Text-Book of Hygiene A COMPREHENSIVE TREATISE ON THB Principles and Practice of Preventive Medicine FROM AN AMERICAN STAND-POINT. BY GEORGE H. ROHE M.D., ' < ■. PROFESSOR OF OBSTETRICS AND HYGIENE IN THE COLLEGE OF PHYSICIANS AND SURGEONS, BALTIMORE ; DIRECTOR OF THE MARYLAND MATERNITY; MEMBER OF THE AMERICAN PUBLIC HEALTH ASSOCIATION; FOREIGN ASSOCIATE OF THE SOClfrrg FRAN^AISE D'HYGlfcNE, OF THE SOCI&t£ DES CHEVALIERS- SAUVETEURS DES ALPES MARITIMES, ETC. SECOND EEDITIOrN Thoroughly Revised and Largely Rewritten, with Many Illustrations and Valuable Tables. PHILADELPHIA AND LONDON: F. A. DAVIS, PUBLISHER, 1890. Entered according to Act of Congress, in the year 1890, by F. A. DAVIS, In the Office of the Librarian of Congress, at Washington, D. C., U. S. A. Philadelphia, Pa., U. S. A.: The Medical Bulletin Printing House, 1231 Filbert Street. TO HENRY INGERSOLL BOWDITCH, A.M., M.D., The Pioneer IN THE FIELD OF PREVENTIVE MEDICINE IN AMERICA. III PREFACE TO THE FIRST EDITION. The aim of the author in writing this book has been to place in the hands of the American student, practitioner, and sanitary officer, a trustworthy guide to the principles and practice of preventive medicine. He has endeavored to gather within its covers the essen- tial facts upon which the art of preserving health is based, and to present these to the reader in clear and easily understood language. The author cannot flatter himself that much in the volume is new. He hopes nothing in it is untrue. V PREFACE TO THE SECOND EDITION. In the present edition the author has endeavored to in- corporate the advances made in sanitary science and art since the issue of the first edition. Additions will be found upon nearly every page, and some of the chapters have been almost entirely rewritten. The size of the book has been increased about one hundred pages, and illustrations have been introduced wherever thought requisite. The thanks of the author are due to Medical Director Albert L. Gihon, United States Navy, for revising the chapter on Naval Hygiene, and to Surgeon Walter Wyman, United States Marine-Hospital Service, for supplying the chapter on Quarantine. VII TABLE OF CONTENTS. CHAPTER I. Air, 1 CHAPTER II. Water, 45 CHAPTER III. Food, 81 CHAPTER IV. Soil, 121 CHAPTER V. Removal of Sewage, 135 CHAPTER VI. Construction of Habitations, 151 CHAPTER VII. Construction of Hospitals, 179 CHAPTER VIII. School of Hygiene, . 192 CHAPTER IX. Industrial Hygiene 207 CHAPTER X. Military and Camp Hygiene, 231 IX X TABLE OF CONTENTS. CHAPTER XI. Naval Hygiene, 243 CHAPTER XII. Prison Hygiene, 255 CHAPTER XIII. Exercise and Training, 261 CHAPTER XIV. Baths and Bathing, 267 CHAPTER XV. Clothing, 275 CHAPTER XVI. Disposal of the Dead, 279 CHAPTER XVII. The Germ Theory of Disease, 285 CHAPTER XVIII. Contagion and Infection, 289 CHAPTER XIX. History of Epidemic Diseases, 293 CHAPTER XX. Antiseptics, Disinfectants, and Deodorants, . . 347 CHAPTER XXL Vital Statistics, 359 CHAPTER XXII. Quarantine, 365 Index, 417 Text-Book of Hygiene CHAPTER I. Air. Exact investigation into the influence of the atmosphere upon health is yet in its infancy. Enough has been learned, however, to show that changes in the composition of the air, in its density, its temperature, its humidity, its rate and direction of motion, and possibly its electrical or magnetic conditions, influence in various ways the health of the individual. It is only very recently that any scientific attempts have been made to trace the bearing of atmospheric changes upon health. The observations already recorded indicate that a thorough study of meteorological phenomena in connection with the origin and progress of certain diseases is a promising field of labor for the educated sanitarian. The meteorological observations which have been gathered by the United States Signal Service during the past eighteen years, together with the elaborate studies made by the meteorologists and climatologists of other countries, already form such a large and tolerably complete and well- arranged body of facts, that reasonably accurate deductions can even now be made. Heretofore, in studying the sanitary rela- tions of the atmosphere, both in this country and abroad, the attention of observers has been riveted almost exclusively upon the changes in its composition occurring within certain limited areas. It is, perhaps, equally important to study this universally diffused and necessary condition of vital activity in its broader and more general relations. It will be shown, in the course of the present work, that the meteorological features of countries, 1 2 TEXT-BOOK OF HYGIENE. or of seasons, or even the daily atmospheric changes, exercise an important influence upon life and health. In order to fully appreciate these relations it will be necessary to first give a brief summary of the facts and laws of meteorology. THE COMPOSITION AND PHYSICAL CONDITIONS OF THE ATMOSPHERE. Atmospheric air is a mixture of four-fifths of nitrogen and one-fifth of oxygen; more accurately, 79.00 of the former to 20.96 of the latter. In addition, there is constantly present a modicum of carbon dioxide, usually a little over .03 per cent. (3 to 4 parts in 10,000), traces of ammonia and nitric acid, and a variable proportion of vapor of water. These proportions are maintained, with but very little change, at different heights. At first thought, it would seem that carbon dioxide, being much heavier than the other con- stituents of air, would accumulate in the lower regions of the atmosphere, and there cause an excess of this poisonous con- stituent, but in obedience to the law of diffusion the interming- ling of the component gases is perfect, and the proportion of carbon dioxide in the atmosphere is quite as great on mountain- tops as in the deepest valleys. The proportion of nitrogen in atmospheric air is generally uniform, while that of oxygen varies, depending to a great ex- tent upon the amount of carbon dioxide present. Hence, an increase in the amount of the latter constituent is usually ac- companied by a diminution of oxygen, inasmuch as the formation of carbon dioxide can only take place at the expense of oxygen. The reciprocal activities of animal and vegetable life are beauti- fully illustrated by these relations between the oxygen and carbon dioxide in the air. In the processes of combustion and oxidation, oxygen is withdrawn from the atmosphere, and com- bines with carbon, forming carbon dioxide. During vegetable growth, on the other hand, carbon dioxide is withdrawn from the air by the leaves of plants, and decomposed into its elements, carbon and oxygen. The carbon is used in building up the COMPOSITION AND PHYSICAL CONDITIONS OF ATMOSPHERE. 3 plant, while the liberated oxygen is restored to the atmosphere. The animal consumes oxygen, and gives out carbon dioxide; the plant resolves this compound into its constituent elements, and gives back the oxygen to the air again. Some recent experiments of Jolly have shown that on days of northerly winds the proportion of oxygen is higher than the average, while under the influence of the south wind the propor- tion of oxygen is deficient. The extremes in a series of 21 observations were 21.01 and 20.53 per cent. The difference, .48 per cent., is too small to have any appreciable influence upon health. The atmosphere extends upward from the surface of the earth to an indefinite distance. The limit has been variously placed at from 75 kilometres to 40,000 kilometres. For all sanitary purposes the former may be taken as the upward limit of the atmosphere. In obedience to the law of gravity, this mass of air everywhere presses directly downward-toward the earth's centre-with a force equal to its weight. If a column of this air be balanced by a column or mass of any other matter- the columns being of the same diameter-we have a relative measure of the weight of the atmosphere. The instrument with which the weight or downward pressure of the air is measured is called a barometer. The atmosphere, at the sea-level, presses downward with a force equal to the pressure of a column of mercury 760 millimetres high. Hence, the barometric pressure at sea-level is said to be 760 millimetres, or 30 inches. If the barometer be carried to the summit of a mountain 1000 metres above the level of the sea, or taken to the same altitude in a balloon, the mercury in the barometer-tube will fall about 90 millimetres. These 90 millimetres of the mercurial column represent the weight of 1000 metres of air now below the barometer, and consequently not measured or balanced by it.1 Upon ascending from the sea-level, it is found also that the 1 The figures here given are not absolute, but merely approximate. The limits of this work do not allow a full discussion of the meteorological elements modifying the pressure of the atmosphere at sea-level. 