be for practical purposes certain, that water contaminated with the discharges from persons suffering from certain diseases will produce similar diseases in those who drink it, and there is also enough evidence that water containing filth of various kinds either produces or promotes disease to warrant much more attention to this subject than has heretofore been bestowed upon it.
The chemical examination of a suspected water is by no means a simple process, and in most cases had better be referred to an expert in such matters. It is highly desirable, however, that the physician should have sufficient technical knowledge to be able to make a rough analysis at least, if for no other reason than that he may be able to appreciate the results reported by the chemist. As a rule, when a water is so polluted with decomposing organic matter as to be positively dangerous it will have an unpleasant odor, which is best developed by half filling a quart bottle with the water to be examined and shaking it thoroughly. The so-called simple and ready methods which are from time to time advocated in the newspapers, such as the addition of sugar to the suspected water and allowing fermentation to take place, the use of tannin as a precipitant, or the decolorization of a solution of potassium permanganate, are really of very little value and should not be relied upon. In the hands of an expert the best simple method of determining the quality of a water is by evaporation of a known quantity and the ignition of the solid residue. From the amount of the total residue, the quantity left after ignition, the amount of blackening produced, and the odor, a very fair opinion can be formed as to the amount of organic matter present, and whether it is of animal or vegetable origin.
It is not within the province of this paper to describe the methods used by chemists in water analysis, of which the principal are known as the Franklin and Armstrong, the Wanklyn, and the permanganate methods. A careful examination of these methods has recently been made under the direction of the National Board of Health, and a preliminary note of the results, prepared by Professor Mallet, has been published in the Bulletin. From this it appears that the chief value of chemical analysis is, first, the verification of gross pollution, which will usually be detected by the appearance and smell of the water; and, second, in periodical examination of a water-supply to detect changes from the normal or usual character of the water, which may be taken to have a certain local standard of purity. Special importance is attached to the careful determination of nitrates and nitrites in water to be used for drinking, these being the results of oxidation of organic matters, and therefore giving evidence of previous contamination.
Prof. Mallet concludes that "there are no sound grounds on which to establish such general standards of purity as have been proposed, looking to exact amounts of organic carbon or nitrogen, albuminoid ammonia, oxygen of permanganate consumed, etc., as permissible or not. Distinctions drawn by the application of such standards are arbitrary and may be misleading." While this is perfectly true, considered from the standpoint of scientific precision, it does not sufficiently take into account the value of probabilities in these matters, considered as motives to action. It is perfectly true that there can be no fixed standard—that a water which the chemist would report as relatively pure might be much more apt to produce disease than one which he would pronounce impure—but it is nevertheless true that from the results of chemical analysis, taken in connection with evidence as to the source and history of the water, an opinion can be formed as to the danger from its use which is sufficiently reliable to be acted upon in the absence of positive evidence, such as the production of disease.
In many cases the matter must be doubtful, and Prof. Mallet truly says that it will not do in all such cases to forbid the use of the water, for it often happens that this should not be done unless it is absolutely necessary; but there are many other cases in which there is very little doubt, and where action should be governed by the probabilities.
The microscopical examination of suspected waters sometimes gives decided indication as to the nature of the impurities; and it may be that hereafter, in connection with physiological tests, it will become of even more importance than the chemical. To determine the presence of organisms in a sample of water the best method known at present is to kill and coagulate them by means of osmic acid or chloride of platinum, and allow them to subside. This method is of course inapplicable if it be desired to use them for either culture- or inoculation-tests.
Chemists have no uniform system of reporting the results of their analyses, some using grains per gallon, U.S. or Imperial as may be, and others parts per hundred thousand or per million of the water. It is therefore difficult to appreciate the value of the figures as given by them. The following, in parts per 100,000, will enable the practitioner to form a general estimate of the character of analytical reports; but the opinion in individual cases is so modified by the coincident amounts of chlorine, ammonia, nitrous and nitric acids, that the experienced sanitarian only is qualified to put on the results an estimate which shall be in accordance with our present knowledge of such matter:
| Upland Surface-Waters. | |||
| Allowable. | Doubtful. | Impure. | |
| Total organic elements | to .4 | .4 to .6 | Over .6 |
| Oxygen required | to .3 | .3 to .4 | Over .4 |
| Albuminoid ammonia | to .015 | .015 to .025 | Over .025 |
| All Other Waters. | |||
| Total organic elements | to .2 | .2 to .4 | Over .4 |
| Oxygen required | to .15 | .15 to .2 | Over .2 |
| Albuminoid ammonia | to .010 | .010 to .015 | Over .015 |
In connection with impure water should be mentioned impure ice. Ice is purer than the water from which it forms, but if cut on a foul pond it will itself be foul, and the vitality of some microscopic organisms is not destroyed by their being frozen, as is shown by the fact that samples from the centre of blocks of ice will inoculate sterilized infusions with the germs of putrefaction, precisely as the water of which the ice is composed would have done before it was frozen. Disease has been traced to impure ice, and it may be that it is more frequently due to this cause than has heretofore been supposed; at all events, it is well to bear the possibility in mind.
The subject of impure water will be further considered in speaking of habitations.
IV. CLIMATE.—The literature of the effects of different climates upon the human body is very extensive, following the general rule that the less positive or precise knowledge there is upon a given subject the more will be written about it. Of all animals, man seems to adapt himself most readily to the extremes of climate; and, although it is commonly supposed that a tropical climate is injurious to those coming from cooler regions, yet it has been found that where he takes the same precautions to ensure cleanliness, pure water and air, and proper food, the European does not have a higher rate of mortality in Algeria or in the East or West Indies than he does at home, if the effects of cholera and yellow fever be excepted.
Dr. Parkes defines the effect of climate upon the human body to be "the sum of the influences which are connected with the solar agencies, the soil, the air, or the water of a place;" in other words, he makes it nearly equivalent to the locality or the environment. By "climate" we understand, commonly, the sum of meteorological influences, the most important of which, as regards health, are temperature, humidity, and wind. The effects of temperature in producing disease are often confounded with the effects of change of temperature, which last is perhaps the more important of the two, and should be specially borne in mind in advising climato-therapy for chronic or wasting diseases.
The influence of climate in causing disease, although well known for over two thousand years, has not led to much effort to avoid or prevent effects which are accepted as inevitable by the great majority. It is true that in the effort to secure physical comfort by houses, clothing, artificial heat, and the like, much hygienic work has been done, and the steadily increasing tendency on the part of all who can afford it to seek rest and comfort at the seaside or in the mountains during hot weather is no doubt due, in part, to the fact that experience has shown that the money expended in thus securing health and strength is a good investment. It is unfortunate that "health resorts," so called, do not always prove to be such: they become fashionable, overcrowded; the arrangements for the disposal of excreta are cheap makeshifts, leading to soil- and water-pollution, until finally an epidemic of diarrhoea or typhoid fever occurs, with the usual results.
The consideration of climate as a therapeutic agent belongs with the articles relating to the several diseases to which it is applicable. The great desideratum wherewith to place this subject upon a scientific and practical basis is a system of reliable returns of the deaths, and if possible of certain diseases, throughout the country, and especially at those points most in vogue as health resorts.
V. HABITATIONS.—That a man's health depends very much on the character, condition, and location of his dwelling-place is now so generally admitted that in many cases where a physician is called in he will be asked whether he thinks the disease has been caused by any peculiarity about the house or the bedroom of the patient. And a careful examination will usually discover in one of them several evils to be remedied, although their connection with the case in hand may be very doubtful. There are very few homes properly constructed from a sanitary point of view; and, although we may not agree with Dr. Wilson, that "the modern prison is in all sanitary essentials the best existing type of what a healthy dwelling ought to be," it is nevertheless certain that the health of the inmates is much more carefully consulted in planning a penitentiary than it usually is in planning a college, a hotel, or a dwelling-house. Matters are gradually improving in this respect: the worst of the tenement-house rookeries and fever-nests in most of our large cities have been improved or abolished, and our wealthier citizens are beginning to pay some attention to their house-drainage as well as to the pattern of their mantelpieces. But the great majority of men are still careless and negligent as to the sanitary condition of their homes, and probably two physicians out of three live in houses in which numerous defects would be pointed out by a sanitary engineer—defects of which they are themselves more or less aware. The majority of people in our large cities under existing conditions cannot afford to have healthy houses, and the great causes of the excessive mortality, and brevity of life, in all such cities, are poverty and overcrowding, the latter resulting from the former. The problem as to the best mode of improving the sanitary condition of the tenement-house population does not, however, come before the practising physician for special consideration, and need not be considered here. Nor is the physician liable to be consulted with regard to the sufficiency, from a sanitary point of view, of the plan of a house yet to be built, although he will occasionally be asked as to the healthfulness of a proposed site. The questions which he will be asked are such as the following: "Is the cause of this particular case of disease in the house, or connected with it? and if so, what is it?"—"Do you think this is a healthy house?"—"Is the location a healthy one?"—"Is it necessary that I should give up this house to preserve the lives and health of my children?" While it is, of course, often impossible to answer with precision such questions as these, an answer of some kind must be given; and this should not be a mere random guess, but based on a deliberate estimate of the probabilities in the case. The healthfulness of a house is to be judged of, in part, from its history, if it be possible to obtain any; in part, from such facts as can be discovered by a careful examination of the premises and vicinity. The sanitary history of a house is the history of the diseases and deaths which have occurred in it, together with a set of plans showing the precise location and character of the house-drainage and of its fresh-air supply. Such a record is in most cases, unfortunately, not attainable, although to a person proposing to buy or rent a house it would often be quite as important as a record of title. In a well-organized health-office it should be possible to ascertain the number and causes of the deaths which have occurred in any given house or square in the city, and also the character and location of its drainage and sewer connections. Such records are especially valuable in an investigation of an outbreak of disease in a community.
