A manual of hygiene and sanitation

Front matter

Glass Book

COPYRIGHT DEPOSIT

A MANUAL

Preface To Second Edition

The rapid disposal of the first edition of his text-book has been extremely gratifying to the author, inasmuch as it has confirmed him in his opinion that such a work had 'a place in the educational literature of to-day. The words of commendation it has received from many sources of authority are appreciated by him, and still more the helpful criticism with which he has been favored.

The brief interval since its original issue has disclosed places and opportunities for improvement in its pages, and has in addition brought forth some new information which should be included in a manual of this kind. Especially has it seemed wise to add the Chapter on Military Hygiene at this time, as recent events have shown the necessity for practical information of that character.

Each page has been carefully revised, and much has been entirely rewritten in the endeavor to make the meaning and teaching clearer and more forcible. The new matter on various subjects and the additional illustrations increase the volume to the extent of sixty-five pages. More foot-notes and references are likewise introduced with the desire to aid the reader desirous of pursuing special subjects.

Trusting that this issue will be as cordially received as the preceding one, and again thanking his readers and friends, the author submits his work to their criticism and kindly consideration.

Seneca Egbert.

Philadelphia, November, 1900.

Preface To First Edition

For a number of years past it has seemed to the author that there was ueed for a manual or text-book which would give a plain statement of the fundamental principles and facts of Hygiene and Sanitation, together with such explanations and details, based on American practice, as would serve to make the work clear and readable.

Of all the medical sciences, that is clearly the most important which prevents disease instead of curing it, and deals with communities as well as with individuals. The vital interest and comparative simplicity of this science have already attracted the laity in great numbers, as well as the medical profession, and to this intelligent interest are largely due the remarkable advances which recent years have witnessed in methods of preserving the public health.

The desultory and often unauthoritative articles in the daily press or monthly magazines are scarcely fit material for satisfying this desire for knowledge, nor, on the other hand, can we expect any extensive study of the larger volumes on the subject. Smaller works exist, but they are either diffuse and lacking in system, or they detail methods and devices adopted abroad and out of harmony with conditions here. It is important for the medical student, at least, that the information given in such a text-book as the present should be as concise and systematic as possible, and that it should devote special attention to those conditions with which he is practically concerned.

viii PREFACE TO FIRST EDITION.

For these reasons, and because I have as yet found nothing which exactly comprises my idea, I have ventured to offer this volume not only to my classes, but to all who are desirous of doing what they can to better the health of themselves and of those about them. The volume deals with personal as well as public health.

In the preparation of the work the principal text-books have been fully consulted, as well as such recent magazine and other articles of authority as were pertinent. Quotations have been credited and references indicated, in order that the reader may know where to seek for further details or fuller information than the limitations of this work will permit. Indeed, I should do wrong were I to give any one the idea that this volume is thoroughly comprehensive, or even a compendium of the whole scope of hygiene or intended to be so. The science is already too great and too important to be treated entirely in a single volume, and, as it is so intimately concerned with every one's personal welfare, it is the author's earnest hope and desire that not only his students but others may use this as an adjunct to further and more extensive reading, and that, inasmuch as hygiene is destined to be even more important in the future than it is now, all should make use of all possible sources of authoritative information.

Whatsoever may be the faults or shortcomings of the work, the labor expended upon it will not have been altogether in vain if it induces any one to take greater interest in the study of all that which pertains to " the preservation and promotion of health and the prevention of disease."

The illustrations have been selected with special reference to the text, and those of special devices or apparatus have been chosen as trustworthy representatives of their

PREFACE TO FIRST EDITION. j x

respective classes. For the four photo-micrographs of bacteria I am indebted to the skill and courtesy of Dr. William Gray, of Washington, D. C, to whom, and to all my other friends and associates who have aided me in the preparation of the work, I have many thanks to extend.

Seneca Egbert.

Philadelphia, May, 1898.

Introduction

Hygiene may be defined as the art and science that considers the preservation, promotion, and improvement of health and the prevention of disease. It treats of the laws of health in the broadest sense, and under the general term may be included a number of subdivisions. Thus, while Personal and Domestic Hygiene are respectively more closely related to the affairs of the individual and the household, Sanitary Science also finds larger fields and broader application in the domain of State Medicine and the Hygiene of Municipalities.

