principal causes of disease and the methods for their investigation or
removal. We have now to consider some of the practical applications
which may be made of the laws of etiology and prevention of disease in
the treatment of the sick. While the removal of the cause of illness
by no means always effects a cure, yet the importance of a knowledge
of this cause as an aid to diagnosis, prognosis, and therapeutics is
so evident as to require no proof.
To discuss with anything like completeness the practical applications
of what would be commonly considered as hygienic rules in the
treatment of disease would be to write a treatise on nursing, and
would also include a large part of the practice of medicine, for
regimen is the more important half of practical therapeutics. The
hygienic requirements peculiar to each disease will be pointed out by
the writers upon special subjects, and I shall only venture upon one
or two general remarks in addition to the hints already given in
speaking of the several causes.
In the acute stages of disease the sensations--or, if the term be
preferred, the instincts--of the patient are usually the best guide to
his regimen so far as they go. In most cases he desires quiet, shade,
but not absolute darkness, and little or no food, although there is
often a craving for drinks, especially of a cooling character. In the
specific fevers which have a tolerably definite period and course it
is important to keep up the nourishment even during the period of
anorexia, in order to provide against the debility which is to follow.
This nourishment is best given in the form of drink, and very
frequently fresh milk is the type of what is required. The old notion
that whatever a sick man desired must be hurtful, and therefore that
the fever patient must be kept hot and refused cool water, has now
almost entirely passed away.
In convalescence from acute disease and in many chronic cases, the
sensations of the patient are not to be trusted as a guide in the
choice of food. In such diseases as yellow fever and typhoid fever to
allow the convalescent to follow the dictates of his appetite is to
run great risk of a fatal result. In other cases the patient really
has no wish in the matter, but it {206} will often be found that one
who can think of nothing which he desires to eat, and who will even
refuse a dish which he has requested and been thinking about, will eat
with enjoyment some unexpected dainty when presented at the right
moment and properly served as a skilled nurse knows how to do. The
manner of serving the food, independent of its cooking, is not a
matter of such small importance that the physician can afford to
overlook it, and he will succeed best as a practitioner who best
appreciates the influence which cracked goblet, a chipped saucer, a
soiled napkin, or, on the other hand, a hot plate or a touch of color
in the shape of a leaf or flower, may have upon the capricious
appetite of the sick. In ordering diet for convalescence it is not an
uncommon error to select only those articles which are agreeable to
the physician himself, forgetting the old proverb, that what is one
man's meat may be another man's poison, and also that it is above all
things desirable to avoid monotony. One doctor always orders chicken,
another eggs, a third a mutton-chop, etc. The practice in this respect
has probably been unduly influenced by the reports of Beaumont of the
results of his observations on Alexis St. Martin, and we still find
that the relative digestibility of various articles of food is
estimated according to the scale laid down in these reports, with no
allowance for individual peculiarities, previous habits, mode of
cooking, etc. The secret of success in the diet of convalescence lies
mainly in the simplicity of the individual dishes, in varying the
different meals, in the manner of serving, and in carefully observing
the effects on the sick person, and being guided by the results.
To promote appetite and digestion, and to secure refreshing sleep, one
of the most important things is fresh air, but in many houses a sick
person will obtain but a very limited allowance of this if the
physician does not give special attention to the matter. Except in
cases of contagious disease, the rules for managing which have been
given in a previous section (p. 201), as soon as a patient is
sufficiently recovered to be moved for a short time into another room
his bedroom should be thoroughly aired and cleansed, and this should
be done morning and evening thereafter.