The sanitary inspection of a house includes the site and the building itself. The character of the site is mainly determined by its dryness, by the presence or absence of organic matter in the soil, and by its porosity taken in connection with the character of the vicinity. One-third of the volume of some soils consists of air, and all dry soils and rocks contain a much larger quantity of air than is commonly supposed. The influence of soil upon health is exerted mainly through the media of water and air, but it also affects temperature and vegetation, being an important factor in climate. Residence on a damp soil has a tendency to produce diseases of the lungs, and especially phthisis; but how it does this is unknown, though it would be easy to construct a plausible theory in connection with the supposed causation of phthisis by a bacillus. The practical point for the physician is, that the prevalence of phthisis in a locality, even if it be so limited as to comprise but a single house, should cause suspicion and investigation as to the character of the soil-drainage. Soil-moisture is also an important factor in the development of periodical fevers, and the effect of thorough drainage in diminishing malaria is now generally understood.
It sometimes becomes an important question as to the influence which a collection of water, such as a mill-pond or a reservoir, has upon the health of a community, and the physician may be called on for an opinion in such cases where large property interests are involved. The essential points to be borne in mind are—first, that stagnant water and damp soil do not in themselves produce malaria; there is something else necessary, which is commonly designated by the word "germ." Second, that they are in most cases essential conditions for the production of the disease, so that if removed the disease will disappear. Third, that the development of malaria may follow either the rise or fall of the ground water. Fourth, that the condition of the border of the collection of water as to presence of organic matter and moisture is of more importance than the pool itself. And, finally, that each case is a problem by itself, to be determined by the history of the sickness of the vicinity, and that only probabilities can be stated in any case, although these probabilities may be so great as to amount, practically, to certainty. Of the four factors which appear to be essential to the production of the malarial poison—viz. moisture, high temperature, organic matter of vegetable origin, and certain micro-organisms—the first is the one which in any given locality is most under human control; it is the link in the chain of causation which is most easily broken.
The influence of the rise and fall of the soil water in typhoid fever, upon which so much stress is laid by Pettenkofer and others, no doubt exists, acting in some cases through pollution of the drinking water by the subsoil water leaking through a polluted soil; in other cases, perhaps, by air from the soil bearing the unknown germ. The filtering power of soil as regards air is, however, very great, a few inches of sand being sufficient to remove the ordinary germs of putrefaction from air drawn through it, and this for a long period; while, on the contrary, many feet of the same sand will not remove the germs from water passed through it. Usually, as Dr. Parkes remarks, in an examination of soil the immediate local conditions are of more importance than the general geological formation, yet this last, as influencing conformation and the movement of water and air over and through a country, is also important. The practical questions on this point are, what higher ground than the site in question exists in the vicinity? what are the character and direction of the strata between such elevation and the site? and, what sources of soil-pollution exist on the higher level? As to the site itself, is it on made ground? what is the height of the foundation above the subsoil water? and, what precautions have been taken to secure drainage and to cut off communication between the interior of the house and the ground air? Probably a trial excavation or boring may be necessary to determine some of these points.
The level of the subsoil water should be at least five feet below the foundations, although it is often impossible to obtain this. At all times when the temperature of the house is higher than that of the external air—i.e. during a large part of the year and nearly every night—there is a strong and constant aspirating force at work to draw into the house, through the cellar floor and walls, all gases and vapors contained in the adjoining soil. If this soil contains a large proportion of organic matter, as is often the case in filled-in ground in cities, or if there be a leaky cesspool or sewer or gas-pipe under or near the house, the ground air passing into the house may be of such a character as to be positively dangerous to its occupants. For this reason it is very undesirable to have a sewer or soil-pipe crossing beneath the site of a house, and when such location is a necessity, as it often is in cities, the soil-pipe should be laid in a cement-lined trench covered with a movable flap, so that it can always be easily inspected and any leaks detected and remedied. Dampness in the cellar or basement of a house is always a sign of danger. The exhalation of gases and vapors from the ground into the house can be to a great extent cut off by a layer of impervious material, such as concrete covered with asphalt, but this layer must cover the sides of the cellar as well as the floor to be thoroughly efficient. If a house have no cellar, the space between the floor and the ground should be thoroughly ventilated; and for this purpose, as well as to secure cleanliness, the floor should be sufficiently elevated to permit of easy access beneath it.
Next to its dryness, the nature and condition of the arrangements for removing excreta and soiled water from a house are of the greatest importance in determining its healthfulness; and in cities it is with regard to the sufficiency of these, including the whole system of house-plumbing and pipe-fitting, that the inquiries of one wishing to determine as to the presence or absence of causes of disease will most frequently be directed. The soil-pipes, etc. of a house are commonly referred to as constituting the system of house-drainage, but it is desirable to use another term, for we need the word "drainage" to describe the removal of surface and subsoil water, and it should be distinguished from "sewerage," which has a different purpose and requirements.
In a properly-arranged system of house sewerage all the pipes, traps, etc. are easily accessible for purposes of inspection, and an examination of them is a comparatively simple matter. This examination is to be made with reference to the following points: 1. Are all the pipes, joints, and connections air-tight? 2. Is the soil-pipe well ventilated, or has it dead ends? 3. Is the communication between the soil-pipe and the street sewer uninterrupted? 4. Are the pipes properly trapped, and is there liability to the removal of water from any of the traps, either by siphonage or evaporation, to such an extent as to break the seal? 5. Is the water-supply of each closet entirely cut off from the main supply to the house by means of a tank or cistern?
In houses as heretofore constructed it is often very difficult to obtain satisfactory information upon these points, because a large part of the soil-pipe and its connections is buried beneath the house or concealed in the walls or floors; in which case the services of a skilled mechanic will usually be necessary to obtain access to the various parts of the system. In a paper of this kind it is of course impossible to go into details as to methods of inspection, or as to what is and what is not satisfactory; but the following are the general principles upon which a judgment as to the merits of a system should be formed, and these should be so clearly understood by every physician that he can be neither persuaded nor frightened into thinking them incorrect by the eloquence of the man with a patent remedy to dispose of. The principal dangers to health from house sewerage are due, first, to the passage of air from the general system of sewers or from a cesspool into the house through the soil-pipe and its connections; second, to the generation of offensive and dangerous gases and organisms in the soil-pipe itself, and the passage of these into the house; third, to leakage of soil-pipe causing contamination of the water-supply either by improper connections of water-pipes with water-closets or slop-hoppers, or by contamination of wells, cisterns, or tanks with sewage or sewer gases.
There is, of course, no such thing as a sewer gas having a definite and distinctive composition, and the nature of the mixture of gases in sewers is constantly varying according to season, temperature, etc. The tendency which sewer air has to cause disease depends in part upon certain gases, in part on minute particles of solid or semi-solid matter which are suspended in the air. In rare instances the sewers also contain illuminating gas, derived from leakage of gas-pipes in the vicinity. These gases produce debility, headache, loss of appetite, etc. As found in sewers and soil-pipes, they are so diluted that they are not absorbed by the water of a trap and given off on the other side to a sufficient extent to produce an evil effect. The air in a soil-pipe which is not ventilated is much more impure than that of the ordinary sewer, since the process of decomposition is constantly going on in the slimy coat which lines the interior of the pipes; and it is for this reason that it is so important to secure thorough ventilation of all the soil-pipes in a building. When this ventilation is secured, the proportion of dangerous gas in the pipes becomes very small, and the amount absorbed by the water in traps is almost inappreciable. The chief danger to life from sewer and soil-pipe air arises from the presence of minute particles of organic matter, dead and living, the so-called germs. Danger to life from these germs cannot be entirely removed by dilution, as can be done with gases. It has been found by the experiments of Dr. Carmichael and Dr. Wernick that an ordinary water-trap entirely prevents the passage of these germs, and that organic putrescible fluid will remain unchanged when exposed only to the air immediately above such a trap. A pin-hole or minute sand-crack in the soil-pipe, or a very slight defect in a joint, is far more dangerous than a trap.
The forms of disease produced by sewer air and its contents are more especially diphtheria, typhoid fever, and ill-defined disorders of the throat and digestive organs. It is possible that the germs of other specific diseases, such as scarlet fever, may be at times transmitted through sewer air, but such transmission must be very rare. While it is true that the germs of the specific diseases are very rarely present in sewer air, the house system of sewerage must be arranged as if they were always present, in order to obtain security. It must also be remembered that a system originally well planned and properly constructed will not always remain so; the pipes will corrode, the joints will become loosened, the valves will become clogged, and whenever alterations or repairs are made there is always danger of injury. Bearing these points in mind, the method of investigating a system can be readily understood.
