Part 35

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 {195} 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 {196} 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 {197} 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 {198} 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 {199} 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 {200} 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.

{201} 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 {202} 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.