In treating cases of contagious disease the question often arises as
to means of individual prophylaxis to be used by those who must be
exposed to the effects of the infected locality or of the presence of
the sick. The attempts which have been made to secure this individual
protection in the midst of an epidemic have been numerous and varied,
ranging from the use of the "vinegar of the four thieves" of the
Middle Ages to the employment of the sulphites and chlorates to make
the blood unsuited to the growth and multiplication of the supposed
germs, or of cotton-wool respirators to strain the infected air, or of
supposed specifics for particular diseases, as belladonna for scarlet
fever and vaccination against small-pox. As yet, there is little or no
satisfactory evidence as to the value of individual precautions
against those diseases whose contagion is conveyed through the air,
small-pox alone excepted, but in case of diphtheria in one member of a
family of children it might be well to try the use of chlorate of
potash internally, combined with the local application of the tincture
of the chloride of iron, as suggested by E. M. Hunt. The question is
one to be investigated by careful observation and experiment; and,
though it is improbable that any definite results will be obtained
except in those diseases which are communicable to animals, and
therefore {207} susceptible of direct experiment, still, it is
possible that some advance may be made. In rare and exceptional
cases--as, for instance, in exploring a crowded, filthy, and intensely
infected typhus-fever nest, as a tenement-house, or an infected
yellow-fever ship--it may be worth while for the physician or
inspector who is unprotected by a previous attack of these diseases to
make use of a cotton-wool respirator, which is readily extemporized,
and belongs to that exceedingly valuable and popular class of remedies
which, "if they do no good, can do no harm." In epidemics of typhus,
cholera, or yellow fever one of the most valuable prophylactics is to
have a mind so occupied with other matters that it pays little or no
attention to the danger, while in case of small-pox fear of the
disease is indirectly the best prophylactic, since it leads to careful
vaccination.
This branch of the subject is closed with the remark that it would be
well if physicians, and especially the younger ones, gave more
attention to the preservation of their own health than many of them
do. The possession of a medical diploma does not prevent the evil
effects of irregular and hurried meals, insufficient sleep, exposure
to inclement weather, and lack of systematic and sufficient exercise;
and too much tobacco, sometimes too much alcohol, and in exceptional
cases too much study and literary work, so often combine with anxiety
about individual patients or with pecuniary worries to damage the
digestion and nervous system of the young practitioner that the wonder
is that so many survive the ordeal. And, in fact, the mortality among
physicians under the age of thirty is higher than that of any other
profession during the same period of life.
III. Public Hygiene in its Relations to Physicians.
An important difference between man and animals is found in the extent
to which he will sacrifice a present pleasure or convenience to secure
a future good or to avoid a future evil. The savage will do this to
only a very limited extent--little more, in fact, than the beaver or
the squirrel--and the lesson is learned but slowly and by sad
experience. This is especially the case as regards matters affecting
health. When a man begins to take special precautions as to his diet
or exercise, having in view rather his future health than his present
comfort and tastes, he has in most cases already begun to suffer from
the effects of his imprudence, and does not commence a hygienic course
of life as a perfectly sound and healthy person. The same is true for
a community. It will not usually submit to the burden of taxation
necessary to secure drains and sewers or a proper registration of
vital statistics, nor to the cost and inconvenience of the machinery
necessary to limit the spread of contagious diseases, until the
neglect of these things has resulted in such an amount of disease and
death as to forcibly call attention to the matter. The result is, that
the burden is far heavier than it would have been had the work been
undertaken in proper season, and individuals may find it to their
interest to leave the place and settle elsewhere rather than remain
and meet their proportion of the expense.
When a state or municipality has so far advanced in civilization as to
consider it desirable to take measures to protect the public health by
preventing individuals from polluting the air or water liable to be
used by {208} their neighbors, etc., the services of the medical
profession are always called upon. The foundation of public hygiene is
information as to the occurrence of certain forms of disease, the
cause of which can be referred with more or less precision to a
certain limited locality. This information may be very imperfect,
consisting of little more than rumor and opinions as to the existence
of an undue amount of sickness or mortality in a certain place, or it
may consist of precise reports setting forth the number of deaths from
each cause, the proportion of each of these to the population by age,
sex, occupation, etc., and of the whole to births--constituting what
is commonly called the "vital statistics of a place"--and also of
reports of the occurrence of certain preventable diseases; and between
these two the information may be of various degrees of completeness,
but, whatever there be, it is for the most part obtained either
directly or indirectly from medical men. The reliability and
completeness of the information thus obtained by the state determines
to a great extent the direction and character of the work done in
destroying or preventing the causes of disease, and it is also an
important means of increasing our knowledge with regard to the nature
of these causes.
The character of this information depends largely upon the character
of the physicians who furnish it. In a large part of the country
medicine is legally in the position of any common occupation; that is,
the term "physician" is defined as applied to "any one who publicly
announces himself to be a practitioner of this art, and undertakes to
treat the sick either for or without reward." Under such circumstances
there can be no guarantee that all who call themselves physicians are
properly qualified or competent to furnish reliable information for
registration purposes, and, as a matter of fact, a large number are
not so qualified. It is for this reason that there is such a close
connection between public health authorities, registration of vital
statistics, and the registration of those physicians whose
certificates as to causes of deaths, etc. will be accepted by the
state; and hence the nature of the public health organization of a
state and the personnel of its officials are matters of great
importance to physicians. On the other hand, the efficiency of a
public health service depends very largely upon the relations which it
holds with, and the light in which it is regarded by, the medical
profession. A health officer who is distrusted and disliked by the
physicians of his district cannot effect much unless he can overcome
this feeling, and his tenure of office must always be very insecure.