The first step is to ascertain whether there is a trap outside the house disconnecting the sewer from the house system and permitting inspection. If there is not, the first thing to be done is to make an excavation and open the drain at the proper point for placing such a trap. The next step is to set the water flowing in the various closets and watch the flow at the external trap, or opening, which has been made to ascertain whether there is any obstruction in the pipe within the house. If the sewer is properly arranged for inspection, as has been above suggested, to determine whether there is any leakage from the sewer under the house will be an easy matter; if, however, it is buried beneath the cellar floor, as is usually the case, an excavation should be made along the floor in the line of the pipe, with a view to having it properly arranged, as well as for the purpose of examining the soil. It may also be tested by opening the upright soil-pipes at the farther end of the house-drain at the height of three or four feet above the floor and pouring water into it, having temporarily stopped up the drain at the external trap or opening. If the water remain at a constant level in the upright piece, the sewer is water-tight; if not, the leakage may be ascertained by the rate at which it sinks. Having settled this, the next point is to determine whether all the soil-pipes are air-tight and properly trapped. The test usually applied for this purpose is the pouring of a small quantity of strong oil of peppermint, followed by a dash of hot water, into the top of the soil-pipe, which should always pass through the roof and be freely opened to the outer air. If the odor of the oil is perceptible in the house, it indicates a leak, which must be further sought for. Ether may be used for the same purpose. The smoke test is, however, the best, but it requires a special apparatus which as yet is little used in this country. It is applied by a small machine with a fan, by which the smoke from burning cotton-waste saturated with oil, or of coarse brown paper impregnated with sulphur, can be blown into the pipes; this locates leaks with great precision.
It is not, of course, expected that a physician will personally make the examination necessary to determine whether the plumbing of a house is in good order, but he should be able to make it, if necessary, if for no other purpose than to know whether the inspector employed for the purpose understands his business.
The dangers to health from a properly-constructed system of house sewerage, such as is now generally agreed upon by sanitary engineers, are so very small as to practically amount to nothing, being, in fact, less than those of a well-kept yard privy of a country house, setting aside altogether the question of water pollution. The real difficulties in the way are the expense of such a system, which is considerable, and the finding of skilled and honest workmen to construct it and keep it in repair. Not every one who chooses to style himself a sanitary engineer or a sanitary plumber is to be regarded as such, by any means, but the physician should make it his business to know who are really reliable in this respect, for he will constantly be called in for advice on this point by those who have learned that good plumbing is the only true economy, but who do not feel themselves competent to distinguish between good and bad work. The main points of a satisfactory system are the following.3
3 For further details consult the following: American Sanitary Engineering, by E. S. Philbrick, N.Y., 1881; House-Drainage and Water-Service, by James C. Bayles, N.Y., 1878; "House-Drainage and Sanitary Plumbing," by W. P. Gerhard, in Fourth Annual Report State Board of Health Rhode Island, 1882; The Sanitary Engineer, a weekly journal published at 140 William St., New York City.
1. All soil- and waste-pipes should be extended up to and through the roof, and be freely open at the top. The extension of the soil-pipe should be full size—i.e. from four to six inches in diameter.
2. There should be a fresh-air inlet in the house sewer just outside the house, and between this inlet and the main sewer should be a trap so arranged as to permit of inspection. This prevents the ventilation of sewers through the soil-pipes. If a perfect system of sewers, uniformity of house-connections, and uniform height of houses could be guaranteed, this inlet and trap would not be so necessary, although even then it would be useful.
3. Every water-closet, wash-bowl, bath-tub, sink, etc. should have a trap placed as close to it as possible. This trap is desirable, whether the discharge be into the sewer system or not. For example, a kitchen sink, the pipe from which passes to the outer air and discharges there, should be trapped, for this pipe is foul, and if it be untrapped will act as an air-inlet.
4. The nearer to the soil-pipe that the fixtures can be arranged the better. It is especially desirable to avoid the necessity for long horizontal waste-pipes from stationary waste-bowls and from bath-tubs.
5. Bell traps, D traps, bottle traps, and mechanical traps are objectionable. The S trap is, upon the whole, the best, but it should be provided with a vent-pipe to prevent siphonage.
6. The best kind of water-closet for general use is probably some form of what are known as the wash-out closets. They are made in one piece of earthenware, have no machinery inside them, have a quantity of water in the basin into which the excreta drop, and do not require a separate trap beneath them. Each closet must, however, be carefully tested by itself: a very small warp or twist produced in the baking may so interfere with the siphonage as to make it practically worthless, and the basin cannot be altered or repaired. For use in public places some of the hopper closets are very satisfactory, the best which I have examined being the Rhoads Hopper and the Hellyer Hoppers. Where there are no children, and it is certain that the fixtures will be used with reasonable care, valve closets may be used. No form of pan closet can be considered as satisfactory, nor have I found any form of plunger closet that I would specially recommend.
7. Water-closets should always be flushed from a special tank provided for the purpose, and never direct from the main system of water-pipes. The flush must be large and rapid, and this requires a large supply-pipe, and for many forms of closets a flushing rim. Whatever be the form of closet, it should not be encased in a wooden box or closet, as is usually done, but it should stand freely exposed to light and air. Sanitarians commonly advise that water-closets should be located in outer walls and have an open window for ventilation. Such a position is usually impossible, and is not specially desirable in our climate. The open window acts as an inlet quite as often as it does as an outlet, and the air of the closet is thus swept into the house. The room should be ventilated in such a way that the tendency of the air at the door shall always be from the house into it. This is to be effected by a shaft passing through the room up and through the roof; and it is well to have this shaft take its air-supply from just behind the closet or from beneath the seat. It is best made of galvanized iron, and at a convenient point should be expanded into a lantern and have a gas-jet placed in it. The air-supply for the closet is to be taken at the bottom of the door or through a transom or louvres. Ventilating pipes from a water-closet should never be run into a brick flue. While it is not so important as many writers seem to think that a water-closet should be placed on an outer wall, it is very important that it should be as light as possible, and the placing it in a dark corner in the basement or under the stairs is very objectionable.
8. No overflow-pipe from any cistern or tank, except the one used for flushing water-closets, should be connected with the soil-pipe or sewer. Trapping such an overflow-pipe does not prevent the danger. The same rule applies to waste-pipes from refrigerators and to the waste-pipes from the safes which are commonly placed beneath fixtures.
9. Grease-traps placed inside a house—for instance, beneath the kitchen sink—are of very doubtful expediency, and if they cannot be placed outside, they had better not be used at all.
In an unsewered city one of the first things to be considered in a sanitary inspection is the manner in which the sewage of the premises is disposed of. The question is, however, by no means superfluous in many sewered cities, for cesspools and vaults are to be found in most of them, and not only in yards, but beneath houses, and houses of the better class. A privy-vault or cesspool beneath a dwelling or near its cellar walls is always to be considered as very dangerous, for it is practically impossible to prevent the passage of gases from it into the interior of the house. A cesspit is a dangerous thing anywhere, even in the country; but in a city it is so dangerous that its existence should not be permitted.
If the water-supply of a house is derived from a well, and there is reason to suspect that this may have been contaminated from a neighboring privy-vault, the first test to be applied to the water is that for the detection of chlorides. If none are present, the water is not polluted. If they are present, the quantity is to be noted, and a peck or two of common salt is then to be thrown into the suspected vault. If repeated examinations of the water show a marked increase in the amount of chlorides present, it may be inferred that the contents of the privy pass to the well. The fact that the water of infected wells and springs is usually much liked and sought for is to a considerable extent due to the presence of these chlorides. Wanklyn recommends the addition of 50 grains of common salt per gallon to drinking water to render it palatable. Popularity of a certain well is therefore a reason for suspecting its purity.
This subject may be dismissed with one caution. Taking the dwelling-houses of a city or town as they come, it will be found on examination that over half of them would be described by a competent inspector as being in a condition which might produce disease. It is therefore more than an even chance that in any case of disease some sanitary defect will be found about the premises quite irrespective of any direct causal connection with the case. Let the physician therefore be cautious in deciding as to such causal connection, and not conclude that because a case of diphtheria or typhoid fever and a leaky soil-pipe occur in the same house, therefore one is the cause of the other. Such cases occur in houses whose sewerage is perfect and in houses which have no sewerage, and it is folly to attribute them exclusively or mainly to sewer gases.
The same caution applies to investigations into the causes of a sudden outbreak of disease in a community where a number of cases occur almost simultaneously or in rapid succession. Such an outbreak may be due to direct contagion, although sometimes very difficult to trace; as, for example, an explosion of small-pox in a community largely unprotected by vaccination, and where, owing to circumstances connected with the first few cases, a large number of persons have been exposed to the cause about the same time. The same applies to an apparently sudden development of yellow fever throughout a city.
Another cause of such outbreaks is a polluted water-supply, as in some epidemics of diarrhoeal disease or of typhoid fever. If the outbreaks of these diseases are pretty sharply localized, and depend upon the fouling of a well or wells, it will usually not be very difficult to trace this cause. If, however, the town has water-supply by means of pipes from a single source, while the outbreak of disease is limited to a part of the town or to a single large building, it will probably be almost impossible to establish any connection between the disease and the drinking water. The possibility of the contamination of a part only of a system of general water-supply by means of the drawing of foul air into the temporarily empty pipes connected directly with a water-closet flush should never be forgotten, for such a case has actually occurred, and the account of its discovery is one of the best pieces of sanitary detective work with which I am acquainted. If the outbreak of typhoid fever cannot be traced directly to the water-supply, the next point to be investigated is the milk, and after that other possible modes of the conveyance of the contagium.
In cases of obscure disease characterized by fever of no definite type, disorder of the digestive organs, headache, malaise, etc., and which seem to be connected with residence in a particular house or in one room in a house, the possibilities of arsenical poisoning from wall-paper or hangings should be remembered, for much useless medication and some real danger will be avoided if this cause be promptly recognized. The effects produced by arsenical dust are very various, and simulate sometimes some of the specific fevers, indigestions, or neuroses in a way that is very puzzling if the true nature of the case is not suspected. The popular notion is that arsenic is found only in greens (more especially in bright greens in wall-papers), whereas in fact it is found not only in dull greens, but in some browns, grays, and dull reds. The test for its presence in quantity sufficient to be a cause of disease is an easy one, and is fully given in any manual of chemistry or toxicology.