4 TEXT-BOOK OF HYGIENE. air, being less pressed upon by that which is still above it, becomes more rarefied and lighter; its tension, as it is termed, is less. Hence, for the second 1000 metres of ascent above the sea, the mercury will fall a less distance in the tube, the weight removed not being so great as in the first 1000 metres. The following table shows the diminution in atmospheric pressure for every 1000 metres above sea-level:- Table I. Height. Barometric Pressure. Sea-level • • • • • . 760.0 millimetres. 1,000 metres, . 670.4 44 2,000 44 . 591.5 44 3,000 44 . 521.0 44 4,000 44 . 460.3 44 5,000 44 . 406.0 44 6,000 44 . 358.2 44 7,000 44 . 316.0 44 8,000 44 . 278,8 44 9,000 44 . 245.9 44 10,000 44 . 216.9 44 11,000 44 . 191.1 44 12,000 44 . 168.8 44 15,000 44 . 115.9 44 20,000 44 . 61.9 44 v anations m temperature and humidity of the air influence the tension of the atmosphere in a marked degree, and affect the height of the barometric column. In fact, most of the changes of atmospheric pressure at the surface of the earth are directly due to changes in temperature and humidity. Increase of temperature diminishes the density of the air. Hence, when the temperature rises the pressure decreases. The proportion of moisture (aqueous vapor), if increased, likewise causes a diminution in pressure. It is found, for ex- ample, that when the amount of aqueous vapor in the air increases the barometer falls. This is due to the fact that the specific gravity of aqueous vapor is less than that of dry air, being in the proportion of .623 to 1.000. Hence, as aqueous COMPOSITION AND PHYSICAL CONDITIONS OF ATMOSPHERE. 5 vapor is diffused through air, the latter becomes lighter,-or, in other words, the barometric pressure diminishes. The warmth of the air is primarily derived from the sun. On a clear day about one-fourth of the heat of the sun's rays is given off directly to the air during the passage of the heat- rays to the earth. Of the remaining three-fourths, part is re- flected from the earth, while the larger portion is first absorbed by the earth, and then given off by radiation and convection to the superincumbent air. The air is always warmer near the earth's surface on a clear, sun-shiny day; for, as soon as the earth gets warmer than the air immediately above it, the excess of heat is given off to the latter by convection and radiation. On ascending from the surface of the earth the temperature decreases, and on the summit of a high mountain the air is always colder than at its base. I'rofessor Tyndall has shown that dry air absorbs less heat than air which is charged with vapor. For this reason the sun's rays strike the earth with much greater intensity on a very dry than on a moist day, while on the latter a larger proportion of the heat-rays is intercepted before they reach the earth. Recent experiments seem to show, however, that the differ- ence in diathermancy between dry and humid air is not so great as supposed by Tyndall. The depth of the air-stratum, through which the sun's rays pass, is of greater influence than the humidity. Air, at different temperatures, is capable of absorbing different amounts of aqueous vapor. Thus, air at a temperature of 4° will require a much smaller amount of vapor to produce saturation than air at a temperature of 30°. For this reason air which appears " damp " at the former temperature, both to the bodily sensations and to appropriate instruments, would be considered as "dry" at the latter temperature, although the actual amount of vapor present, or absolute humidity, is the 6 TEXT-BOOK OF HYGIENE. same in both cases.1 In meteorological observations for sanitary purposes, the relative humidity is the condition deserving especially careful study. It must be borne in mind that the mere statement of the percentage of relative humidity, without taking into account the temperature of the air, is of little significance. A like remark is justified with regard to statements of absolute humidity, when used to illustrate the apparent effects of atmospheric moisture upon life and health. The following table shows the absolute humidity corre- sponding to the same relative humidity at different tempera- tures. It also includes the total possible absolute humidity and the difference between the actual and possible humidity (deficiency of saturation) at the temperatures given :- Table II. Tempera- ture °C. Relative Humidity (per cent.). Absolute Humidity (grammes per cubic metre). Greatest Possible Absolute Humidity. Deficiency of Saturation. -20 60 0.638 1.064 0.426 -10 60 1.380 2.300 0.920 0 60 2.924 4.874 1.950 +10 60 5.623 9.372 3.749 20 60 10.298 17.164 6.866 30 60 18.083 30.139 12.056 In forests the relative humidity is usually higher than over unwooded districts, although the absolute humidity may be the same, or, perhaps, even less. The evaporation is usually much greater in the open air than in forests. In closed apartments the evaporation may be greater or less than in the open air, de- pending upon the local conditions present. 1 By "absolute humidity" is meant the total amount of vapor present in a certain mass of air. By the term "relative humidity " meteorologists designate the proportion of vapor present at certain temperatures, compared with full saturation of the air with vapor, which is reckoned 100. Thus, air which is saturated, or whose relative humidity is 100 at 4°, would have a relative humidity of only 24, if the temperature were raised to 27°, because in the latter case the capacity of the air for aqueous vapor is increased. Relative humidity is always designated in percentages; absolute humidity in grammes per cubic metre or grains per cubic foot. COMPOSITION AND PHYSICAL CONDITIONS OF ATMOSPHERE. 7 The motion of the air-wind-is caused by differences in pressure; the latter being due to differences in temperature and humidity. A mass of air traversing a large body of water absorbs vapor, unless already saturated, and becomes moist; if it pass over a wide tract of dry land it loses moisture and becomes dry. Therefore in the eastern portion of the American continent, an easterly or southerly wind, which comes from over large bodies of water, and which is usually warm, and thus capable of hold- ing a large quantity of water in a state of vapor, is always moist. On the other hand, a northerly or westerly wind, com- ing over a large extent of dry land, and from a colder region, is nearly always a dry wind. On the Pacific coast these condi- tions are reversed; there a westerly wind is a moist wind, while an easterly wind is dry. The dreaded easterly wind of England is likewise a dry wind. It is probable that the direction and rate of motion of air-currents have considerable influence upon the origin or intensification of certain diseases. The electrical and magnetic conditions of the atmosphere have been as yet studied to little advantage. It is only known that atmospheric electricity is, in most cases, positive, and that its intensity increases with condensation of vapor. There seems to be no doubt that the varying states of atmospheric electricity are closely connected with evaporation and condensation. There is reason to believe that a fuller knowledge on these topics will yield most important results to the student of hygiene. Ozone and antozone, or hydrogen peroxide, are usually present in the atmosphere in varying proportions. Careful and extended observations have failed to show any connection be- tween the presence of these agents in the atmosphere and modi- fications of health. It is probable that the sanitary importance of ozone and of hydrogen peroxide have been much overrated. It is not known that either of these substances has any other function in the atmosphere than that of an oxidizing agent. The sanitarian should be a practical meteorologist. In addition to a knowledge of the principles of the science, he 8 TEXT-BOOK OF HYGIENE. should possess the skill to make accurate observations of me- teorological conditions, and estimate their significance. But the acquisition of an elaborate collection of instruments, and their regular observation, is too expensive and time-consuming. A German physicist, Lambrecht, has de- vised an instrument which combines in itself nearly all the requirements of a trustworthy meteorological instrument (Fig. 1). This instrument is called a polymeter, and shows, on easily-readable scales, the temperature, relative humid- ity, dew-point, absolute humidity in grammes per cubic metre, and vapor tension. INFLUENCE OF CHANGES OF ATMOSPHERIC PRESSURE ON HEALTH. The effects of a considerable dimi- nution of pressure are familiar to every one in the " mountain sickness " which attacks most persons on ascending high mountains. M. Bert has shown experi- mentally that similar effects can be produced in an air-tight chamber by diminishing the pressure.1 The symp- toms produced under a pressure equiva- lent to an altitude of from 4000 metres to 5000 metres were a feeling of heavi- ness, nausea, ocular fatigue, rapidity of pulse, convulsive trembling on slight exertion, and a sensation of languor and general indifference to the surroundings of the individual. M. Lortet, who has left on record his experiences in the higher Alps, says that the symptoms noticed on ascending to Fig. 1. Lambrecht's Polymeter. 