CHAPTER I. ANTRODUCTION
CHAPTER II.
BacrerioLocy AND PaRAsIToLocy .
CHAPTER III. Tue ATMosPHERE—AIR . . .
CHAPTER IV.
VENTILATION AND HEATING . .
CHAPTER V. Warr ssw.
ChiaPrer vi. Foop .
CHAPTER VII.
STIMULANTS AND BEVERAGES
CHAPTER VIII. Persona, Hygiene . . . . . .
CHAPTER IX. Scnoot Hyoene
WwW
36
69
101
146
229
277
285
314
viii CONTENTS
CHAPTER X. Disinrection
CHAPTER XI. Quarantine
CHAPTER XII.
Tue Removat anp DisposaL or SEWAGE
CHAPTER XIH.
InpustriaL Hyciene anp OccupationaL Diseases -
CHAPTER XIV.
Muuirary Hyciene
CHAPTER XV.
Virax Statistics
CHAPTER XVI.
Tur Exasination or Am, WATER, AND Foo
338
370
389
439
455
494
HYGIENE AND SANITATION.
CHAPTER I. INTRODUCTION.
Hyciene 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 respec- tively 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 Public Health and State Medicine, in the Hygiene of Municipalities and of Occupations, and in that which especially relates to the physical welfare of armies, navies and other large and particular groups of men.
A little thought will show that under the general head we may consider the preservation and promotion of health; practical disinfection and the means of avoiding preventable diseases; adaptation of diet and other factors to the prevention and cure of perversions of nutrition; improvement of environment; advances in sanitation and industrial hygiene, etc. 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 sur- roundings of our dwellings and communities; and at the same time the study of the means of recognizing, avoiding, correcting, or removing all detrimental factors affecting any of these. In addition, there must be the
. 2 (7)
18 INTRODUCTION 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 factors initiating and governing epidemics, and 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 conduct 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 bal-
_ anced 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 (dif- ferent 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 appar- ently 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 con- sidered: First, 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 rela- tion to nature at large. Second, in his social and corporate relations, as a member of a community with certain cus- toms, trades, etc.; subjected to social and political influ- ences, sexual relations, etc. Third, in his capacity as an independent being, having within himself sources of action in thoughts, feelings, desires, personal habits, all
SCOPE OF THE SCIENCE 19
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 preceding paragraph indicates the individual or personal aspect that marked the common concept of the subject until a comparatively short time ago. More recently the tendency is also to view its func- tions, opportunities and problems from a social and altruistic stand-point, and the field has so enlarged in this direction that it is questionable whether it may not be better to supplant the older word—Hygiene— when used to refer to the general science, with the newer term—Public Health and Preventive Medicine. But, after all, he who works to improve the sanitary condition of his neighbors and his neighborhood, no matter how extensive these may be in numbers and area, at the same time well serves his own interests, for not only is disease no respecter of persons, but its transmission and dis- semination depend very much upon one’s relationships with others.
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 advan- tages resulting from, the pursuit of hygienic measures and sanitary methods based on those laws and our experi- ence. 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 consideration, 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 pre- serve health and to ward off disease. Hippocrates (400B.c.)
20 INTRODUCTION
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, Ali- ment, Exercise and Rest, Sleep and Wakefulness, Reple- tion 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.”
The excellence of the Mosaic code is acknowledged by all sanitary authorities, and the effects of its observance are seen to this day in the comparative longevity of the Hebrew race. The Greeks cultivated to the extreme both the physical and mental faculties and had for their motto, A sane mind in a sound body. Recognizing the triune nature of humanity, we shall do well if we include with these the cultivation also of a spiritual health. The Romans, in their aqueducts for conveying water to the city and in the cloaca maxima, have left examples of sanitary engineering which are, in certain respects, not yet sur- passed. 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, espe- cially in matters pertaining to sanitation or “State Medi- cine,” 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
1 Treatise on Airs, Waters, and Places. (About 400 3.c.)
- 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 DuChatelet, 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.