A little thought will show that under the general h< ad we may consider : 1. The preservation and promotion of health. 2. Practical disinfection and the means of avoiding preventable diseases. 3. Adaptation of diet to the prevention and cure of perversions of nutrition. Under one or another of these themes will fall the discussion of the air we breathe, the water we drink, the food we eat, the soils and surroundings of our dwellings and communities; and at the same time the study of the means of recognizing, avoiding, correcting, or removing all impurities affecting any of these. In addition, there must be the study of climate and meteorology; of clothing and shelter; of the care of the sick, not only for their own sake, but that they may not endanger the well ; the dangers of the abuse of stimulants, narcotics, etc ; the desirability of chaste and temperate living, exercise, rest, etc.

Parkes says that, " taking the word ' hygiene' in its largest sense, it signifies rules for the perfect culture of mind and body. It is impossible to dissociate the two. The body is affected by every mental or moral action; the mind is profoundly influenced by bodily conditions. [So is the moral couduct of individuals or communities.] For a perfect system of hygiene we must train the body, the intellect, and the moral faculties in a perfect and balanced order." Again, he says: "Looking only to the part of hygiene which concerns the physician, a perfect system of rules of health would be best arranged in an orderly series of this kind. The rules would commence with the regulation of the mother's health while bearing her child, so that the growth of the new being would be as perfect as possible. Then, after birth, the rules (different for each sex at certain times) would embrace three epochs: of growth (including infancy and youth); of maturity, when for many years the body remains apparently stationary; of decay, when, without actual disease, though doubtless in consequence of some chemical changes, molecular feebleness commences in some part or other, forerunning general decay and death. In these several epochs of his life the human being would have to be considered : Ftrsf, in relation to the natural conditions which surround him, and which are essential for life, such as the air he breathes, the water he drinks, etc.; in fact, in relation to nature at large. Second, in his social and corporate

INTRODUCTION. 19

relations, as a member of a community with certain customs, trades, etc.; subjected to social and political influences, sexual relations, etc. Third, in his capacity as an independent being, having within himself sources of action, in thoughts, feelings, desires, personal habits, all of which affect health, and which require self- regulation and control. Even now, incomplete as hygiene is, such a work would, if followed, almost change the face of the world.* '

The student will readily see that the scope of the science is so vast that, in a limited work like the present one, it would be impossible to go over the entire ground completely and thoroughly. The most that may be attempted will be to discuss its fundamental laws as we now understand them, especially those that are most closely connected with the conscientious physician's duties and practice, and to show the reasons for and the advantages resulting from the pursuit of hygienic measures and sanitary methods based on those laws and our experience. Hygiene is, however, a science in the study of which common- sense must be freely used, and if the student will only bring this to his aid and add to it sincere attention, he will speedily find that there is little that is difficult, beyond his grasp, or less than really fascinating.

It has always been, as it always will be, an art to preserve health and to ward off disease. Hippocrates was among the first to define principles of public health or sanitation. He summed up the knowledge of his day concerning hygiene under six headings, viz.: Air, Aliment, Exercise and Rest, Sleep and Wakefulness, Repletion and Evacuation, and the Passions and Affections of the Mind; and he even pointed out that there must be an exact balance between food and exercise, and that " disease would result from excess in either direction." 1

The excellence of the Mosaic code of the Hebrews is acknowledged by all sanitary authorities, and its effects are seen to this day in the comparative longevity of the race. The Greeks cultivated to the extreme both the physical and mental faculties, and had for their motto A sound mind in a sound body. The Romans, in their aqueducts for conveying water to the city and in the Cloaca Maxima, have left some wonderful examples of sanitary engineering, which are, in certain respects, not yet surpassed. All of which serves to show that the ancients appreciated the importance of maintaining and improving health, and the influence of material conditions and environment upon sanitation.

The development of hygiene as a science, however, has been within comparatively recent years. Perhaps the first great impulse among English-speaking peoples, especially in matters pertaining to sanitation or " State medicine/ ' can be traced to the labors of Dr. William Farr, and to the establishment, through his efforts, of the British Registrar-General' s office in 1838. 2 Since then the task of determining the principles and laws of health has been carried on with unflagging zeal by workers both here and abroad, and within the last score of years or less the knowledge gained in the new study of the bacteria,

1 Treatise on Airs, Waters, and Places (about 400 B. C).

2 Note should be made, however, of the writings of Johannes Petrus Frank, in the first quarter of the nineteenth century and even earlier, and of Parent Du Chatelet, between 1820 and 1836. Of the work of the former it has been said that "It was the first orderly presentation of that which had hitherto been known upon these subjects, and was the first systematic effort to rescue from chaos such useful information as might be of service in the organization of a department of sanitary supervisors, or, as the author preferred to call them, medical police." (A. C. Abbott, University Medical Magazine, July, 1900.)