The official relations of the practitioner with the health authorities
are usually confined to the subjects of registration of vital
statistics and of checking the spread of contagious diseases. The most
marked exception to this rule is furnished by the States of Alabama
and North and South Carolina, in which the State Medical Society is
the State Board of Health, having been given legislative powers and
the right of selecting the health officers. The most complete
organization of this kind is that of the State of Alabama, where by
the act of 1875 the Medical Association of the State was constituted
the State Board of Health, and the county medical societies in
affiliation with the State Society were made county boards of health,
to be under the general direction of the State Board. These county
boards at first had advisory powers only, and were to be conducted
without expense to the State or the county, except that the competent
legal {209} authorities of any county might invest the county board
with such powers and duties for the promotion of the public health as
might be mutually agreed on; but in such case the right to elect or
appoint those employed in sanitary administration is reserved to the
board of health, while all questions relating to salaries,
appropriations, and expenditures shall be reserved to the legal
authorities. It was further provided "that no board of health, or
advisory or executive medical body of any name or kind for the
exercise of public health functions, shall be established by authority
of law in any county-town or city of this State except such as are
contemplated by the provisions of this act, the object of this
prohibition being to secure a uniform system of sanitary supervision
throughout the State." By an act of 1881 the county board is directed
to elect a health officer, who is to keep a register of the births,
deaths, and cases of pestilential or infectious diseases occurring in
the county, and furnish to physicians, free of charge, reliable
vaccine--to obtain information as to the sanitary condition of his
county, etc. etc. It will be seen that this plan of organization is an
attempt to overcome the practical difficulties in the way of obtaining
from physicians the information necessary for the registration of
vital statistics and the work of preventing the spread of infectious
diseases.
While the great majority of physicians are willing to furnish the
information as to the cause of death, etc. which is necessary for a
useful registration, there are always some who either neglect or
refuse to do so; and if the law be made compulsory, it provokes
hostility unless compensation is furnished, while as regards the
requiring physicians to furnish information as to the existence of
contagious diseases, this always rouses opposition on the part of a
certain number of medical men, even if payment for such notification
is provided. And while this opposition is no doubt in many cases due
to improper motives, such as personal hostility to the existing
authorities, party politics, or a desire for notoriety, its strength
nevertheless rests upon the fact that it is unjust for the state to
compel the services of any man or class of men without furnishing
compensation. The advocates of health and registration laws are thus
placed between Scylla and Charybdis: if they propose compensation,
which involves appropriations from the public treasury, the law cannot
be passed; if there is no compensation allowed, complete results
cannot be obtained.
The Alabama law makes compulsory the furnishing by physicians of
information relating to births, deaths, and infectious diseases, and
gives compensation--not in money, but by allowing the medical
profession to have the sole management of the matter and to choose the
health officers to whom they are to report; in other words, they are
allowed to tax themselves. The result in Alabama is yet doubtful. If
competent and faithful health officers and registrars can be obtained
without paying them a fair compensation, it will be contrary to
experience; and if these officers receive a salary, it will be strange
if the positions do not become the reward of partisan political work.
It should be noted that the requiring a physician to report the births
occurring in his practice stands on a very different basis from the
requiring him to report the cause of death, since there is no special
necessity for the former. It requires no expert knowledge to report a
birth, and the duty should obviously devolve on the householder.
{210} In those States in which by law only properly qualified medical
men, as determined by examination, have the right to practice, to hold
medical office, or to furnish medical certificates, the State
certainly is entitled to require of all physicians thus registered and
authoritatively recommended to the people as competent, that they
shall furnish, free of charge, certificates of the cause of death in
those cases where they are cognizant of such cause.
States and municipalities often demand much more than this; as, for
instance, that the medical man shall fill out the whole certificate,
including age, nativity, nativity of parents, etc., and that he shall
furnish the information to the registrar. In some cases it is provided
that any physician having attended a person during his last illness
shall furnish the certificate: this would apply to cases where the
physician may not have seen the case for weeks before death.
