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.