1 Popular Science Monthly, v, p. 379. INFLUENCE OF CHANGES OF ATMOSPHERIC PRESSURE. 9 high altitudes are: Labored respiration, increased rapidity of pulse, depression of temperature (as much as 4° to 7° C.). The normal temperature was restored, however, after a brief rest.1 Still more severe symptoms have been noticed on ascending high mountains in South America and Asia. Aeronauts have lost consciousness, and in several instances life, on rapidly ascending to great altitudes.2 According to the observations of the brothers Schlagintweit, distinguished explorers of the highlands of Asia, the effects of diminished pressure upon the human organism are: " Headache, difficulty of respiration, and affec- tions of the lungs,-the latter even proceeding so far as to occasion blood-spitting,-want of appetite, and even nausea, muscular weakness, and a general depression and lowness of spirits. All these symptoms, however, disappear in a healthy man almost simultaneously with his return to lower regions." A singular observation was made by these travelers on the effect of motion of the air upon the symptoms described. They say: " The effects here mentioned were not sensibly increased by cold, but the wind had a most decided influence for the worse upon the feelings When occupied with observa- tions, we took very little, if any, bodily exercise, sometimes for thirty-six hours; it would frequently occur nevertheless, even in heights not reaching 17,000 feet (about 5150 metres), that an afternoon or evening wind would make us all so sick as to take away every inclination for food. No dinner was cooked; the next morning, when the wind had subsided, the appetite was better. " The effects of diminished pressure are considerably aggra- vated by fatigue. It is surprising to what degree it is possible for exhaustion to supervene ; even the act of speaking is felt to be a labor, and one gets as careless of comfort as of danger. Many a time our people-those who ought to have served us as guides-would throw themselves down upon the snow, declaring 1 Realencyclopaedie d. ges. Heilk., v„ p. 529. 2 MM. Siveland Croce-Spinelli, two aeronauts, lost their lives in this manner during an ascent from Paris, in April. 1875. 10 TEXT-BOOK OF HYGIENE. they would rather die upon the spot than proceed a step farther."1 These symptoms disappear when persons are exposed to these conditions for a prolonged time. Thus, in the Andes there are places 4000 metres above sea-level which are per- manently inhabited; and in the Himalayas there are villages at a height of over 5000 metres constantly occupied. In this country, Pike's Peak, 4350 metres above the sea, has been occupied since 1873 by observers of the signal service. The men seem to become acclimated, as it were, and suffer little or no inconvenience from the diminished pressure after a time. The minor disturbances of healthy function produced by diminished pressure (within the limits of 4000 metres altitude, or 460 millimetres barometric pressure) are an increase in the pulse and respiration rate. This is probably due to the struggle of the organism to take up the required quantity of oxygen which is reduced in proportion by the rarefaction of the air. For example, the proportion of oxygen at a pressure of 460 millimetres would be equivalent to 12.6 per cent, at sea-level, instead of the normal 20.9 per cent. Paul Bert has shown by personal experiments in the pneumatic chamber that the increase in pulse and respiration rate is not due to the merely mechanical diminution of pressure, but to the deficiency of oxygen. Hence the physiological effects of high altitudes upon circulation and respiration are not purely physical, due to diminished pressure, but vital, and depend upon the change in the chemical composition of the atmosphere. The simple diminution of oxygen without reduction of pressure will produce similar though not identical effects upon the organism. Above the height of 4000 metres above sea-level (below 460 millimetres pressure) the profounder disturbances of func- tion characterized as " mountain sickness " come on. Different 1 Results of a Scientific Mission to India and High Asia. By Hermann, Adolphe, and Robert De Schlagintweit, vol. ii, pp. 484, 485. 11 INFLUENCE OF CHANGES OF ATMOSPHERIC PRESSURE. individuals react in different degree to the morbific influences of greatly diminished atmospheric pressure (and coincident reduc- tion of oxygen). Thus Glaisher reached an elevation of 11,000 metres (191.1 millimetres pressure) and returned to the earth alive, while Croce-Spinelli and Sivel perished at the considerably lower elevation of 8000 metres, equivalent to a pressure of 260 millimetres (7.2 per cent, of oxygen). The sanitarian is most concerned about the effects of press- ure of the atmosphere from 760 millimetres down to 460 milli- metres (or up to an altitude of 4000 metres above sea-level). The climatotherapy of various diseases requires that the effects of variations of pressure between these limits should be carefully studied. The observations of Mermod and Jourdanet1 have illustrated the common physiological effects of these circum- scribed changes, while the experiences of therapeutists have established the fact very clearly that many cases of phthisis improve markedly in a rarefied atmosphere. Other observers have also shown that the effects of diminished pressure are not always beneficial, and Dr. Loomis has warned against the send- ing of patients with heart disease to high altitudes. Whether the lethal effects that have been recorded in such cases are due to the increased activity of the heart and heightened blood- pressure from deficient oxygen, or as suggested by Dr. F. Don- aldson, Jr., to dilatation of the heart-walls from diminution of external pressure, is as yet unsettled.2 It is probable that the diurnal or accidental3 oscillations of barometric pressure at sea-level have no appreciable influence upon the organism. The statement is occasionally met that patients subjected to grave surgical operations oftener do badly during low atmospheric pressure, and some surgeons never 1 Jourdanet states that while the French and Belgian soldiers in Mexico had an accel- erated pulse, the natives had a normal pulse. In Mermod's observations the average frequency of the pulse at St. Croix (1106 metres above sea-level) was nearly four beats greater than at Strass- burgh (142 metres). The condition of the natives at the high settlements of the Andes and Hima- layas has not yet been investigated with exactitude. 2 American Climatological Association, 1887. 3 Meaning the oscillation produced by storm waves. 12 TEXT-BOOK OF HYGIENE. operate when the barometer is low or falling if they can avoid it. An inquiry undertaken by the writer in 1876, in which the excellent records of the Massachusetts General Hospital and the observations of the Boston station of the United States Signal Service for five years were used as the basis of comparison, resulted negatively. The deaths following operations done on days when the barometer was high or rising were exactly equal in number to those following operations when the barometer was low or falling. Unfortunately, the investigation was never pursued to the extent of including other meteorological elements, such as humidity, cloudiness, precipitation, etc. The numerous studies of the relations of variations of pressure to the progress of infectious diseases have also failed to yield any fruits of value. Whether the nerve-pains so frequently complained of, especially by elderly patients, during the progress of areas of low barometer, are due to the diminished pressure, or to the influence of some other meteorological factor, such as humidity or electrical con- dition, cannot yet be decided. Increased atmospheric pressure, as noticed in caissons, tun- nels, and mines, produces increase in frequency and depth of respiration, diminution in the number of beats and volume of the pulse, pallor of the skin, increase of perspiration (although Smith states that this is only apparent and due to lack of evapo- ration from the surface), increased appetite, and more abundant excretion from the kidneys. Among the distinctly pathological effects of increased at- mospheric pressure are rupture of the drum of the ear, pain in the frontal and maxillary sinuses, neuralgic pains, nausea, some- times vomiting and local paralyses. Dr. A. H. Smith1 defines this collection of symptoms as "The Caisson Disease," and gives the following summary of its characteristic features:- "A disease depending upon increased atmospheric pressure, but always developed after the pressure is removed. It is char- 1 The Physiological, Pathological, and Therapeutical Effects of Compressed Air, p. 47. Detroit, 1886. INFLUENCE OF CHANGES OF ATMOSPHERIC PRESSURE. 