While it is most convenient to have the certificate of cause of death
upon the same form which contains the data necessary to identify the
individual, the certificate should be distinct from the latter, and
the duty of making the return to the registrar should devolve on the
householder or undertaker, and not on the physician. On the other
hand, it is easy for the physician to be hypercritical in these
matters: his certificate is to be considered rather as a statement of
opinion than as a statement of facts within his personal knowledge,
precisely as he would certify as to his own age and birthplace.
The compulsory notification of infectious diseases to the health
authorities is a matter presenting much greater difficulties than that
of certificates as to causes of death. The state has no right to
require such notification from the physician without giving some quid
pro quo, and it is not expedient to make it compulsory, even with
payment, except from physicians employed by the state or municipality,
to furnish gratuitous medical attendance to the poor. The state has
the right to require such information from the parent or householder,
and it has also the right to require the physician to notify the
parent or householder as soon as he recognizes the existence of such
infectious disease. It is extremely desirable that the health
authorities of a city should receive promptly, and direct from
physicians, notification of the occurrence of such diseases, and there
will usually be no difficulty in obtaining this if the health officer
has tact and discretion and the city is prepared to do its duty. This
duty is not confined to registering the information or placarding the
house, nor will it be properly performed by merely removing the sick
person to a hospital and disinfecting the premises. If the case occur
in a family which can secure its proper isolation, and the attending
physician certifies that it is so isolated and makes himself
responsible for its management (for which responsibility he should be
paid by the patient or his friends), the health officer should not
interfere nor do more than furnish a competent person to secure
disinfection if required. The employment of a trained nurse known by
the health authorities to be competent and reliable would do away with
most of the difficulties connected with such cases in the upper and
middle classes of society; and such nurses should be registered just
as physicians and midwives are.
Where the case cannot be thus isolated and properly cared for, it
should be removed to a proper hospital. This presupposes that the city
has such a hospital, and if it has not, and is not prepared for such
cases, notification {211} is useless. When the city places a house in
quarantine so as to interfere with business, it should be for the
shortest possible time consistent with securing thorough disinfection
of the premises, and the city should bear not only the cost of such
disinfection, but the cost of caring for the persons in the house in
an isolated place until no further danger is to be apprehended for
them. When the city undertakes to pay all expenses for isolation and
disinfection of such cases, it has the right to require that all such
cases shall be so treated, leaving it to private parties to meet the
cost in case they prefer not to use the buildings and apparatus
provided by the city for that purpose. And when the city does its duty
in this respect, it will be found that physicians and the people will
do theirs, with rare exceptions.
When a city becomes very unhealthy the usual policy is to conceal the
fact as much as possible, and to attribute the mortality to some other
than the real cause. The influence of the mercantile part of the
community is in such a case strongly exerted on the daily press and on
the health authorities to produce such representations of the
condition of things as will tend to allay apprehensions on the part of
their customers. The healthfulness of a place is usually estimated
from its mortality reports, but the reliability of these is by no
means always what it should be. Yellow fever is called typho-malarial
or pernicious fever, typhoid is reported as diarrhoea or malarial
fever, etc. etc., and great stress is laid upon what is called the
sanitary condition of the place, which is declared to be excellent.
Unfortunately, this phrase, "sanitary condition," means different
things at different times. When the mortality is low, sanitary
condition means the healthfulness of a place; when it is high, it
means the cleanliness of a place. To a certain extent physicians are
responsible for the truth of the statistical returns, not so much in
relation to the number as to the causes of deaths; but none save those
who have practised in a city liable to epidemics can realize the
enormous pressure which is brought to bear on medical men to induce
them to aid in or wink at concealing the true state of the case. Of
course, this ostrich-like policy is in the long run an exceedingly
unwise one, but neither the average householder nor community can be
expected at present to pursue any other, except under pressure.
There are many questions as to the best form of public health
organization, and the powers and duties which should be conferred upon
it, which can only be properly answered by taking into consideration
the circumstances in each case. In a large city the health officers
must have great powers if they are to be really efficient. They have
to contend with ignorance, custom, and self-interest, and their action
must in many cases be prompt and unrestricted if it is to be
efficacious. They must sometimes be in conflict with wealthy and
powerful corporations, whose interests are opposed to the reforms
which they urge, and although their business is to protect the most
important interest of the community at large--_i.e._ its
health--against the interests of individuals, yet these last are much
more immediately concerned, and are, naturally, so active that they
are often, although few in number, able to defeat any attempt to
interfere with their occupations.