VI. OCCUPATION.—While the effects of occupation upon health are no doubt great, they are in many cases so blended with those of condition in life, including habitation, food, and intemperance, that it is very difficult to distinguish them. In attempting to investigate these effects by means of statistics, it is necessary to beware of a fallacy which not unfrequently vitiates the conclusions drawn from otherwise carefully prepared tables intended to show for different occupations either the relative mortality or the average age at death. This fallacy lies in the fact that the number of persons engaged in each business is unknown; that, in this country at least, men often change their occupations; and that certain trades or professions are chiefly carried on by persons of certain ages. This last is perhaps best illustrated by the remark of Dr. Farr, that the fact that the average age at death of second lieutenants is much less than that of major-generals proves nothing with regard to the comparative healthfulness of the two grades. Statistics showing merely the number of a particular class or grade dying in a given time are absolutely worthless, unless the number of the same class or trade living at the same time is also given.
It is also necessary to bear in mind the power of habit and the effects of natural selection, especially when the effects of an unhealthy occupation are immediate and marked upon those unfitted for them. For example, young men, when first employed as scavengers or in sewage-pumping works, usually suffer from disorders of the digestive organs. A certain number find it necessary for their health and comfort to soon leave the business; some acquire protection by passing through an attack of fever; and by this process of selection a class of men are obtained who seem to thrive in the midst of filth and remain unaffected by effluvia which will promptly cause illness in those unaccustomed to them. When men find that, to use a common phrase, they "cannot stand" a particular kind of work, they are apt to give it up and try something else, especially if the effects are prompt and well marked.
Much attention has been given of late years in England, France, and Germany to the means of protecting both the workmen and the neighborhood from the ill effects of dangerous and offensive trades, and the reports of the medical officer of the Privy Council and of the Local Government Board are a mine of information on this subject. It may be truthfully asserted that in those trades in which the special danger is caused by dust of various kinds, or by gases, or by metallic poisons—and these three include the greater number of the dangerous occupations—it is almost always possible to so arrange the work as to make it comparatively healthful and harmless. Overcrowded and unventilated workrooms are responsible for much disease, and when to these is added the risk of metallic poisoning, as is the case with printers, artificial-flower makers, etc., bad results are almost sure to follow. It is curious that so comparatively little ill effect seems to be produced by exposure to great heat, as in stokers, foundry-men, glass-blowers, etc.; but further information is needed on this point as to the real facts in the case. In some occupations the chief evils arise from want of out-door exercise, a subject which will be considered presently. The want of useful or interesting occupation sometimes becomes indirectly the cause of disease among the wealthier classes, and the giving a man or woman something to do is in such cases the best prescription which can be made. This danger is especially apt to occur in the case of an active, energetic man who retires from business, intending to spend the rest of his life in pleasure and in the enjoyment of the fruits of his industry: the preventive or remedy is obvious.
VII. FOOD.—The comfort, energy, usefulness, and moral character of a man depend largely upon his digestion, and this in turn depends largely on what it has to act upon—viz. food. There are, it is true, many men who boast that they can digest anything, and who are really comparatively indifferent as to the kind, or mode of preparation, of the food set before them, so that the quantity be sufficient; but were it not that habit and heredity—which is the family habit—combine with natural selection to adapt men to their food, it is probable that the frying-pan, the pie, and soda-bread would depopulate large portions of this country. As it is, there can be no doubt that fried food swimming in grease, leathery, sodden pie-crust, and heavy bread tend to make life short and the reverse of merry; and when the effect of these is combined, as it often is, with those of malaria, damp soil, and a free use of whiskey, the result is plenty of work for the doctor and very little to pay him with. This state of things is being gradually improved, but in all classes of society and in almost all parts of the country the rule is, that while the raw materials of food are abundant and of excellent quality, the cooking is bad. This is due, in part, to an idea that it is to a certain extent discreditable to a person that he should give much attention to his food, at least so far as its appearance and taste are concerned, and that a man who can plan a good dinner must be more or less of a sensualist and a glutton.
Another popular error is, that a large amount of disease is due to overeating, and that abstemiousness in diet is either certain to secure health, or is, at all events, indispensable for this purpose. Upon this point the reader should consult a capital paper by Dr. Austin Flint on "Food in its relations to personal and public health," which will be found in vol. iii. Reports American Public Health Association, N.Y., 1877. After remarking that many of the popular errors about food and diet are relics of old and abandoned medical theories, one of which is embodied in the not uncommon advice that one should always stop eating before the appetite is fully satisfied, and that food should only be taken at regular fixed periods, no matter how hungry one may be, he says: "Physiology, experience, and common sense are alike opposed to these popular notions relating to food. Conditions for perfect health are, first, a sufficient appetite; second, the gratification of normal appetite before the want of food reaches the abnormal degree expressed by hunger; third, the satisfaction of appetite by an adequate quantity of food. These conditions of health are fulfilled by compliance with instructive provisions for alimentation. But, it will be asked, is appetite infallible as a guide in dietetics? Following it as a guide, is food never taken beyond the requirements of health? I answer, It is a reliable guide under normal circumstances. The inevitable circumstances of life are often not altogether normal, although producing no distinct morbid affection. Experience teaches, for example, that in a state of fatigue or exhaustion (which is not a normal state) inconvenience may arise from the full gratification of appetite; that if unusual exertions, mental or physical, are to follow, a hearty meal may occasion disturbance; and other examples might be added. Irrespective of abnormal or disturbing influences, if appetite be not infallible, it is, at all events, more reliable than a rule based on theoretical ideas, popular notions, or on purely physiological data. Moreover, it was evidently not intended that the quantity of food should be accurately adjusted to the needs of the economy. To do this is impossible, and therefore it is necessary to elect between the risk of taking either more or less food than is actually required. Which is to be preferred? Undoubtedly, it is vastly better to incur the risk of taking too much than that of taking too little. Nature provides for a redundancy, but there is no provision against a persistent deficiency. Ex nihilo nihil fit. An ample supply of alimentary principles is indispensable to nutrition; and inasmuch as the supply cannot be made to contain precisely the needed amount of the different alimentary principles, we may say that a superabundance of food is a requirement for health.
"As in appetite we have a guide in respect of the times of taking food and the quantity to be taken, so taste is a guide in respect of the kinds of food required. The discrimination of food with reference to the wants of the system is the evident purpose of the sense of taste, and the enjoyment connected with this sense was designed to afford a security, in addition to appetite, for adequate alimentation.
"Among professional men and those who live sedentary lives the mistake is not uncommon of paying too much attention to the sensations after a meal, and deciding therefrom whether certain articles of food are unhealthy or not. If the man who does this is not already dyspeptic, he will pretty surely become so. The remedies in this case are exercise and attracting the attention to something else."
A physician ought to understand something of cooking, and a short course of practical instruction in what might be dignified as the culinary laboratory would be of more real value to him than some of the branches which are now considered indispensable in the medical curriculum. He should know why oysters are the best thing with which to begin a dinner, and why a cocktail is one of the worst; how to make a salad, or a cup of good coffee, or a perfect consommé; and a number of other things pertaining to gastronomy of which most people are woefully ignorant.
It is not within the scope of this paper to give details with regard to the diet of either the sick or the well, but it seems proper to remark with regard to the feeding of infants, more especially in our large cities in the summer months, that all the various patent preparations for infants' food are more or less pernicious, and should be discountenanced by all medical men. The proper food of an infant is milk—human milk if it can be had, cow's milk if it cannot. If it be remembered that an infant suffers from thirst as well as hunger, and care be taken to give it enough pure cool water to quench this thirst, it will be found that in most cases it will thrive on pure cow's milk.
With regard to adulterations of food, the only form of such adulteration found in this country, which has any special interest from the sanitary point of view, pertains to milk. This adulteration is in most cases the dilution of the milk by water, and this is very common in large cities. The danger from the use of such milk is by no means confined to infants, and it is probable that a larger proportion of the typhoid fever, diphtheria, scarlet fever, cholera infantum, and diarrhoeal diseases in our cities is due either directly or indirectly to the milk-supply than is now even suspected. The possibility of this mode of origin should always be borne in mind in investigating the causation of such affections.
A very large amount of food is now furnished preserved in tin cans, and it is almost invariably of excellent quality. There is a possibility of the contamination of such food by the salts of lead or tin, but such contamination to an extent which is injurious to health must be so extremely rare as to be hardly worth considering. The danger from the entrance of parasites, such as trichinæ, etc., in the food is also extremely small—in fact, is nothing where the food is properly cooked.
Milk has so often been the cause of disease, and is so universally used, that it seems worth while to refer to it again. The special aptitude of milk for absorption of odors has long been known, and of late years it has been clearly proven in a number of instances that milk has been the means of conveying the cause of typhoid fever and of scarlatina. Diphtheria, yellow fever, and intermittent fever have also been supposed to be conveyed by milk. The variety of nutritive principles contained in milk, which makes it so valuable as a food, also gives it the power of sustaining many different sorts of minute organisms, and it perhaps comes as near being a universal culture-fluid as anything yet devised for that purpose. The possibilities of the contamination of milk are so numerous, and especially in the case of that furnished from small establishments, that, in the case of outbreaks of typhoid or diarrhoeal diseases in a town, investigations into causation should always include the milk- as well as the water-supply. Milk from diseased animals is no doubt often used without producing bad results, but its effects in conveying to man the disease known as milk-sickness are well established, and it has also been known to produce symptoms of the contagious aphthæ, or foot-and-mouth disease, in man, when derived from an animal affected with that disease. The only danger in the use of the milk of animals fed upon sewage-grown grass appears to be in the possible contamination of the milk, after it is drawn, by particles of dust in the stable, derived from the food or litter of the animal or from uncleanliness of the exterior of the udder, etc.