13 acterized by extreme pain in one or more of the extremities, and sometimes in the trunk, and which may or may not be associated with epigastric pain and vomiting. In some cases the pain is accompanied by paralysis more or less complete, which may be general or local, but is most frequently confined to the lower half of the body. Cerebral symptoms, such as headache and vertigo, are sometimes present. The above symptoms are con- nected, at least in the fatal cases, with congestion of the brain and spinal cord, often resulting in serous or sanguineous effu- sion, and with congestion of most of the abdominal viscera." INFLUENCE OF CHANGES OF TEMPERATURE ON HEALTH. Many of the derangements of health ascribed to high tem- perature are to a considerable degree due to other factors, promi- nent among which are high humidity, intemperance, overwork, and overcrowding. There can be little doubt, however, that the importance of the high temperature itself can hardly be over- rated. It has been generally accepted heretofore that a high temperature, together with a high relative humidity, is most likely to be followed by sun-stroke. A careful comparison in a series of deaths from sun-stroke in the city of Cincinnati in the summer of 1881 shows, however, conclusively that a very high mean temperature with a low relative humidity is more liable to be followed by sun-stroke than the high temperature when ac- companied by a high humidity. The same series of observa- tions also shows that the number of deaths was greater on clear days than on cloudy or partly cloudy days.1 A corroboration of this result is found in the fact that sun-strokes very rarely occur on shipboard, at sea, where the relative humidity is always high. The direct influence of the sun's rays upon the skin pro- duces at times an erythematous affection which may run into a 1 The Sun-stroke Epidemic of Cincinnati, 0., during the Summer of 1881. A, J. Miles, Public Health, vol. vii, pp. 293-304. 14 TEXT-BOOK OF HYGIENE. dermatitis if the insolation is prolonged. Artificial heat may produce similar effects. Diarrhoeal diseases, both of adults and children, are much more frequent during hot than cold weather (and in hot than in cold climates), but it is probable that other factors aid in the production of these diseases besides the high temperature. Certain epidemic diseases are likewise more frequent in, or exclusively confined to, hot climates. These are cholera, yellow fever, and epidemic dysentery. Elephantiasis and the prevalence of certain skin diseases seem also to have some connection with a constantly high external temperature. The intimate relation between cause and effect is not clearly understood, although the belief is current that the origin and spread of such diseases depend upon the development of various parasitic organisms. Regarding the morbific effects of continued high tempera- tures, it is probable that an appropriate mode of life, proper diet, and suitable clothing would avert many of the bad conse- quences. Nevertheless, the fact remains that certain tropical or hot-weather diseases must be considered as primarily dependent upon high temperature, although the pathological effects may be due to an intermediate factor. It is not improbable that micro- organisms will be found to explain yellow fever, cholera infan- tum, and tropical dysentery. Cholera has already been shown to depend upon a pathogenic organism. In this case the high temperature is one of the associate but none the less indispens- able factors in the production of the disease. Extreme low temperature, as observed in the arctic regions, seems to produce a progressive deterioration of the blood (anaemia), in consequence of which most natives of temperate regions who are compelled to remain in the far north longer than two winters succumb to various haemic diseases, scurvy be- ing the most prominent. It is not improbable, however, that the dietary furnished is responsible for a large share of the evil effects ascribed to cold. The absence of sunlight for a consider- able part of the winter season may also have much to do with INFLUENCE OF CHANGES OF TEMPERATURE ON HEALTH. 15 the bad influences for which the low temperature is held responsible. Among the acute effects of great cold, frost-bite is the most frequent as well as the most serious. Loss of portions of the nose, or ears, or even of entire members are not infrequent results of frost-bite. In the arctic regions one of the most annoying affections which the traveler has to contend against is snow-blindness, a severe ophthalmia produced by the glare of the snow. Neutral tinted glass goggles should be worn as a preventive.1 Dr. Henry B. Baker2 has placed upon record a large mass of observations which appear to indicate that most of the acute diseases of the respiratory organs are caused by a low tempera- ture in conjunction with a low absolute humidity. Dr. Baker furnishes numerous diagrams, which seem to demonstrate that the curves for influenza, tonsillitis, croup, bronchitis, and pneu- monia are in general outlines all practically the same, and that they follow the curve for atmospheric temperature with surpris- ing closeness, rising after the temperature falls and falling after the temperature rises. He claims that this sameness indicates that the controlling cause is one and the same for all of these diseases, and that, directly or indirectly, the atmospheric tem- perature is that cause. They are diseases of the air-passages, and may be supposed to be influenced or controlled by the at- mosphere which passes through them. Although the curves are all similar, yet their differences still further support his view, because the order of succession of the several diseases is such as would be expected if caused in the manner which he sup- poses. Thus croup and influenza precede in time bronchitis and pneumonia; the curve for bronchitis shows that disease to respond quicker than does pneumonia to the rise and fall of the 1 See Payer's Narrative of the Austrian Arctic Voyage of 1872-74, pp. 250-8 and 317, for an account of the effects of cold on the organism, and on the best prophylactic measures to be adopted. The Report of the Surgeon-General of the U. S. Navy for 1880 also contains (pp. 350-8) a valuable memorandum by Ex-Surgeon-General Philip S. Wales, on Arctic Hygiene. 2 Trans. Ninth International Med. Congress, vol. v. 16 TEXT-BOOK OF HYGIENE. temperature. He suggests that the explanation of the causa- tion of these diseases has not been grasped before because one of the principal facts has not been apprehended, namely, the fact that cold air is always dry air ; on the contrary, it has been generally stated that when these diseases occur the air is cold and damp. He explains that while the cold air is damp rela- tively it is always dry absolutely, and he thinks that its bad effects on the air-passages are mainly through its drying effects, which can best be appreciated by reflecting that each cubic foot of air inhaled at the temperature of zero, F. [- 17.8° C.], can contain only J grain of vapor [1.33 grammes per cubic metre], while when exhaled it is nearly saturated at a temperature of about 98° F. [36.5° C.], and therefore contains about 18J grains of vapor [about 43 grammes per cubic metre], about 18 grains of which have been abstracted from the air-passages. Thus cold air falling upon susceptible surfaces tends to produce an abnormal dryness which may be followed by irritation and suppuration. He claims that coryza is sometimes so caused. Under some conditions the nasal surfaces are not susceptible to drying, the fluids being supplied in increased quantity to meet the increased demand made by the inhalation of cold air. In that case an unusual evaporation of the fluid leaves behind an unusual quantity of non-volatile salts of the blood, such as sodium chloride, and an unusual irritation results; he thinks influenza is the name commonly given to this condition. The effects which the inhalation of cold air has on the bronchial surfaces depend greatly upon how the upper air-passages have responded to the increased demand for fluids; because, if they do not supply the moisture it must be supplied by the bronchial surfaces, in which case bronchitis results. Finally, if the de- mands for moisture made by cold air are not met until the air- cells are reached pneumonia is produced. These claims are partly supported and partly opposed by an elaborate paper by Dr. J. W. Moore.1 According to the 1 The Seasonal Prevalence of Pneumonic Fever, Trans. Ninth Internal. Congress, vol. v. INFLUENCE OF CHANGES OF TEMPERATURE ON HEALTH. 