VALUE OF SANITATION 21
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 forty years the knowledge gained in the new study of the bacteria and other microdrganisms and their hosts, especially that regarding the causation and 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 lasting and secure.
It would be wrong, nevertheless, to give the impression that hygiene is as yet an exact science. While it is tapidly attracting popular notice and attention, and has under the broader and more altruistic development already referred to, attained within comparatively recent years a dignity that it did not hitherto have in this new world, it is on a somewhat firmer basis abroad. Some of the best minds of the time are 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 practise. Especially is such new knowl- edge to be sought for in the study of the prevention of disease, the domain of bacteriology and the parasitic diseases, and physiologic and biologic chemistry.
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 80 per 1000; now it is about 15 per 1000. It is computed that in the eighteenth century— the one preceding the introduction of vaccination—fifty millions of people died in Europe of smallpox alone; now it is almost an extinct disease where vaccination is compulsory, as in Germany. 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
22 INTRODUCTION
called preventable, the average yearly number in Eng- land and Wales is about 120,000.” This result was actually more than achieved by 1889, and in 1912 the mortality-rate for these countries had fallen to 13.3 per 1000 of population as compared with an average of 22.6 for the decade 1862-71, this representing a saving of over 300,000 lives in the later year.
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. Im- proved sanitary laws are being enacted and enforced, streets better paved and cared for, houses more wisely constructed and ventilated, more attention given to iso- lating the sick and protecting the well, and the people in general are awakening to the importance of improving as well as maintaining the public health. New ‘York City has reduced her death-rate per thousand within twenty-five years (1890 to 1915) from 25.4 to 13.9; Chicago, from 19.1 to 14.3; Philadelphia, from 20.76 to 15.6; Beston, from 23.4 to 16.1, ete.'
Notwithstanding the increase in population, there were actually 7780 fewer deaths in New York City (Manhat- tan Borough) in 1916 than in 1891, although the increase in population during this period was over 50 per cent., or almost one million of additional citizens. Similar encouraging, if not so striking, reports from many other cities enable their authorities to attribute the good results to advance in medical and surgical knowledge along the lines of preventive medicine, improved sani- tary surroundings, better water-supplies, cleaner streets, in-
1 The importance of auch statistits is not fully appreciated unless the reader remembers that in a city of, say, a million inhabitants a reduc- tion of the death-rate by one point means the saving of one thousand lives annually.
RECENT VITAL STATISTICS 23,
inspection of milk- and food-supplies, isolation and modern treatment of infectious diseases, additional public parks, etc.'
DeaTH Rates PER THOUSAND oF POPULATION Ld wy : J creeds sn faegigueae ton dea |_.--[Rurpl Port of Reg Téfravdon States ry 7s 7 ns ng Yo fos as | ” 6 bse s 7 HOS. Loe / Sy Pad “ - mn 77 fae 8, $900 HO 190Z 1903 1904 1905 1006 1907 1908 1909 110 19m FIT
Fro. 1.—A comparison of urban and rural mortality (in registration states as constituted in 1900) from all causes.
COMPARATIVE DECLINE IN URBAN AND RURAL MORTALITY (IN REGISTRATION STATES AS CONSTITUTED IN 1900) FROM ALL CAUSES. Decline in —Death-rates per 1000 of population _donth-rate Av'ge | Av'ge
"a "12 from ‘00, 1900. 1905. 1910. 1912. ‘01-05. '05-'09. Actual. Pet, Registration states. 17.2 15.9 15.6 14.6 15.9 15.5 2.6 15.1 Rural part of registra- tion atates - 15.2 4 17 13.9 WL 42 13 8.5
Cities in registration states 2... 18.9 17.1 16.2 14.9 17.4 16.4 4.0 21.2
1 Twelfth Census of the United States, 1900, vol Vital Statistics.