VIII. INTEMPERANCE.—Every one knows that alcoholic drinks are the cause of a vast amount of disease, crime, and misery in all civilized countries. No one knows how this is to be prevented, for no one knows how to make the great mass of the people wise and contented. The effects produced by excessive use of alcohol are well known to all physicians, and the remedy is self-evident. I see no use in adding to the heap of useless rubbish which exists in the shape of the great mass of existing popular literature on this subject, and therefore leave the subject to the reader, who is quite sure to know all that is really important on this subject.
IX. CLOTHING.—The hygiene of clothing is also a subject which may be treated summarily in this paper. People wear what they can afford, made according to the prevailing style. Diseases due to insufficient, excessive, or badly-fitting clothing occur most frequently in women and children, and the use of such clothing is for the most part due to poverty or fashion, either of which is beyond the power of the physician to successfully cope with. Here and there, in individual and exceptional cases, he may be able to do a little good by advising against tight lacing, high-heeled shoes, insufficient covering for the chest or legs, etc., and he will find that a knowledge of the peculiarities of the various styles of modern under-clothing will sometimes be very useful. Men are, as a rule, comfortably and sensibly dressed to suit their business and surroundings, and require no advice on this subject.
X. EXERCISE.—The ease and completeness with which the functions of an organ or of an organism are performed depend to a great extent upon the frequency and regularity with which such functions are exercised. Hence comes the importance of bodily exercise for the preservation of health, and every physician meets cases of disease due largely to want of work.
The term "exercise," or "bodily exercise," is commonly used as if it referred only to the muscles, and the amount of exercise which a man should take in a day is stated as equal to a certain number of foot-pounds. The mere giving work to muscles is not, however, exercise in the sanitary sense. A better definition is that of Du Bois Reymond—viz. that "exercise is the frequent repetition of a more or less complicated action of the body with the co-operation of the mind, or of an action of the mind alone, for the purpose of being able to perform such actions better." From this point of view it will be seen that exercise relates quite as much to the nervous system as to the muscles. When, for example, a student takes a walk over ground with which he is familiar, and is at the same time so deeply engaged in thought as to be practically unconscious of what he is doing, only being recalled to himself, it may be, by arriving at his own door, the exercise which he has had is but partial and insufficient. Going to the extreme, we can, as Du Bois Reymond remarks, conceive of a man with muscles individually exercised until they were like those of the Farnese Hercules, and yet who would be unable to walk, much less execute more complicated movements; for the proper co-operation of the muscles, which is effected through the nervous system, is quite as necessary as the force of their contraction.
The amount of exercise which is necessary for health varies with the individual and with age, season, etc., so that it is difficult to state any general rule upon this subject; but if stated in terms of muscular force only, the estimate of Dr. Parkes seems a fair approximation—viz. that every healthy man ought to take daily an amount of exercise equivalent to 150 tons lifted 1 foot, or a walk of about nine miles. The majority of trades and bodily occupations demand at least this amount of work, but in some of them the greater part of the exertion is made only by certain groups of muscles, and they are carried on in crowded and ill-ventilated shops. Such workmen, as well as all who are engaged in sedentary pursuits, require exercise in the open air—exercise which will bring into play the unused muscles and will break the train of thought of the professional man.
One of the most important questions with regard to physical exercise is the extent to, and manner in, which it should be provided for in a proper system of education. One of the latest and most instructive articles on this subject is that by Du Bois Reymond in the "Physiology of Exercise," a translation of which is given in the Popular Science Monthly for July and August, 1882. He divides the physical training which is more and more becoming a part of modern systematic education into three classes: The first, the turning, or gymnastics of the Germans; the second, the Swedish system, in which the exercises are limited to very simple though varied movements; and the English system, or rather want of system, consisting largely of athletic games and contests of various kinds. His objection to the Swedish system is that, while it strengthens the muscles, it does not increase the power over composite movements; in other words, it does not exercise the nervous system. Naturally, he prefers the German system to any other, although admitting that the English meets better the demands arising from our structure. "Were the end masterhood in running, jumping, climbing, in dancing, fencing, riding, in swimming, rowing, or skating, then nothing could be more advisable than to practise equally the necessary concatenations in the actions of the ganglion cells, without pausing at the not practically applicable preliminary and intermediate steps of the German turning."
From a sanitary point of view, the gymnasium, as usually located and managed, is by no means equivalent to out-of-door sports and contests, although it is often the best substitute for them. The form of exercise most used by men whose occupation does not involve bodily labor is walking, and next to this riding. Whatever mode be selected, it is very desirable that it should be taken for some other object than that of the mere making muscular exertion, or otherwise it will soon come to be looked upon as an unpleasant task, the time spent upon which is given grudgingly; and it will be partially or wholly abandoned as soon as the immediate discomfort which induced its use has ceased.
It is not an uncommon error among men engaged in mental work to suppose that they can, and ought to, take the same amount of exercise which gives good results in those whose occupations involve physical rather than mental effort, or to think that the more exercise they take the more study or writing they are equal to. This is a grave mistake. Expenditure of brain-tissue is not to be repaired by muscular exertion, but by sleep and food, and exercise in the fresh air sufficient to produce appetite and sufficient weariness to ensure restful sleep is all that is necessary. For a time it is true that the student or writer who has a well-developed body can continue to burn the candle at both ends, and win literary honors while also standing high as an athlete; but this surely leads to physiological bankruptcy in the end.
It is to be remembered that good muscular development is not necessarily synonymous with health, and that strength is not a guarantee against disease. And, while it is true that in this, as in most other matters of individual hygiene, each man must to a great extent be a law to himself, and learn by experience what kind of exercise and how much of it he requires, yet the physician can often supply the motive which was wanting, or check undue effort. Exercise for the sake of health and comfort is not an end, but a means; yet if this means can be made to secure to the patient an end agreeable and pleasant in itself, so much the better.
XI. CONTAGION AND DISINFECTION.—By "contagion" we mean the communication of disease from one person to another, either by direct contact or through some medium, such as air, water, etc. It therefore includes "infection," which is now generally used as a synonym for it. The so-called infective diseases of modern German writers (Infections-Krankheiten) include, besides what are commonly termed in English, contagious diseases, the so-called miasmatic diseases.
The characteristic of a contagious disease is its specificity; that is, the disease transmitted is always the same in its essential characteristics. It does not, however, follow that all cases of the disease are equally liable or have the same power to transmit it; in other words, the degree of virulence of the contagiousness is not an essential characteristic. That the same disease sometimes spreads rapidly and is very fatal, and at other times seems hardly to have any contagious properties and is very mild, has long been noticed, and has been attributed to an unknown something called the medical constitution of the place—the constitution médicale of French writers. The true cause is probably very complex, but in some cases, at all events, it seems to be due to difference in the contagion itself. If we suppose this contagion to be a minute organism, it is easy to form a theory as to the cause of these differences, but there is much careful experimental work to be done before we shall have positive knowledge on this point. The results obtained by Pasteur in attenuating the virus of chicken cholera and splenic fever indicate one line which these experiments will take, and the researches of Koch point out another.
The diseases which spread by contagion until they form epidemics are those which have from the earliest times attracted the most general attention, and which have given rise to organized efforts for prevention—i.e. to public hygiene.
They are also the diseases which have given rise to the most bitter controversies among medical men as to the means of their propagation and the best methods of prevention. Plague, cholera, yellow fever, and typhus are those with regard to which this difference of opinion has chiefly occurred—one party considering their chief cause to be contagion, or specific germs derived directly or indirectly from the bodies of the sick; the second party declaring that they are due to filth plus an unknown something, which is variously termed epidemic constitution, pandemic wave, Providence, or x. The great majority of opinions at present is in favor of the view that they are all contagious, but not all, or always, contagious from person to person—that they spread from infected localities, which localities receive their infection from cases of the disease. The best means of dealing with them under ordinary circumstances are now tolerably well understood, and where these means can be commanded—as, for instance, among troops in time of peace—epidemics of these diseases can be stopped with great precision and promptness by isolation and disinfection.
By "isolation" is meant not only the separation of the sick from the well, but the isolation of the infected locality or water-supply until it has been rendered harmless.
By "disinfection" is meant the destruction of the specific causes of disease, and more especially of the infectious or spreading diseases. A disinfectant is not necessarily an antiseptic or a deodorant, nor are these last necessarily disinfectants. The best practical antiseptic for sanitary purposes is cleanliness; the best disinfectants are heat, bichloride of mercury, sulphate of iron, chloride of zinc, sulphurous acid, chlorine, sunlight, and pure air, and, for yellow fever, cold. With our present very imperfect knowledge of the nature of specific causes of disease which we wish to destroy, we have no means of determining the presence of these causes in or on an article of clothing or of furniture, or in a room or other locality, except by the production of their specific effects on man or by inductive reasoning; in other words, we can only say that it is more or less probable that such causes are present. This makes it necessary, or at least expedient, to employ disinfectants in many cases where the presence of such causes is doubtful. The practical difficulties are, first, to bring the disinfecting agent into such relation with the causes of disease that it can act upon them, and act upon all of them; second, to avoid unnecessary destruction or injury of things which should be preserved. The majority of the causes of disease upon which we wish to act by disinfectants are probably minute particles of solid or semi-solid matter which are living, and may be conveniently designated by the word "germs." In the presence of moisture the destruction of the vitality of these germs can be effected with comparative ease and rapidity, but when they have become dried, or, as in the case of the bacilli, are in the form of spores, it is a more difficult matter.