INTR OD UCTION. 2 1

especially that regarding the causation and true nature of infectious diseases, has furnished us with a wealth of facts with and by which we may make the foundations of our science more secure and lasting.

It would be wrong, nevertheless, to give the impression that hygiene is, as yet, an exact science. While it is rapidly attracting popular notice and attention, and has attained within comparatively recent years a dignity that it did not hitherto have in this new world, it is already on a somewhat firmer basis in the old. The brightest minds of the day are still busy with many of its problems, and facts and laws are being made clear that more firmly fix or may altogether change some of our beliefs and our practice. Especially is such new knowledge to be sought for in the study of the prevention of disease, the domain of bacteriology, the parasitic diseases, and the chemistry of the animal alkaloids and kindred compounds.

Perhaps a few statistics will help one to realize that the study is not in vain, and that the promise of the future is even more brilliant than the results and achievements of the past. Three centuries ago the death-rate of London was more than eighty per thousand; now it is about twenty. It is computed that in the eighteenth century — the one preceding the introduction of vaccination — fifty millions of people were killed in Europe by smallpox alone; now it is practically almost an extinct disease. In 1872 Sir John Simon estimated " that the deaths which occur in England are fully a third more numerous than they would be if our existing knowledge of the chief causes of disease were reasonably well applied throughout the country, and that of deaths which in this sense may be called preventable the average yearly number in

England and Wales is about 120,000." In confirmation of the accuracy of this statement, official reports show that the annual death-rate of England and Wales, which averaged 22.6 per 1000 for the decade from 1862 to 1871 inclusive, fell to 18.9 for 1881, this giving a saving of 92,000 lives annually; while for 1 889, even with the correction for the lowered birth-rate, it was only 17.9, indicating a yearly saving of at least 125,000 lives, and completely substantiating the above estimate of Simon. Moreover, the death-rate from the seven principal zymotic (infectious) diseases had dropped from an average of 4. 11 for the period from 1861 to 1870 to 2.40 for 1881-1885, and that of typhoid fever from 0.39 per 1000 in 1869 to 0.137 in 1892. This for England and Wales. In Munich from 1866 to 1881 the average yearly hospital admissions of typhoid fever cases were 594, or 3.32 per 1000 of population, and the average deaths from this disease were 208, or 1.15 per 1000. From 1881 to 1888, following the introduction of improved systems of sewerage and a better water-supply, the average hospital admissions (typhoid) were 104, or only 0.42 per 1000, and the average deaths were 40, or only 0.16 per 1000 of population.

In this country a like improvement is to be noted, though it is only within the last few decades that much attention has been given to sanitary affairs. The death-rate of most of our cities is being progressively lowered, though the populations are constantly increased by large numbers of ignorant and uncleanly immigrants from abroad. Improved sanitary laws are being enacted and enforced, streets better paved and cared for, houses more properly constructed and ventilated, more attention given to isolating the sick and protecting the well, and the people in general are awakening to the importance of im-

INTB OD UCTION. 23

proving as well as maintaining the public health. New Yurk has reduced her death-rate per thousand within the last decade (1889 to 1899) from 25.32 to 18.41; Philadelphia, from 19,74 to 18.78; Boston, from 23.52 to 20.12, etc. 1

Nevertheless, there is still much to be done. Tuberculosis, which is said to cause from one-seventh to one-fourth of all the deaths in the civilized world, is practically a preventable disease, and we now not only know its cause but also have efficient means for a cure in a large proportion of cases, as well as for its general prevention. So with a number of the other infectious diseases. Almost every day marks an increase in our knowledge of their etiology and the securing of immunity from them, and not only must physicians make use of this knowledge as they acquire it, and employ their utmost endeavors to secure the enactment and enforcement of sanitary laws and regulations, but they must realize that a large part of their work lies in the enlightenment and education of the people in all matters pertaining to the public health. 2

In the preparation for a study like the one on which we are about to enter there is some question as to just what may be the most advantageous order and arrangement of the subjects to be treated. For instance, it would be

1 The importance of such statistics is not fully appreciated unless the reader remembers that in a city of, say, a million inhabitants a reduction of the death-rate one point means the saving of one thousand lives annually.

2 It is encouraging to find that, although almost 12 per cent, of the whole number of deaths recorded in Philadelphia in 1899 were caused by consumption, a progressive and marked lowering of the death-rate from this disease in that city is taking place, and that, notwithstanding an increase in population of over 33.4 per cent., the fatalities from this disease are actually less in number than they were fourteen or fifteen years ago. For example, the deaths from pulmonary tuberculosis in 1885 numbered 2821, and in 1886 were 2»34, rates respectively of 2.97 and 2.92 per 1000 living ; while in 1899 there were only 2818 deaths, or a rate of 2.23 to 1000 living.

interesting to discuss our scieuce in its relation, in turn, to the individual, the household, and the people in general — that is, personal, domestic, and public hygiene; and to show wherein the treatment of these subdivisions is similar and wherein they differ. Such a threefold consideration would be not only logical, but extremely instructive.