17 statistics furnished by this writer, bronchitis and pneumonia show a remarkable contrast as to seasonal prevalence. The sta- tistics of London and Dublin agree very closely upon this point. Bronchitis falls to a very low ebb in the third or summer quarter of the year (July to September, inclusive), when only 12 per cent, of the deaths annually caused by this disease take place in Dublin and only 11 per cent, in London. In the last or fourth quarter (October to December, inclusive) the percentage of deaths from bronchitis rises to 27 in Dublin and 30 in London. The maximal mortality occurs in the first quarter (January to March, inclusive), when it is 38 per cent, in both London and Dublin. In the second or spring quarter (April to June, inclu- sive) the bronchitic deaths decline to 23 per cent, in Dublin and 21 per cent, in London. The mortality from pneumonic fever is differently distrib- uted throughout the year. In the summer quarter more than 14 per cent, of the annual deaths referable to the disease are recorded in Dublin and more than 15 per cent, in London. In the first quarter the figures are-London, 31 per cent.; Dublin, 31 per cent. In the second quarter they are-London, 26 per cent.; Dublin, 30 per cent. In the fourth quarter they are-London, 27 per cent.; Dublin, 24 per cent. It therefore appears that the prevalence and fatality of pneu- monic fever from season to season do not correspond with the seasonal prevalence and fatality of bronchitis. The latter dis- ease increases and kills in direct relation to the setting in of cold weather; it subsides in prevalence and fatality with the advance of spring and the advent of summer. Pneumonic fever, on the other hand, increases less quickly in winter and remains more prevalent in spring than bronchitis; its maximal incidence coin- cides with the dry, harsh winds and hot sunshine of spring, when the diurnal range of temperature also is extreme. Dr. Moore believes that acute bronchitis is produced directly by the influence of low temperature, while pneumonia requires an additional cause, which he supposes to be a specific micro- organism. 2 18 TEXT-BOOK OF HYGIENE. HUMIDITY OF THE ATMOSPHERE AS CONNECTED WITH CHANGES IN HEALTH. The propagation of certain acute infectious diseases is be- lieved to be due to a high relative humidity. There can be no longer any doubt that a very humid soil and air, especially if connected with a variable temperature, are almost constant factors in the production of pulmonary phthisis. Recent experi- ence in this country and abroad has shown that the high plateaus and mountains, far inland, where the soil is dry and the relative humidity of the air low, are the best resorts for consumptives. Of the effects of excessively dry air on health little definite is known. It seems probable, however, that catarrhal affections of the respiratory mucous membrane are more frequent in a dry than in a humid climate.1 THE SANITARY RELATIONS OF AIR-CURRENTS. Primarily, winds or air-currents may be considered as favor- able to health. By the agitation of the air ventilation is secured, foul air removed from insanitary places, and diluted by ad- mixture of purer air. But air-currents may also be regarded as either directly or indirectly unfavorably influencing health. Vertical currents rising from the ground may carry morbific germs or viruses and give rise to disease. Horizontal currents or winds proper may also be the direct or indirect cause of de- rangements of health. Full credit is given by the public to cold winds and draughts in producing catarrhs and rheumatic pains. The progression of certain infectious diseases, especially malaria, is believed with good reason to stand in a definite relation with the direction of the wind. Certain local winds are known to have a deleterious effect upon living beings, especially when the latter are in bad health. Among these winds is the mistral, a cold, dry, parching north- 1 See ante. SANITARY RELATIONS OF AIR-CURRENTS. 19 west wind which blows along the Gulf of Lyons. It brings on rheumatism and muscular pains, and is said to excite pleurisy and pneumonia and to act unfavorably upon consumptives. The bora is a cold, dry wind coming down from the Alps and continuing across the Adriatic. The Texan northers are well known in the southwestern part of the United States. They are extremely dry, and are often accompanied by a sudden fall of temperature. Changes of 28° C. (50° F.) within twelve hours are not infrequent in Western and Central Texas. Both man and beast suffer in- tensely from the cold, parching character of the wind. The sirocco of Northern Africa, Sicily, and Southern Italy has a world-wide notoriety for its depressing effect upon human energy. The harmattan is equally noted on the west coast of Africa. It is hot and dry, while in Southern Europe the sirocco is hot and moist. The simoon is a hot, scorching wind of India, and is said to be deadly in its effects upon vegetation and extremely dele- terious to men and animals who are encountered by it. In Australia and South Africa hot winds are said to occur which completely destroy vegetable life in their track, and are often unwholesome in their effects upon animal life. The evil reputation of the Alpine fohn is very well known, and neither native nor traveler is anxious to encounter it. It is warm and dry. With reference to the influence of electrical conditions of the atmosphere upon health, no observations have been made which justify definite conclusions.1 Mr. Alexander Buchan and Dr. Arthur Mitchell have analyzed the influence of the weather and season upon the 1 Dr. S. Weir Mitchell has shown, from the record of the case of Captain Catlin, U. S. A (American Journal Med. Set, April, 1877, and N. Y. Med. Jour., August 25 and September 1,1883), that attacks of neuralgia-in this case, at all events-accompanied the progress of storms across the continent. Also, that the periods of maximum pain occurred with a high but falling barom- eter and increasing absolute humidity. There seems also to be some relation in this case between the maximum pain and the maximum magnetic force as shown by the declinometer. Dr. Mitchell's papers are among the most valuable positive contributions to hygienic meteorology, and deserve careful study. 20 TEXT-BOOK OF HYGIENE. causation of disease, or, rather, upon the mortality from various diseases.1 Taking the records of the city of New York from 1871 to 1877, it appears that the maximum number of deaths from small-pox occurred in May, the minimum in September. From measles there were two annual maxima and minima, the greater in July and September and the smaller in February and April. From scarlet fever the maximum was in April, the mini- mum in September. From typhoid fever the maximum was from August to November, the minimum almost equally distrib- uted throughout the rest of the year; from diarrhoea, the maxi- mum in July and August, the minimum from December to March; from diphtheria, the maximum in December, the mini- mum in August;2 from whooping-cough, maximum in Septem- ber and February, minimum in November and June; for croup the curves agree pretty closely with the diphtheria curves; from phthisis, the maximum in March, minimum in June. The following charts, reproduced by permission of the Massachusetts State Board of Health from the report of that body for 1888, show an almost identical movement of the mortality from different diseases throughout the year. They exhibit the reported mortality for 1888 and also for the six years from 1883 to 1888. From suicide, curiously, the greater number of deaths occurs in May, the smallest in February. This is contrary to the usual supposition that gloomy weather predisposes to suicide. The six summer months-from April to September-show a much larger number of self-murders than the remaining half-year. In eleven years, ending 1880, there were 1521 cases of self-destruction in New York. Of these 341 occurred during January, February, and March; 417 during April, May, and June; 412 during July, August, and September; and 351 during the last three months of the year. In Philadelphia, the results of examination 1 Journal Scottish Meteorological Society, 1875-78. (Abstract in Richardson's Prevent- ive Medicine, p. 533 et seq. Philadelphia, 1884.) 