To illustrate the methods to be pursued and the precautions to be taken, let us suppose the physician to be called on for directions as to the management of a case of scarlatina, the object being to prevent its spread. The first thing to be done is to get the patient in a room by himself, and to leave nothing in this room which is not necessary. Remove the carpet, curtains, and all stuffed or upholstered furniture. Let the nursing be done, as far as possible, by one person only, and do not allow others, and especially children, to enter the room, no matter if they have had the disease. The danger of contagion depends upon particles coming from the skin and mucous membranes. All excreta, and more especially the sputa or discharges from the mouth or nose, are to be treated as dangerous. The excreta should be received in vessels containing a solution of sulphate of iron, one and a half pounds to the gallon. All clothing, towels, bed-linen, handkerchiefs, napkins, etc. should be placed in a solution composed of four ounces of sulphate of zinc and two ounces of common salt to the gallon of water as soon as they are not needed for further use. Especial care should be taken that none of these articles are removed from the room while dry, and while they are in the room, and before they have been moistened, they should not be shaken or disturbed more than is absolutely necessary. If for any reason the zinc solution above referred to is not at hand—which should very rarely be the case—the clothing, etc. should be placed in a bucket, tub, or boiler containing enough scalding water to entirely cover them, and be removed from the room in this vessel. All such articles should be boiled at least one hour.
No sweeping or dusting in the ordinary way is to be done in the room; dust and dirt are to be removed by damp cloths, which are to be treated like the bedding and clothing. The great object is to prevent as far as possible the production of dust in the atmosphere of the room. The entire body of the patient, including head, face, and limbs, should be kept thoroughly anointed with camphorated oil, vaseline, or some similar substance, and especial care should be taken in this respect during the period of convalescence so long as any roughness or desquamation of the skin continues. No toys or books which it is desired to preserve should be allowed to remain in the room, and under no circumstances should books or toys be borrowed to amuse the child if they are to be returned. The best way to disinfect such articles is to burn them in the room.
When the patient is fully convalescent and all desquamation has ceased, cleanse him thoroughly with a warm bath and soap for four successive days. If at the end of that time no roughness of the skin remains, he may be dressed in clean clothes and taken from the room, for he is no longer a source of danger. The room itself and the furniture are then to be thoroughly cleansed and disinfected. The ceiling and walls, if of ordinary hard finish, are to be scraped and whitewashed. All woodwork should be rubbed with damp cloths and the floor well scrubbed. Care should be taken to remove all dust from the ledges over windows and doors. All the cloths used in this cleansing process are to be burned.
If these directions have been carefully carried out, there is no need for further disinfection. But if upholstered furniture has been allowed to remain in the room, or other articles which cannot be burned or scrubbed or soaked in the zinc solution, it may be desirable to attempt to disinfect the whole room and its contents by means of chlorine or sulphurous acid gases. Of these, sulphurous acid gas is the cheapest, and upon the whole the best, but it must be used in large quantity, and for a longer time than is customary, if it is to be relied upon. For this purpose all openings into the room should be closed, and pillows, mattrasses, upholstered furniture, and articles which cannot be treated with the zinc solution should be opened, so that they may be exposed throughout to the fumes. The sulphur should be burned in an iron pan or pot, placed in a tub containing water or upon a large surface of sand. About 18 ounces of roll sulphur should be used to each 1000 cubic feet of space, and after twenty-four hours 12 ounces more should be burned and the room be then closed for twenty-four hours longer, after which it may be opened and aired. In case of death the body should at once be wrapped in a sheet thoroughly soaked with the chloride of zinc solution, and either be placed in an air-tight coffin at once or be buried without delay. The funeral should be strictly private, and the sheet referred to should not be disturbed or the body exposed to view.
The cases most liable to spread the disease are those in which the attack is very light and the child is not confined to its bed. It is desirable that children in a house in which there are cases of scarlet fever should not be allowed to attend school or mingle with other children who have not had the disease.
With regard to disinfectants, it may be well to note that none of the various patent disinfectants are superior to bichloride of mercury, chloride of zinc, sulphate of iron, chlorine, and sulphurous acid; very few are equal to them, and none cost so little. As a gaseous disinfectant for rooms, etc. chlorine is superior to sulphurous acid, but it has the disadvantage of injuring metals, is not so easily applied, and is more costly. It will destroy the vitality of the spores of the bacilli more rapidly and certainly than sulphurous acid, which last, to make sure work, must be exhibited for a much longer period than is customary. I should not feel confident as to the thorough disinfection by sulphurous acid of the hold of an infected ship unless the fumes had been applied for sixty hours. Carbolic acid as ordinarily used is an antiseptic rather than a disinfectant. Its vapor in a sick room is absolutely useless. When applied in strong solution it is effective, for a time at least, but as thus used it is expensive, its odor is unpleasant to many, and masks the odors from putrefying substances and excreta, etc., thus preventing the warning which these odors would give. Its use is in many cases very much like removing the rattle from the rattlesnake.
The suggestions made above for limiting the spread of scarlatina from a case to be treated in the residence of the patient apply—with certain modifications for each form of disease, which will readily suggest themselves to the physician—to all the affections due to portable contagia.
Among the poorer classes, however, it will often be found impossible to obtain the separate room and service and the constant intelligent care which are necessary to ensure the desired result; and in such a case the patient should be removed to a hospital, for his own sake as well as for that of the community. The utility of small hospitals for infectious diseases is by no means generally understood, and very few of our small cities and towns are provided with anything of the sort. If the subject is urged on the authorities of a place, the reply will be that it is an unnecessary expense, that the people would not go to it, and that such an institution is in itself a source of danger. The facts are, that such a hospital costs very little, and is the cheapest insurance against epidemics which a town can have; if it is kept clean and comfortable, the people will use it freely, and if properly managed it does not offer the slightest danger to the vicinity. This question will be further discussed in the last section of this paper.
The principles of isolation as applied to a single case as indicated above may also be applied to infected localities in case of epidemics. When taken in time, all diseases which depend upon particulate contagia for their origin can be stamped out by isolation and disinfection. Unfortunately, to effect this promptly and successfully requires money, labor, and the co-operation of the well in the vicinity; which last it is usually impossible to obtain voluntarily or to compel sufficiently to secure the desired results. A question which sometimes arises in case of epidemics, and with regard to the necessity for which physicians will be consulted, relates to the closure of the public schools. It is certain that the assemblage of children in schools exerts a powerful influence on the spread of such diseases as scarlet fever, diphtheria, and whooping cough. On the other hand, the closure of the schools infringes upon the rights of a large number of the community, and if long continued, as it sometimes must be to be really efficacious, inflicts upon them a permanent loss. It is, moreover, a confession on the part of the authorities of inability to induce or compel what must always be a comparatively small part of the community to take the proper precautions. It is never justifiable to close schools on account of small-pox, and where there is a competent health authority supported by the influence of the medical profession, it must be a very exceptional set of circumstances which justifies their closure for diphtheria or scarlatina.
It is not deemed expedient here to discuss the vexed question of quarantine. It is more important against yellow fever than any other disease, because every day of delay of the entrance of the disease which it secures lessens largely the subsequent mortality, since the duration of the disease is limited by frost. This is not the case with cholera, and the mere keeping this disease out of a place for a few weeks does not diminish its ravages when it has once gained an entrance. To rely altogether on quarantine, either maritime or inland, to keep yellow fever, cholera, or any other disease out of this country is a far greater mistake than to neglect it altogether. The practical way to isolate and quarantine is to get as close to the affected spot as possible. Precautions at Havana for yellow fever, or at Hamburg for cholera, are far more useful to the United States than the same amount of work at our own ports can possibly be; really good work in this direction must be not only national, but international.
XII. MENTAL CAUSES OF DISEASE.—A man may give too much attention to his health and the means for its preservation, and the doing so is both a sign and a cause of disease—probably oftener the former than the latter, except in cases of psychological epidemics. The power of expectant attention, especially if accompanied by belief or fear, to produce derangement of function in the nervous system, and through this to affect the circulatory and digestive systems, is well known to medical men. The effects of an undue amount of brain-work, and especially of the anxiety and worry which often accompany this when it is specially directed to the acquiring of wealth, fame, or power, are also familiar to physicians in our large cities. The analogies between mental and physical exertion are close in some respects, and especially as to the effects of over-exertion in a limited time under the influence of excitement.
The danger from simple mental work, such as study, when there is no excitement from a contest, is small, and depends mainly on lack of physical exercise and consequent disorder of the digestive organs. The risk of producing what Fothergill calls "physiological bankruptcy" is greatest in the youth studying for a prize, the speculator, the man who feels responsibility which he knows he probably cannot meet. The danger of injury from overwork under excitement is a very real one in many of our schools, and, while the evil results are most apparent in girls of the middle and upper classes, the boys and the young men also suffer. The system of pass examinations, in which the standing of the pupil is to be determined, not from the average results of his daily recitations, but from a single examination at the end of the year, produces the greatest risks to health; and this is especially the case where the ambition and pride of the children are stimulated by competition for prizes, medals, etc. Such systems of grading by a single final examination should not be used in ordinary schools, and for some pupils there will always be a risk to health connected with them even when they are of age. No doubt the stimulus of competition is useful with the majority of children as well as of adults, but with some of them it is pretty sure to go too far.
