Regulation of Traffic
Business must be conducted in epidemic as well as in normal time, and employees must go to and from their places of occupation. In cities where the distance from the residence to the business districts is great, street cars and other public conveyances must be used. Their use undoubtedly increases the number of contacts and leads to a wider distribution of the disease, but, like eating in public restaurants, it is a chance which many have to take. Few places offer better opportunities for exposure than street cars—where people of all grades of intelligence, representing all states of health and degrees of cleanliness and uncleanliness, are crowded closely together, breathe into each other’s faces, and handle the same straps and supports.
In Pittsburgh the cars have a seating capacity for from 30 to 50 persons, but during the morning and evening hours they are crowded to capacity, and are commonly seen to carry more than 100 passengers at a time. Here, too, the unkempt, indifferent foreign element is conspicuous, and these people are known to disregard all hygienic teachings. A few days after the appearance of the epidemic the street cars were placarded with warnings against coughing, spitting and sneezing. The cards instructed people who became ill to go home, to go to bed and to remain there until they were well. Later a second order appeared which gave notice that all windows in street cars were to be kept raised six inches and that no heat was to be allowed in the car. The order was intended to improve ventilation, and, for a wonder, it was enforced. During the first few days the weather was fine, warm and clear, and the draught caused by the open windows brought no discomfort; but later the weather became cold and several days of drizzling rain set in. The cars with open windows became very uncomfortable, but the streetcar employees insisted upon obeying the order to the letter. No judgment was exercised by them, and the windows were kept open night and day, cold or warm, crowded or empty, in fair and rainy weather alike, and no heat was allowed to be turned on. Many people preferred standing to exposing their backs and necks to the cold draughts, and it is more than likely that such use of open windows did far more harm than good. As above quoted, Vaughan pointed out that crowding is just as dangerous out of doors as indoors, and it is certain that crowding in cold, draughty cars is dangerous, both from the close contact and because of the added danger of lowering bodily resistance.
In an attempt to decrease the crowding on public conveyances the so-called “stagger-hour” system was adopted in New York. Under this arrangement manufacturers and business houses changed their working hours in such a way that the morning and evening travel was spread out and the average number of people carried per hour was proportionately decreased.
Looking backward over the methods used to decrease the spread through the use of public conveyances, it seems that the following procedures have the best claims for retrial: (1) Placarding the cars. This appeared to reduce the amount of coughing and sneezing, even in face of the fact that the cars were unusually draughty and chilly. (2) The adoption of the “stagger-hour” system where the practice is feasible. (3) The instruction of the people to use the street cars as little as possible.
Enforcement of Anti-Spitting Ordinances
All street cars and trains carry anti-spitting notices either to the effect that spitting will be prohibited on penalty and fine and imprisonment, or giving stated amounts of the fine. Yet spitting is constantly indulged in in these places and one rarely sees or hears of the enforcement of the law. If the ordinance was worth making a law, it is certainly worth enforcing, and yet there is probably no law so flagrantly broken. Ordinary police officers pay no attention to the enforcement of the spitting ordinance and have been known to refuse to even reprimand spitters. The incident of a sanitary officer wearing a uniform and a cap, indicating to the public his official position, who was seen sitting in the smoking car in a local suburban train and spitting profusely on the floor has been recounted on very reliable authority. Another incident is known in which a street car conductor was asked by one passenger to stop another who was expectorating abundant mucoid sputum upon the floor. The conductor replied that he had orders not to notice such things. It is no wonder that people are indifferent to such impotent measures. Whether it is possible to convey epidemic influenza or not by means of sputum, it is certain that tuberculosis is spread in this way, and that influenza predisposes to tuberculosis and causes old healed tuberculous foci to become active. People should be made to understand that they may have tuberculosis without knowing it themselves, and that by spitting it may be transmitted to other persons. Spitting by persons aware that they have tuberculosis is criminal negligence and such persons should undoubtedly be prosecuted. If a person knows that he has tuberculosis and deliberately spreads about the infection so that other persons contract the disease and die from it, he is directly responsible for the deaths. It would be hard to imagine trying to control manslaughter committed in any other way by merely putting up signs in conspicuous places forbidding the act. The average boy acquires the spitting habit between the ages of 8 and 12 years, and in many instances carries it to the grave. The one possible way of stopping spitting seems to lie in teaching the dangers of it to children, beginning in the kindergarten and emphasizing it throughout the child’s education. It is possible that in this way spitting may become obsolete in two or more generations.
Increasing Natural Resistance by Augmented Healthfulness
If there is any way of increasing the natural resistance against epidemic influenza, it is a most desirable goal toward which to work, but it must first be determined along what lines the effort is to be directed. It was not the aged, the unconditioned nor the physically unfit who suffered most from influenza, but was rather the best trained, most healthful and most robust young persons we had. Those in the army had been selected because of their physical fitness and they had further received excellent physical training in the various camps and cantonments. It would not be possible to bring any large percentage of the general public up to such a stage of “augmented healthfulness” as healthfulness is generally understood. It has been said that men in the military camps were more commonly infected because they were more active, went about more and were, therefore, more frequently exposed. In one particular this statement is true, for men marching rapidly and exercising violently breathe more deeply and at a faster rate than they do under ordinary conditions, so that they naturally draw greater quantities of air into their lungs. It was an obvious fact that those persons given to sedentary lives were less often affected than the active and vigorous. Practically speaking, it would seem that during influenza epidemics people should be instructed to take more than the usual amount of sleep and rest, to indulge only in mild exercises, to eat good, wholesome food, to wear warm clothing, to seek mental and physical relaxation at home, and, above all, to avoid crowds and public gatherings.
In some instances the constant use of oils in the nose and throat was advised, the theory being that the oil served the double purpose of preserving the healthy condition of the mucous membranes by lessening crusting, crevicing and drying, and of mechanically protecting from infection by the presence of the layer of oil. Many of the different liquid paraffins, both medicated and in the natural state, were used. It is probably advisable to apply such oils either with a swab or from a medicine dropper, rather than to attempt to spray them, since in the latter method there is some danger of blowing infectious material down into the trachea and larynx.