2 See paper on the Relation of Weather to Mortality from Diphtheria in Baltimore, by Richard Henry Thomas, in Trans. Med. and Chir. Faculty of Maryland, 1883. INFLUENCE OF SEASON UPON MORTALITY. 21 i&d3 to iaaa incluoive iaaa. Reported Mortality from Consumption for each Week for 1888, and for the Six Years (1883-1888). CONSUMPTION. 22 TEXT-BOOK OF HYGIENE. Reported Mortality from Acute Lung Diseases for each Week, 1888, and for Six Years (1883-1888). ACUTE LUNG DISEASES. iao3 to laaa inclusive. isao. INFLUENCE OF SEASON UPON MORTALITY. 23 1883 TO 1688 INCLUSIVE. 1888. DIARRHCEAL DISEASES. Reported Mortality from Diarrhceal Diseases for each Week, 1888, and for Six Years (1883-1888). 24 TEXT-BOOK OF HYGIENE Reported Mortality from Typhoid Fever for each Week, 1888, and for Six Years (1883-1888). TYPHOID FEVER. iaaa to laao inclusive. isea. INFLUENCE OF SEASON UPON MORTALITY. 25 1883 TO I8S8 INCLUSIVE. iaaa. DIPHTHERIA AND CROUP. 26 TEXT-BOOK OF HYGIENE. of the statistics of suicide for ten years are almost exactly similar. Out of 636 cases of suicide, 78 occurred in May, 71 in August, 57 in December, 54 each in October, July, and April, 52 in June, 49 in November, 44 each in December and Feb- ruary, 43 in March, and 36 in January.1 Dr. Lee is led to be- lieve that " a low barometric pressure, accompanied by a high thermometric registry, with sudden fluctuations from a low to a high temperature, together with much moisture and prevailing southwest winds, might somewhat account for the frequency of self-murder in the spring and summer months." THE SANITARY RELATIONS OF CHANGES IN COMPOSITION AND OF IMPURITIES IN THE AIR. The average proportion of carbon dioxide in the atmosphere is from 3 to 4 parts in 10,000. Pettenkofer2 places the maxi- mum limit of carbon dioxide allowable in the air of dwellings at 7 parts in 10,000. It is probable that this limit is very fre- quently exceeded without serious consequences to health, if the air is not at the same time polluted by organic impurities, the products of respiration. Prof. William Ripley Nichols found the air in a school-room in Boston to contain eight times the normal proportion of carbon dioxide, while Pettenkofer found, also in a school-room, after the same had been occupied two hours, eighteen times the normal proportion, or 72 parts in 10,000.3 While such an excess of this poisonous gas must unquestionably have an unfavorable influence upon health, it is probable that the most serious effects are due to the coincident diminution of oxygen and the pollution of the air by the prod- ucts of respiration which necessarily take place during respira- tion. Carbon dioxide alone may be present in the air to a much greater extent than above mentioned without causing any appre- ciable inconvenience. In the air of soda-water manufactories 1 Suicide in the City and County of Philadelphia during a Decade, 1872 to 1881, inclusive, by John G. Lee, Trans. Am. Med. Asso., vol. xxxiii, p. 425. 2 Quoted in Buck's Hygiene and Public Health, vol. i, p. 615. s See table in Buck's Hygiene and Public Health, vol. i, p. 612. SANITARY RELATIONS OF IMPURITIES IN THE AIR. 27 there is frequently as large a proportion as 2 per cent, of this gas present without producing any ill effects upon those breathing such an atmosphere. The amount of carbon dioxide in the atmosphere is greatest at night. It is also greater very near the ground than at a dis- tance of several feet above it. As carbon dioxide is absorbed by the leaves of plants during the day-time, but given off at night, the difference may partly be thus accounted for. Accord- ing to Fodor,1 the source of a large proportion of the carbon dioxide in the air is the decomposition going on in the soil. This accounts for the larger percentage of carbon dioxide near the ground. This would also explain the variation of the pro- portion of carbon dioxide in the air under different meteoro- logical conditions. For example, it is found that during rainy weather the carbon dioxide in the air is diminished. This is accounted for partly by the absorption of the carbon dioxide by the saturated ground, while at the same time the porosity of the soil is diminished and the escape of the ground-air prevented. Mr. R. Angus Smith made a number of experiments upon himself to determine the effects of an atmosphere gradually becoming charged with the products of respiration and per- spiration. His experiments were conducted in a leaden cham- ber holding 5 cubic metres of air. This air was not changed during the experiment. After remaining for an hour in this chamber, an unpleasant odor of organic matter was perceptible on moving about. The air, when agitated, felt soft, owing, doubtless, to, the excess of moisture contained in it. The air soon became very foul, and, although not producing any dis- comfort, the experimenter states that escape from it produced a feeling of extreme pleasure, like " that which one has when walking home on a fine evening after leaving a room which has been crowded."2 1 Hygienische Untersuchungen ueber Luft, Boden und Wasser, Braunschweig. 1882, 2te Abth. • Air and Rain, p. 138. 28 TEXT-BOOK OF HYGIENE. Hammond 1 confined a mouse in a large jar in which were suspended several large sponges saturated with baryta water, to remove the carbon dioxide as rapidly as formed. Fresh air was supplied as fast as required. The aqueous vapor exhaled was absorbed by calcium chloride. The mouse died in forty-five minutes, evidently from the effect of the organic matter in the air of the jar. The presence of this organic matter was demon- strated by passing the air through a solution of potassium per- manganate. The horrible story of the " black hole " of Calcutta is familiar to every one. Of 146 prisoners confined in a dark cell at night, 23 were found alive in the morning. Among the sur- vivors a fatal form of typhus fever broke out, which carried off nearly all of them. After the battle of Austerlitz 300 prisoners were crowded in a prison ; 260 died in a short time from inhal- ing the poisoned air. Numerous other similar examples of the effects of polluted air are recorded. Usually the effects of foul air are not so sudden and strik- ing. In most instances, especially where the pollution has not reached a high degree, there simply results a general deficiency of nutrition, which manifests itself in anaemia, loss of vigor of body and mind, and a gradual diminution of resistance to disease. It seems to be beyond question that persons who are con- stantly compelled to inhale impure air, especially if combined with an improper position of the body or lack of sufficient or appropriate food, furnish a very large percentage of chronic pul- monary affections. Phthisical patients, in the overwhelming majority of cases, are drawn from the classes whose occupations keep them confined in close rooms. -AVant of exercise and of good food doubtless aid in the development of the lung disease. Formerly, when less attention was paid to the proper construc- tion and ventilation of barracks and prisons, the mortality from 1 A Treatise on Hygiene, with Special Reference to the Military Service, by William A. Hammond, M.D., Surgeon-General U. S. Army, p. 170. Philadelphia, 1863. SANITARY RELATIONS OF IMPURITIES IN THE AIR. 29 phthisis among soldiers and criminals was much greater than it is now. In animals kept closely confined the same disease claims a large share in the mortality. Near the end of the last century over one-third of the in- fants born in the old Dublin Lying-in Hospital died of epidemic diseases. After the adoption of an improved system of ventila- tion the mortality fell to about one-tenth of what it had pre- viously been. To illustrate the effect of similar conditions upon the health of domestic animals, the following instance is cited: Upward of thirty years ago a severe epidemic of influenza in horses appeared in Boston. At the instigation of Dr. H. I. Bowditch, every stable in the city was inspected, and classified as " excellent," " imperfect," or " wholly unfit," in respect' to warmth, dryness, light, ventilation, and cleanliness. It was found that in the first class fewer horses were attacked and the disease was milder, while in the third class every horse was attacked and the more severe and fatal cases occurred. Carbon monoxide is a very dangerous impurity often present in the air of living-rooms. Being an ingredient of illuminating gas, as well as the so-called coal-gas, which so frequently escapes from stoves and furnaces, its dangerous char- acter becomes apparent. Many persons die every year in this country from the inhalation of illuminating gas. People un- acquainted with the mechanism of the gas-fixtures frequently blow out the light instead of cutting off the supply of gas by turning the stop-cock. It is also a prevailing custom to keep the light burning " low " during the night. Any considerable variation of pressure in the pipes, or sudden draught, may put out the light and permit the gas to escape into the room, with fatal effect. Leaks in pipes or fixtures may have the same results. Coal-, coke-, or charcoal- fires may produce serious or fatal poisoning if the gas, which contains a large proportion of car- bon monoxide, is permitted to escape into the room.1 In 1 See paper by Dr. John Graham in Transactions of Philadelphia College of Physicians for 1885. 