The symptoms produced by undue mental strain are familiar to all physicians, and there is usually little difficulty in tracing the effect to the cause when attention has been directed to the matter; in fact, the patient himself usually knows very well the cause of his troubles. The remedy is, of course, rest—but that does not mean idleness. In speaking of occupation, allusion has been made to the fact that the physician must at times advise his patient as to the adoption of some pursuit, and in cases of this kind such advice is also useful.
The effects of mental strain are often mingled with, and aggravated by, those of stimulants which have been used to spur the flagging energies. Alcohol, tobacco, opium, or coffee used in this way finally increase the very discomforts which at first they relieved.
II. Personal Hygiene in its Relations to the Practice of Medicine.
In the preceding section have been indicated briefly some of the principal causes of disease and the methods for their investigation or removal. We have now to consider some of the practical applications which may be made of the laws of etiology and prevention of disease in the treatment of the sick. While the removal of the cause of illness by no means always effects a cure, yet the importance of a knowledge of this cause as an aid to diagnosis, prognosis, and therapeutics is so evident as to require no proof.
To discuss with anything like completeness the practical applications of what would be commonly considered as hygienic rules in the treatment of disease would be to write a treatise on nursing, and would also include a large part of the practice of medicine, for regimen is the more important half of practical therapeutics. The hygienic requirements peculiar to each disease will be pointed out by the writers upon special subjects, and I shall only venture upon one or two general remarks in addition to the hints already given in speaking of the several causes.
In the acute stages of disease the sensations—or, if the term be preferred, the instincts—of the patient are usually the best guide to his regimen so far as they go. In most cases he desires quiet, shade, but not absolute darkness, and little or no food, although there is often a craving for drinks, especially of a cooling character. In the specific fevers which have a tolerably definite period and course it is important to keep up the nourishment even during the period of anorexia, in order to provide against the debility which is to follow. This nourishment is best given in the form of drink, and very frequently fresh milk is the type of what is required. The old notion that whatever a sick man desired must be hurtful, and therefore that the fever patient must be kept hot and refused cool water, has now almost entirely passed away.
In convalescence from acute disease and in many chronic cases, the sensations of the patient are not to be trusted as a guide in the choice of food. In such diseases as yellow fever and typhoid fever to allow the convalescent to follow the dictates of his appetite is to run great risk of a fatal result. In other cases the patient really has no wish in the matter, but it will often be found that one who can think of nothing which he desires to eat, and who will even refuse a dish which he has requested and been thinking about, will eat with enjoyment some unexpected dainty when presented at the right moment and properly served as a skilled nurse knows how to do. The manner of serving the food, independent of its cooking, is not a matter of such small importance that the physician can afford to overlook it, and he will succeed best as a practitioner who best appreciates the influence which cracked goblet, a chipped saucer, a soiled napkin, or, on the other hand, a hot plate or a touch of color in the shape of a leaf or flower, may have upon the capricious appetite of the sick. In ordering diet for convalescence it is not an uncommon error to select only those articles which are agreeable to the physician himself, forgetting the old proverb, that what is one man's meat may be another man's poison, and also that it is above all things desirable to avoid monotony. One doctor always orders chicken, another eggs, a third a mutton-chop, etc. The practice in this respect has probably been unduly influenced by the reports of Beaumont of the results of his observations on Alexis St. Martin, and we still find that the relative digestibility of various articles of food is estimated according to the scale laid down in these reports, with no allowance for individual peculiarities, previous habits, mode of cooking, etc. The secret of success in the diet of convalescence lies mainly in the simplicity of the individual dishes, in varying the different meals, in the manner of serving, and in carefully observing the effects on the sick person, and being guided by the results.
To promote appetite and digestion, and to secure refreshing sleep, one of the most important things is fresh air, but in many houses a sick person will obtain but a very limited allowance of this if the physician does not give special attention to the matter. Except in cases of contagious disease, the rules for managing which have been given in a previous section ([p. 201]), as soon as a patient is sufficiently recovered to be moved for a short time into another room his bedroom should be thoroughly aired and cleansed, and this should be done morning and evening thereafter.
In treating cases of contagious disease the question often arises as to means of individual prophylaxis to be used by those who must be exposed to the effects of the infected locality or of the presence of the sick. The attempts which have been made to secure this individual protection in the midst of an epidemic have been numerous and varied, ranging from the use of the "vinegar of the four thieves" of the Middle Ages to the employment of the sulphites and chlorates to make the blood unsuited to the growth and multiplication of the supposed germs, or of cotton-wool respirators to strain the infected air, or of supposed specifics for particular diseases, as belladonna for scarlet fever and vaccination against small-pox. As yet, there is little or no satisfactory evidence as to the value of individual precautions against those diseases whose contagion is conveyed through the air, small-pox alone excepted, but in case of diphtheria in one member of a family of children it might be well to try the use of chlorate of potash internally, combined with the local application of the tincture of the chloride of iron, as suggested by E. M. Hunt. The question is one to be investigated by careful observation and experiment; and, though it is improbable that any definite results will be obtained except in those diseases which are communicable to animals, and therefore susceptible of direct experiment, still, it is possible that some advance may be made. In rare and exceptional cases—as, for instance, in exploring a crowded, filthy, and intensely infected typhus-fever nest, as a tenement-house, or an infected yellow-fever ship—it may be worth while for the physician or inspector who is unprotected by a previous attack of these diseases to make use of a cotton-wool respirator, which is readily extemporized, and belongs to that exceedingly valuable and popular class of remedies which, "if they do no good, can do no harm." In epidemics of typhus, cholera, or yellow fever one of the most valuable prophylactics is to have a mind so occupied with other matters that it pays little or no attention to the danger, while in case of small-pox fear of the disease is indirectly the best prophylactic, since it leads to careful vaccination.
This branch of the subject is closed with the remark that it would be well if physicians, and especially the younger ones, gave more attention to the preservation of their own health than many of them do. The possession of a medical diploma does not prevent the evil effects of irregular and hurried meals, insufficient sleep, exposure to inclement weather, and lack of systematic and sufficient exercise; and too much tobacco, sometimes too much alcohol, and in exceptional cases too much study and literary work, so often combine with anxiety about individual patients or with pecuniary worries to damage the digestion and nervous system of the young practitioner that the wonder is that so many survive the ordeal. And, in fact, the mortality among physicians under the age of thirty is higher than that of any other profession during the same period of life.
III. Public Hygiene in its Relations to Physicians.
An important difference between man and animals is found in the extent to which he will sacrifice a present pleasure or convenience to secure a future good or to avoid a future evil. The savage will do this to only a very limited extent—little more, in fact, than the beaver or the squirrel—and the lesson is learned but slowly and by sad experience. This is especially the case as regards matters affecting health. When a man begins to take special precautions as to his diet or exercise, having in view rather his future health than his present comfort and tastes, he has in most cases already begun to suffer from the effects of his imprudence, and does not commence a hygienic course of life as a perfectly sound and healthy person. The same is true for a community. It will not usually submit to the burden of taxation necessary to secure drains and sewers or a proper registration of vital statistics, nor to the cost and inconvenience of the machinery necessary to limit the spread of contagious diseases, until the neglect of these things has resulted in such an amount of disease and death as to forcibly call attention to the matter. The result is, that the burden is far heavier than it would have been had the work been undertaken in proper season, and individuals may find it to their interest to leave the place and settle elsewhere rather than remain and meet their proportion of the expense.
When a state or municipality has so far advanced in civilization as to consider it desirable to take measures to protect the public health by preventing individuals from polluting the air or water liable to be used by their neighbors, etc., the services of the medical profession are always called upon. The foundation of public hygiene is information as to the occurrence of certain forms of disease, the cause of which can be referred with more or less precision to a certain limited locality. This information may be very imperfect, consisting of little more than rumor and opinions as to the existence of an undue amount of sickness or mortality in a certain place, or it may consist of precise reports setting forth the number of deaths from each cause, the proportion of each of these to the population by age, sex, occupation, etc., and of the whole to births—constituting what is commonly called the "vital statistics of a place"—and also of reports of the occurrence of certain preventable diseases; and between these two the information may be of various degrees of completeness, but, whatever there be, it is for the most part obtained either directly or indirectly from medical men. The reliability and completeness of the information thus obtained by the state determines to a great extent the direction and character of the work done in destroying or preventing the causes of disease, and it is also an important means of increasing our knowledge with regard to the nature of these causes.
The character of this information depends largely upon the character of the physicians who furnish it. In a large part of the country medicine is legally in the position of any common occupation; that is, the term "physician" is defined as applied to "any one who publicly announces himself to be a practitioner of this art, and undertakes to treat the sick either for or without reward." Under such circumstances there can be no guarantee that all who call themselves physicians are properly qualified or competent to furnish reliable information for registration purposes, and, as a matter of fact, a large number are not so qualified. It is for this reason that there is such a close connection between public health authorities, registration of vital statistics, and the registration of those physicians whose certificates as to causes of deaths, etc. will be accepted by the state; and hence the nature of the public health organization of a state and the personnel of its officials are matters of great importance to physicians. On the other hand, the efficiency of a public health service depends very largely upon the relations which it holds with, and the light in which it is regarded by, the medical profession. A health officer who is distrusted and disliked by the physicians of his district cannot effect much unless he can overcome this feeling, and his tenure of office must always be very insecure.
