of those signs of the general vital condition to which we have just
been giving attention, but also of such as are more or less peculiar
to each disorder. To a certain extent these signs may be grouped. We
may refer to good and bad signs in pulmonary, cardiac, intestinal,
renal, cerebral, and febrile affections respectively. Still, there
will be for each malady, if it really has a distinctive character,
some tokens which experience shows to be specially indicative of
favorable or unfavorable progress and results.
Let us notice some of these as examples.
In pneumonia the best signs are the lowering of a high temperature,
reduction of the number of respirations to 20 or 25 in the minute,
expectoration of sputa less and less tinged with red or brown, and
gradual reduction of the region of dulness on percussion. Worst, in
the same disease, are an axillary temperature over 106°, respirations
40 or more per minute, with delirium, and expectoration becoming more
abundant, grayish, and purulent; also with continued dulness on
percussion and abundant mucous râles on auscultation.
In croup the best sign is, after a hoarse, dry, barking cough and
dyspnoea, a soft, liquid râle, heard in the larynx and trachea during
respiration or coughing. Worst, in croup, is a steadily or
paroxysmally increasing difficulty of breathing, with a dry hissing or
whistling sound of respiration and cough succeeding the barking sounds
of the earlier stage.
In phthisis pulmonalis among the best signs are the patient's
increasing in weight, coughing and expectorating less, ceasing to have
hectic and night sweats. These may give renewed hope, even before much
change is discernible in the physical signs. Of bad omen are intense
hectic fever, incessant cough with abundant nummular sputa, copious
perspirations, diarrhoea, breathing growing shorter and shorter, and
extreme emaciation and debility.
In all organic affections of the heart an extremely rapid and
irregular pulse, with orthopnoea and increasing anasarca, and
especially the Cheyne-Stokes respiration (described under DIAGNOSIS),
must cause unfavorable expectations.
In obstruction of the bowels the best of all symptoms is, usually, of
course, a copious fecal evacuation. Yet a few cases have occurred in
which a very large evacuation, delayed by obstruction for a week or
two, has been almost immediately followed by collapse and death. The
worst signs in cases of obstruction are (besides long-unyielding
constipation) {171} stercoraceous vomiting, a small, rapid pulse, and
increasing coldness and clamminess of the surface of the body.
In cholera infantum the best signs are cessation of vomiting and
purging, the discharges growing more nearly natural, the face becoming
less shrunken in aspect, sleep taking the place of coma vigil or
waking apathy, and water or milk, when taken, remaining on the
stomach. Worst, in the same disease, are incessant rejection of
everything swallowed, watery passages from the bowels every half hour
or hour, shrinking of the face and body to skin and bone, with an
apathetic expression of the open or half-open eyes, the latter rolling
often from side to side.
In epidemic cholera good signs are the arrest of vomiting and of
rice-water discharges from the bowels, rapid movement of the blood in
the veins after removal of momentary pressure, return of natural color
and warmth to the skin, with filling up of the pulse at the wrist. Bad
signs in cholera are shrinking of the cheeks and of the flesh upon the
hands, deepening ashiness or blueness of the skin, coldness and
clamminess to the touch, dyspnoea, loss of pulse, incessant vomiting
and purging of rice-water stools, constant cramps of the limbs, and
suppression of urine.
In acute cerebral meningitis good signs are lessened temperature of
the head, quiet sleep without stertor, disappearance of delirium, more
natural pulse, and attention to surrounding objects, without
disquietude. Bad signs in the same disease are deep stupor,
strabismus, convulsions, paralysis, involuntary defecation and
urination.
In typhus fever good signs are the pulse becoming slower and fuller,
the skin less hot, more soft and moist, the tongue moist and clean,
the face losing its dusky flush, and consciousness returning instead
of muttering delirium.[40] Bad, in the same fever, are deepening of
the flush of the countenance, profound stupor, rapid and feeble pulse,
lying on the back and sinking down toward the foot of the bed, with
suppression of urine.
[Footnote 40: Incidentally, it may be mentioned that the return of the
pulse to its normal rate is often considerably delayed in
convalescence from typhus and typhoid fevers and other protracted
diseases. If, then, the temperature is not above 99° F., and is stable
from morning to night, the tongue is clean and moist, and appetite
begins to appear, we need not be alarmed, although the pulse continues
as high as 90 or 100 per minute, in a case attended by positive
debility.]
In typhoid fever many of the good and bad signs are the same as in
typhus, belonging to closely similar general conditions. But in
typhoid fever we observe also as favorable signs the lessening of
tympanites, more nearly natural fecal stools, and the absence of
tenderness in any part of the abdomen. As unfavorable, increase of
tympanites and diarrhoea, sometimes large hemorrhages from the bowels;
worst of all, at a late stage, sudden increase of abdominal
distension, with dulness on percussion, coldness of the skin, great
rapidity and feebleness of the pulse following perforation of the
bowel, resulting usually in fatal peritonitis.
In scarlet fever, measles, and small-pox it is a favorable sign for
the eruption to come out well at the usual time; its sudden recession
threatens malignancy. In small-pox a confluent eruption marks a
dangerous case, and so does the occurrence of distinct pustules in the
throat. Early in scarlet fever stupor is very threatening, though not
necessarily mortal. Late in the same disease bloody urine, or, worse
yet, suppression of urine, may well cause alarm.
In all children's diseases the early occurrence of convulsions shows a
{172} severe but not always a dangerous attack. The late occurrence of
convulsions is commonly much more serious in its significance.[41]
Convulsions are always of vastly less importance, prognostically, in
children than in adolescents or adults. Yet they are always serious
signs. While recovered from in the large majority of cases, they may
at any time be fatal.
[Footnote 41: Yet I saw a case of acute cerebro-meningitis, in a girl
ten years of age, in which a violent convulsion occurred on about the
sixth day of the disease, and was followed by convalescence.]
These enumerations, selected as examples merely, might be much farther
extended but that the special prognosis of each disease will be fully
set forth in the several articles upon them in the body of this work.
Those now given may suffice for the illustration of the method and
general principles by which the physician must be guided in his
anticipation of the progress and result of cases of disease. The
caution may be repeated, to observe great care in forming a conclusion
in regard to prognosis in every instance, and still more in expressing
it, unless in the presence of very clear and positive evidence.
{173}
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 {174} 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]
[Footnote 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, {175} 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
{176} 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 {177} 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 . . . . . . . . . . 30
(Except for ten-year endowments, then 20 years.)
If in two members (not parents) . . . . . . . . . . . . . 35
If in one member (brother or sister) . . . . . . . . . . 20
(Except for ten-year endowments, when peculiarly favorable.)"
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.