However, since the bacteria have been shown to have so important a part in many of the processes intimately connected with health or disease, it will doubtless be advisable to devote the next chapter to a brief review of the science of bacteriology. This done, it seems to the writer that we shall, as beginners, obtain a more comprehensive and thorough view of our subject if we pursue a method somewhat as follows : First, to discuss air, water, aud food — three things absolutely essential to life — in the varying conditions and circumstances under which they may affect the physical welfare, either for good or bad, of the individual or of the community. Then to take up, in such order as may seem best, the other themes, whose consideration is only a degree less important than the above on account of their influence in the preservation of health aud prevention of disease, such as climatology, habitations, disinfection and quarantine, disposal of sewage, clothing, exercise, school hygiene, etc. In this way, while the whole ground may not be covered, the importance of the various subdivisions may be estimated in their relationship to one another, and we shall be the better prepared to pursue the study as opportunity may offer in the future.

It is doubtless in place just here to review briefly the reasons why it is the special duty of the physician to be able to recognize and remove insanitary conditions whereever they may be found, aud why he should make par-

INTRODUCTION. 25

ticular and constant study of the science in all its branches and developments.

Every true physician soon finds that the respect and affection of his patients and associates are worth far more than mere mercenary gain, and that his highest aim should be to prevent disease rather than simply to cure it; and, though this may seem to militate against his personal interests, he is unworthy the name of physician if his object and purpose is solely or primarily to make money. However, the observer quickly learns that in a community kept in good health and hygienic condition there will always be more or less need of a doctor's services, in spite of every effort to prevent sickness, and that such a community will pay more promptly and more liberally for such services than one in which all sanitary precautions are neglected. Health means ability to work and to earn good wages; and a healthy community means more business, more money, and more comforts. Moreover, as a rule, good wages ensure prompt and cheerful payment of the doctor's bills, as well as of others. We may note here the close relations existing between sanitary science and social and political economy — a relationship which is very intimate, as we shall see from time to time in our work, for as the physical condition of a people is bettered it becomes more possible and more certain that they will likewise improve both mentally and morally.

Again, though the science of hygiene and sanitation is comparatively a new one, public attention is being strongly directed toward it, not only because it vitally interests every one, but because new discoveries and new applications of the laws pertaining to it are being constantly made, which are, in turn, swiftly given to the world by both the scientific and the popular press. This creates a demand for first class teachers, which demand is bound to increase in the near future and promises materially to exceed the supply. In fact, within a very few years not only the medical, but the academic and scientific colleges of the country will be compelled by powerful public opinion to establish in their faculties well-equipped and well-endowed chairs of hygiene and sanitary science, and it will be from the ranks of the educated physicians of the country that these teachers must naturally come. It will not be long before the people in general realize that it is fully as important that the college student or graduate be instructed how to do his part in taking care of the health of himself, his future family, and the community in which he is to reside, as that he shall be well taught in the abstract principles of theology or the classics of dead languages.

So, also, considerably more time and attention than are now accorded to it should be given to hygiene in the work of the various normal schools for teachers. The graduates of these schools will have much of the physical as well as the mental welfare of thousands of young and growing children in their keeping, and it is unquestionably their duty to prevent or obviate the ills of school life as far as lies in their power, and to give instruction in and to inculcate habits of living which will continually tend to preserve and improve the physical health of those under their care. One need scarcely intimate that, as the subject and its study are comparatively new and the demand for instructors is likely to be in excess of the supply, the recompense of the latter should be accordingly lucrative.

Lastly, the time has come when a physician must necessarily have a knowledge of hygiene, preventive medicine, and sanitary science. Many States require as thorough

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INTB OD UCTION. 27

examinations in this as in any other branch of medicine before granting the right to practice within their boundaries. So do the army, navy, and marine hospital services of the Government. Moreover, the people generally, as has been intimated, are awakening to an interest in sanitary matters and the prevention of disease, and expect their physicians to be well versed on all pertaining subjects; if they find a doctor lacking in knowledge or interest in this respect, they are apt to think, rightly or wrongly, that he will also be deficient in the other branches of medicine.