The official relations of the practitioner with the health authorities are usually confined to the subjects of registration of vital statistics and of checking the spread of contagious diseases. The most marked exception to this rule is furnished by the States of Alabama and North and South Carolina, in which the State Medical Society is the State Board of Health, having been given legislative powers and the right of selecting the health officers. The most complete organization of this kind is that of the State of Alabama, where by the act of 1875 the Medical Association of the State was constituted the State Board of Health, and the county medical societies in affiliation with the State Society were made county boards of health, to be under the general direction of the State Board. These county boards at first had advisory powers only, and were to be conducted without expense to the State or the county, except that the competent legal authorities of any county might invest the county board with such powers and duties for the promotion of the public health as might be mutually agreed on; but in such case the right to elect or appoint those employed in sanitary administration is reserved to the board of health, while all questions relating to salaries, appropriations, and expenditures shall be reserved to the legal authorities. It was further provided "that no board of health, or advisory or executive medical body of any name or kind for the exercise of public health functions, shall be established by authority of law in any county-town or city of this State except such as are contemplated by the provisions of this act, the object of this prohibition being to secure a uniform system of sanitary supervision throughout the State." By an act of 1881 the county board is directed to elect a health officer, who is to keep a register of the births, deaths, and cases of pestilential or infectious diseases occurring in the county, and furnish to physicians, free of charge, reliable vaccine—to obtain information as to the sanitary condition of his county, etc. etc. It will be seen that this plan of organization is an attempt to overcome the practical difficulties in the way of obtaining from physicians the information necessary for the registration of vital statistics and the work of preventing the spread of infectious diseases.
While the great majority of physicians are willing to furnish the information as to the cause of death, etc. which is necessary for a useful registration, there are always some who either neglect or refuse to do so; and if the law be made compulsory, it provokes hostility unless compensation is furnished, while as regards the requiring physicians to furnish information as to the existence of contagious diseases, this always rouses opposition on the part of a certain number of medical men, even if payment for such notification is provided. And while this opposition is no doubt in many cases due to improper motives, such as personal hostility to the existing authorities, party politics, or a desire for notoriety, its strength nevertheless rests upon the fact that it is unjust for the state to compel the services of any man or class of men without furnishing compensation. The advocates of health and registration laws are thus placed between Scylla and Charybdis: if they propose compensation, which involves appropriations from the public treasury, the law cannot be passed; if there is no compensation allowed, complete results cannot be obtained.
The Alabama law makes compulsory the furnishing by physicians of information relating to births, deaths, and infectious diseases, and gives compensation—not in money, but by allowing the medical profession to have the sole management of the matter and to choose the health officers to whom they are to report; in other words, they are allowed to tax themselves. The result in Alabama is yet doubtful. If competent and faithful health officers and registrars can be obtained without paying them a fair compensation, it will be contrary to experience; and if these officers receive a salary, it will be strange if the positions do not become the reward of partisan political work.
It should be noted that the requiring a physician to report the births occurring in his practice stands on a very different basis from the requiring him to report the cause of death, since there is no special necessity for the former. It requires no expert knowledge to report a birth, and the duty should obviously devolve on the householder.
In those States in which by law only properly qualified medical men, as determined by examination, have the right to practice, to hold medical office, or to furnish medical certificates, the State certainly is entitled to require of all physicians thus registered and authoritatively recommended to the people as competent, that they shall furnish, free of charge, certificates of the cause of death in those cases where they are cognizant of such cause.
States and municipalities often demand much more than this; as, for instance, that the medical man shall fill out the whole certificate, including age, nativity, nativity of parents, etc., and that he shall furnish the information to the registrar. In some cases it is provided that any physician having attended a person during his last illness shall furnish the certificate: this would apply to cases where the physician may not have seen the case for weeks before death.
While it is most convenient to have the certificate of cause of death upon the same form which contains the data necessary to identify the individual, the certificate should be distinct from the latter, and the duty of making the return to the registrar should devolve on the householder or undertaker, and not on the physician. On the other hand, it is easy for the physician to be hypercritical in these matters: his certificate is to be considered rather as a statement of opinion than as a statement of facts within his personal knowledge, precisely as he would certify as to his own age and birthplace.
The compulsory notification of infectious diseases to the health authorities is a matter presenting much greater difficulties than that of certificates as to causes of death. The state has no right to require such notification from the physician without giving some quid pro quo, and it is not expedient to make it compulsory, even with payment, except from physicians employed by the state or municipality, to furnish gratuitous medical attendance to the poor. The state has the right to require such information from the parent or householder, and it has also the right to require the physician to notify the parent or householder as soon as he recognizes the existence of such infectious disease. It is extremely desirable that the health authorities of a city should receive promptly, and direct from physicians, notification of the occurrence of such diseases, and there will usually be no difficulty in obtaining this if the health officer has tact and discretion and the city is prepared to do its duty. This duty is not confined to registering the information or placarding the house, nor will it be properly performed by merely removing the sick person to a hospital and disinfecting the premises. If the case occur in a family which can secure its proper isolation, and the attending physician certifies that it is so isolated and makes himself responsible for its management (for which responsibility he should be paid by the patient or his friends), the health officer should not interfere nor do more than furnish a competent person to secure disinfection if required. The employment of a trained nurse known by the health authorities to be competent and reliable would do away with most of the difficulties connected with such cases in the upper and middle classes of society; and such nurses should be registered just as physicians and midwives are.
Where the case cannot be thus isolated and properly cared for, it should be removed to a proper hospital. This presupposes that the city has such a hospital, and if it has not, and is not prepared for such cases, notification is useless. When the city places a house in quarantine so as to interfere with business, it should be for the shortest possible time consistent with securing thorough disinfection of the premises, and the city should bear not only the cost of such disinfection, but the cost of caring for the persons in the house in an isolated place until no further danger is to be apprehended for them. When the city undertakes to pay all expenses for isolation and disinfection of such cases, it has the right to require that all such cases shall be so treated, leaving it to private parties to meet the cost in case they prefer not to use the buildings and apparatus provided by the city for that purpose. And when the city does its duty in this respect, it will be found that physicians and the people will do theirs, with rare exceptions.
When a city becomes very unhealthy the usual policy is to conceal the fact as much as possible, and to attribute the mortality to some other than the real cause. The influence of the mercantile part of the community is in such a case strongly exerted on the daily press and on the health authorities to produce such representations of the condition of things as will tend to allay apprehensions on the part of their customers. The healthfulness of a place is usually estimated from its mortality reports, but the reliability of these is by no means always what it should be. Yellow fever is called typho-malarial or pernicious fever, typhoid is reported as diarrhoea or malarial fever, etc. etc., and great stress is laid upon what is called the sanitary condition of the place, which is declared to be excellent.
Unfortunately, this phrase, "sanitary condition," means different things at different times. When the mortality is low, sanitary condition means the healthfulness of a place; when it is high, it means the cleanliness of a place. To a certain extent physicians are responsible for the truth of the statistical returns, not so much in relation to the number as to the causes of deaths; but none save those who have practised in a city liable to epidemics can realize the enormous pressure which is brought to bear on medical men to induce them to aid in or wink at concealing the true state of the case. Of course, this ostrich-like policy is in the long run an exceedingly unwise one, but neither the average householder nor community can be expected at present to pursue any other, except under pressure.
There are many questions as to the best form of public health organization, and the powers and duties which should be conferred upon it, which can only be properly answered by taking into consideration the circumstances in each case. In a large city the health officers must have great powers if they are to be really efficient. They have to contend with ignorance, custom, and self-interest, and their action must in many cases be prompt and unrestricted if it is to be efficacious. They must sometimes be in conflict with wealthy and powerful corporations, whose interests are opposed to the reforms which they urge, and although their business is to protect the most important interest of the community at large—i.e. its health—against the interests of individuals, yet these last are much more immediately concerned, and are, naturally, so active that they are often, although few in number, able to defeat any attempt to interfere with their occupations.
It not unfrequently happens that a health board may have all the power necessary, so far as the laws are concerned, and yet may be able to accomplish little for want of funds to pay the inspectors and other officials whose services are necessary. For a city, a health officer usually does better work than a board of health: his responsibility is more direct, and he has stronger motives to do good work, than a board. Of course, a poor health officer is less efficient than a good board of health, but the general rule is as above stated. The problems of hygiene require special knowledge, and the man who is to deal with them requires special training. The folly of treating diseases by their names with popular or patent remedies is not greater than that of the attempt to make a healthy house or city by men who are not architects or engineers or physicians, or who have only the information possessed by the average architect or engineer or physician. And, of all professional or educated men, the physician especially should recognize his own ignorance. When he is asked what one should take for dyspepsia or pneumonia his answer is, "Take the advice of a physician;" and so when he is asked how the plumbing of a house should be arranged, how a hospital should be ventilated, how a city should be sewered, how a marsh should be dealt with or a water-supply provided, he should reply, "Get expert advice and supervision, and be prepared to pay the amount necessary to secure it." It is the special duty of the physician to exert his influence to secure properly constituted sanitary authorities for his own locality, his State, and for the nation, and to support these against the hostility which they must inevitably arouse if they are efficient. And he should do this, not blindly and as a partisan, but intelligently and with due consideration of all the important interests involved.
The body of educated physicians in a community forms the tribunal by which the work of sanitary officials is to be judged, and they cannot judge wisely unless they appreciate the difficulties with which health officials have to contend. If a city has an incompetent or dishonest board of health, the medical profession of that city are to a certain extent responsible for it; if a competent, energetic, and faithful sanitary officer is crippled and harassed or forced out of office because he is on the wrong side of politics, or because in the legitimate and proper exercise of his functions he has come in conflict with the interests of powerful and wealthy individuals or corporations, it is the duty of medical men to support him, and to do this actively and promptly. And I take great pleasure in being able to say, as the result of somewhat extended observation, that, as a rule, the physicians of this country do cheerfully and promptly co-operate with the sanitary authorities where such exist, and are the first to try to have them properly organized and given the necessary means and powers to do effective work.