30 TEXT-BOOK OF HYGIENE. certain parts of Europe, notably in France, the inhalation of the fumes of a charcoal fire is a favorite method of committing suicide. The gas which sometimes escapes from the stove when coal is burning has the following composition :- Carbon dioxide, 6.75 per cent. Carbon monoxide, ..... 1.34 " Oxygen, 13.19 " Nitrogen, 79.72 11 Sulphuretted and carburetted hydrogen are not infrequently present in the air, especially about cess-pools and in mines and certain manufacturing establishments. Sulphuretted hydrogen is generally considered to be a violent poison, but there is no evidence that it is so unless oxygen is excluded. Carburetted hydrogen is the so-called "fire-damp" of mines, which is so often the cause of fatal explosions. Its in- halation does not seem to be especially noxious. It will be more fully referred to in a succeeding chapter. Variations in the proportion of ammonia present in the air are frequent. Its presence is an indication of organic decom- position in the vicinity, but nothing is known of the influence of the gas itself upon health, in the proportion in which it is ever found in the atmosphere. SEWER-AIR. Sewer-air, or sewer-gas, as it is often improperly called, is a variable mixture of a number of gases, vapors, atmospheric air, and solid particles, and is derived from the decomposition of the animal and vegetable contents of sewers. A number of analyses by different chemists have shown that the composition of sewer-air is extremely variable. The most important com- ponents, in addition to the constituents of atmospheric air, are: Carbon dioxide, ammonia, sulphuretted hydrogen, and a number of volatile organic compounds, which give to sewage its peculiar odor, but which are present in such small quantity as to prevent SEWER-AIR. 31 accurate determination by chemical means. Sewer-air may also contain particulate bodies, bacteria, and other microscopic or- ganisms, which are supposed by many to be the active causes of infectious diseases. Some recent researches by Carnelly and Haldane have shown that sewer-air usually contains a less number of micro-organisms than the external air of cities. The proportion of carbon dioxide found was also much less than was expected. When the contents of sewers remain in these re- ceptacles or conduits long enough to undergo decomposition, sewer-air is always present. It is believed by some physicians and sanitarians that sewer-air is the direct cause of such diseases as typhoid fever, scarlet fever, diphtheria, and cholera, while others hold the view that the sewer-air is merely a favorable breeding-place for the germs of these diseases, and that it thus merely acts as a medium in which the infective agent grows, re- produces itself, and is conveyed from place to place. There is no absolutely trustworthy evidence in favor of either of these doctrines. It is hardly open to question, however, that the continual breathing of air polluted by emanations from sewers often pro- duces more or less serious derangements of health. Diarrhoea and other intestinal affections, mild cases of continued fever, and even cases of undoubted typhoid fever have been so frequently noted in connection with defective sewerage, and the escape of sewer-air into inhabited rooms, that doubt upon this point is hardly justifiable. With regard to typhoid fever, however, it is probable that the sewage in these cases contained the particular virus (bacillus ?) which, it is now generally believed, causes this disease. The effluvia from cemeteries, knackeries, and other places where the bodies of animals are undergoing decomposition, are popularly regarded as deleterious in their effects upon health. The evidence in favor of this view is, however, very indefinite. Professor Tyndall has shown1 that even the apparently 1 Essays on Floating Matter of the Air. New York, 1882. 32 TEXT-BOOK OF HYGIENE. clearest air is, when in motion, constantly filled with innumerable particles of dust, which are believed by many to give rise to various forms of disease. The presence of these particles can be easily demonstrated by means of the electric light. Every one has observed these minute particles in a bright ray of sun- light. Under ordinary conditions these particles of dust would, of course, give rise to no trouble, but, if intermingled with these dust-specks there were disease germs,-whether these germs be considered as living organisms, or as particles of dead tissue from the body,-then manifestly the inhalation of such " dust " would be dangerous.1 The quantity of dust found in the air of cities is much greater than in the country. Tissandier found that in Paris the percentage of dust was eight to twelve times greater than in the open country. One-fourth to nearly one-half of this atmos- pheric dust is organic, either animal or vegetable. Very recent observations have shown that in Paris the air contains nine or ten times as many bacteria in a given volume as the air at the observatory of Montsouris, just without the city. The relative proportions of organic and inorganic particles vary as 25 to 75 in Paris, 45 to 55 in Dublin, and 25 to 75 in the open country. The organic particles are either particles of dead or- ganic matter, or minute organisms. The proportion of the latter varies in different seasons, being least in winter and spring, and greatest in summer and autumn. These organisms are not necessarily pathogenetic, but the conditions which favor the proliferation of non-pathogenic bacteria are likely to promote the development of disease-producing ones likewise. Among the pathogenic micro-organisms found in the at- mosphere are spores of achorion Schoenleinii, the so-called ma- laria bacillus of Klebs and Tommasi-Crudeli, and Fehleisen's erysipelas germ. It is probable, also, that the bacilli of tuber- culosis, cholera, and typhoid fever, and other organisms, at times 1 See Chapter IX, on Industrial Hygiene, for effects of inhalation of dust in various industries. SEWER-AIR. 33 undergo multiplication in the air, and that the latter may be the medium of communication of these diseases. But it must be admitted that our knowledge upon this point is at present rather vague and unsatisfactory. As regards the diseases that may be produced by the in- halation of pathogenic organisms there can be no doubt that diphtheria, glanders, measles, scarlet fever, whooping-cough, in- fectious pneumonia, and, above all, pulmonary tuberculosis, are so caused. It is likewise probable that yellow fever, epidemic influenza, cholera, and typhoid fever may be produced in this manner. TESTS FOR IMPURITIES IN THE AIR. The sense of smell will indicate the presence of sulphu- retted hydrogen, or of volatile organic matter. Chemical tests and the microscope will, however, be necessary to determine the presence of carbon dioxide, carbon monoxide, or suspended particulate matter in the air. In order to detect the presence of carbon dioxide, advantage is taken of the affinity of this compound for certain alkalies with which it forms insoluble compounds. If a stream of carbon dioxide gas is passed through lime- or baryta- water, an insoluble carbonate of lime or baryta is instantly formed, and produces a milky precipitate in the water. If, instead of passing a stream of gas through the liquid, the latter be agitated with air con- taining carbon dioxide, a similar precipitate is produced. The most exact method of determining the amount of carbon dioxide in the air is that known as Pettenkofer's,1 but it is somewhat complicated. A readier method has been devised by Mr. Angus Smith, and is termed the minimetric test.2 A series of six wide- mouthed bottles, having a capacity respectively of 450, 350, 300, 250, 200, and 150 cubic centimetres,3 is fitted with clean, tightly- 'Lehrbuch der Hygiene, Nowak, p. 149. ' Op. tit., p. 152. 