Happily these causes all combine to place preventive on the same high plane with curative medicine, and the time is fast passing in which the chair of hygiene fails to have a primary place in any thorough medical school. May the day soon come when it shall have at least equal importance in the curriculum of all academic and normal colleges and schools.

It is evident that the successful physician and practical student of hygiene must have a thorough knowledge of three things: 1. Health and its laws; how to obtain and preserve it. This, of course, implies a knowledge of the human body and its functions, viz., of anatomy, physiology, and physiological chemistry. 2. He must study disease and its causes and nature. He must also understand the distinction between diseases due to causes external and those due to causes internal to the body; and that while some of these causes may be prevented or modified, others, with our present knowledge, may not be so readily overcome. 3. He must be conversant with and know how to use the therapeutic agents, both preventive and curative, that he has at his disposal, including not only drugs, but also all substances and forces that he can make efficacious to his purpose. The workman must know his tools to be able to use them intelligently.

Health is " that condition of the body and its organs necessary to the proper performance of their normal functions/' and disease may be defined as " a condition of the body marked by inharmonious action of one or more of the various tissues or organs, owing to abnormal condition or structural change." It is, accordingly, well to consider briefly the nature and causes of disease, that we may the better understand the influence upon its prevention or production of all those varying factors, phases, and conditions of our environment which we hope to study in our work.

Disease is an entity, not a spiritual thing; a condition, not a theory. Consequently, it is to be fought and, if possible, conquered with matter, force, and physical means, though not necessarily with violence. In fact, when once we understand the minuteness and delicate structure of the ultimate cells and tissues affected, we realize that, oftentimes the gentlest application of the forces and means employed may be the most helpful and efficient. But when one has seen the ravages caused by it, as revealed in the pathological laboratory and at autopsies, not to speak of its manifestations in the -living, as seen in the sick-room and in hospitals, I am sure that he cannot logically, or even for a moment, give credence to those who proclaim that it can be dissipated by the mere action of mind or of faith; nor to those others who declare that by subdividing and diluting and subdividing again infinitesimally a single grain of substance, whether primarily powerful or inert, you endow it with a miraculous power to remove the " ills that flesh is heir to." Virchow gave a priceless boon to modern medicine in his theory of

INTR OB UGTION. 29

cellular pathology and in showing its superiority to the old humoral theories and a priori reasoning. He wrote " whatever outside of a cell acts upon it (abnormally) works a mechanical or chemical change within it, which change is disorder or disease." The sooner we realize that the laws of physics and chemistry govern cell life and action and, consequently, the functions and organs of the body, the more accurate will be our treatment and the more certain our prevention of disease.

For convenience sake, diseases may be divided into two main classes, somewhat different in their origin, nature, and character, although the line between the two is not always clearly marked. Diseases of the first class arise within the body, and are usually due to some alteration or disturbance of nutrition and assimilation, or of function, and may be called autogenetic. The second class comprises those which are due to causes from without, favored, it may be, by either internal or external predisposing conditions, but each of necessity depending upon the reception or inoculation of the special cause, which cause has the power of reproduction and development, of vitality and virulence. Such diseases are called contagious, infectious, specific, or zymotic.

A third class or a subdivision might also be indicated, which would include those maladies which are almost purely psychical and whose symptoms are largely notional and the result of perverted imagination. But it is a question whether the primary cause of almost all such disorders is not an altered and abnormal nutrition or functioning of the general nervous economy of the body and the symptoms simply the reflex manifestations of irritative disturbances of distant organs.

In the first class, with our present knowledge, we

.

should place such maladies as rheumatism, gout, diabetes, neurasthenia, etc.; while into the second will obviously fall all that are now known to be due to living " germs " or organisms, such as cholera, typhoid fever, malaria, etc. However, we must not overlook the numerous impulses often given to the causation of certain members of the second class by faulty conditions of nutrition or assimilation, as is especially exemplified in many easel of tuberculosis. The character of the soil may influence the growth and product of a plant almost as much as the species itself, and so the difference in constitution and tissue of individuals may materially determine the variation in symptoms and virulence so often manifested by an infectious malady.

Prophylaxis is " the use of hygienic or other precautions conducive to the prevention of disease ;" or it may be defined as u a series of methods or procedures whereby disease is restricted and prevented by suppressing or removing its predisposing conditions, and destroying or modifying the exciting causes." Its first function, of suppressing or removing predisposing conditions, is accomplished by sanitation ; the second, that of destroying or modifying exciting causes, is carried out by disinfection. The term "predisposing conditions" should be used instead of " predisposing causes," because these conditions cannot in themselves originate a disease, though they may make the system more susceptible to the exciting causes of a disease.