3 The equivalents in English measures are 14 ounces, 11 ounces, 9% ounces, 8 ounces, 6*4 ounces, and 4% ounces. 34 TEXT-BOOK OF HYGIENE. fitting corks. The bottles are made perfectly clean and dry, and 15 cubic centimetres (3^ drachms) of clear, fresh lime- or baryta- water put into the smallest, the cork replaced, and the bottle well shaken. If the water becomes turbid there is at least .16 per cent. (16 parts per 10,000) of carbon dioxide in the air treated. If only the water in the largest bottle becomes cloudy, the proportion of carbon dioxide is probably less than 5 parts in 10,000. For the intermediate series of bottles the amounts of carbon dioxide necessary to produce cloudiness are, respectively: For 200 cubic centi- metres of air, 12 parts in 10,000; for 250 cubic centimetres, 10 parts; for 300 cubic centimetres, 8 parts; and for 350 cubic centimetres, 7 parts per 10,000. If, therefore, a cloudiness is produced with any of the bottles except the largest, the amount of carbon dioxide present exceeds the standard allowable in pure air. The test should be frequently made, in order to acquire familiarity with its use. The same quantity of the test-liquid is, of course, used in each bottle. A simple and easily-managed instrument, called an "air-tester," has been devised by Professor Wolpert, a distinguished German meteorologist. It is described as follows by Dr. S. W. Abbott, who first called attention to its merits in this country1: The little instrument consists of a simple rubber bulb (A) of a capacity of 28 cubic centimetres, a glass outlet-tube (B) with a constriction near its extremity (E). A glass test-tube, 12 centimetres in length (C) and 2 millimetres in diameter, has a horizontal mark near the bottom, indicating the point to which it must be filled with perfectly clear lime-water, to contain 3 cubic centimetres. The bottom of the tube is whitened and has a black mark stamped upon it (D). A small, wooden stand, a brush or swab, a vial of vinegar for cleaning the tube, and a bottle of clear lime-water complete the outfit. Fig. 2. Aik-Tester. 'Boston Med. and Surg. Journal. TESTS FOR IMPURITIES IN THE AIR. 35 In order to use the instrument, the lime-water (saturated solution) should be poured into the test-tube till it reaches the horizontal mark. Press down the bulb with the thumb, so as to expel the air within it as completely as possible, and allow it to fill with the air of the apartment, insert the small tube into the lime-water nearly to the bottom, and again expel the air with moderate rapidity, so that the bubbles may rise nearly to the top of the tube, but do not overflow, taking care to continue the pressure of the thumb till the small tube is removed from the lime-water. Repeat this process until the mark upon the bottom of the test-tube is obscured by the opacity produced by the reaction of the carbonic acid upon the lime-water, the observer looking downward through the lime-water from the top of the test-tube. With very foul air it is necessary to examine the mark after filling and discharging the bulb a few times only; with good air, it must be filled twenty-five times and upward. The bulb represented in the cut is made a little larger than the required capacity, since a small amount of residual air usually remains in the bulb and cannot be expelled without great care. After each observation, the test-tube must be washed out and wiped dry. If a white incrustation forms upon the tube, it may be easily removed with a little vinegar, after which the tube should be thoroughly washed with pure water and dried. If the mark becomes obscured after filling the bulb ten or fifteen times only, the air of an apartment is unfit for continuous respiration. In a sick-chamber the air should be so pure that the tur- bidity of the lime-water will not render the mark invisible until thirty or forty fillings are made. The instrument should be used by daylight, over a white ground, as a sheet of writing-paper, and care should be taken not to vitiate the result bv the observer's own breath. The following approximate table is taken from the article 36 TEXT-BOOK OF HYGIENE. by Professor Wolpert, the first column representing the number of fillings of the bulb, and the second column the parts per 1 (),()()() of carbon dioxide in a given sample of air:- Number of Fillings. Carbon Dioxide per 10,000. Number of Fillings. Carbon Dioxide per 10,000. Number of Fillings. Carbon Dioxide per 10,000. 1 200. 21 9.5 41 4.9 2 100. 22 9.1 42 4.8 3 67. 23 8.7 43 4.6 4 50. 24 8.3 44 4.5 5 40. 25 . 8. 45 4.4 6 33. 26 7.7 46 4.3 7 29. 27 7.4 47 4.2 8 25. 28 7.1 48 4.1 9 22. 29 6.9 49 4.1 10 20. 30 6.6 50 4. 11 18. 31 6.4 51 3.9 12 16. 32 6.3 52 3.9 13 15. 33 6.1 53 3.8 14 14. 34 5.9 54 3.7 15 13. 35 5.7 55 3.7 16 12.5 36 5.5 56 3.6 17 12. 37 5.4 57 3.5 18 11. 38 5.3 58 3.5 19 10.5 39 5.1 59 3.4 20 70. 40 5. 60 3.3 Carbon monoxide is detected by its reaction with palladium chloride, which gives a black color when brought in contact with the gas. If a strip of linen or blotting-paper be moistened with a solution of the palladium chloride (1 to 500) and sus- pended in air containing carbon monoxide, the black color will be developed. The suspected air may also be passed through a solution of sodio-chloride of palladium, when the liquid will turn black if carbon monoxide be present. The percentage of organic impurity in the air of an occu- pied room (products of respiration, etc.) is difficult to ascertain directly. Pettenkofer has found, however, that the proportion of carbon dioxide present is indirectly a measure of the organic impurity from respiration.1 As the determination of the carbon TESTS FOR IMPURITIES IN THE AIR. 37 dioxide is easy by the minimetric method of Angus Smith, or the ready method of Wolpert, the extent to which the air is polluted by respiratory impurities is readily ascertained. The presence of organic and other suspended impurities can be best demonstrated with a microscope. An objective, mag- nifying upward of 400 linear diameters, and experience in the use of the instrument will be needed to obtain correct results. By moistening a glass slide with glycerin and exposing it in the suspected air, a sufficient quantity of the suspended matters may be collected in the course of twenty-four hours to permit some conclusions to be drawn from a microscopic examination.2 A common method of determining the presence or absence of a large quantity of carbon dioxide, for example, at the bottom of a well or privy-vault is to lower a lighted candle to the bottom. If the light is extinguished, the air is considered irre- spirable; but, if it continue burning brightly, the air is believed to be sufficiently pure to sustain life. Sulphuretted hydrogen and sulphide of ammonium are sometimes found in privy-vaults, and, although they will not extinguish a light, they speedily prove fatal if inhaled in a concentrated form, and to the exclu- sion of a sufficiency of oxygen. Cases have frequently occurred where serious or fatal results ensued from the presence of a dan- gerous gas, which was thought to be excluded by the burning candle. 1 Recent observations in this country (see Annual Reports of the Surgeon-General of the Navy for 1879, pp. 45 and 46, and the same for 1880, pp. 31 to 34) seem to throw some doubt upon the entire reliability of this method of determining the amount of organic matter in the air examined. Prof. Ira Remsen (Report National Board of Health, 1879, p. 77, and 1880, p. 308 et seq.) has shown the insufficiency of the chemical methods at present in use, and points out the difficulties of making trustworthy and satisfactory determinations of organic matter in the air. The great technical difficulties of the various analytical processes render it unwise to burden these pages with a description of them. Only expert chemists are qualified to make a thorough air analysis, and the author does not feel competent to offer advice to them. Dr. Cornelius B. Fox's book on " Sanitary Examinations of Water, Air, and Food," and Fliigge's "Lehrbuch der Hygienischen Untersuchungsmethoden" contain detailed descriptions of the best methods employed. 2 Dr. G. M. Sternberg, IT. S. A. (Report National Board of Health, 1880), gives an ac count of his investigations into the suspended matters of the air. The question is also con- sidered in a practical manner by Surgeons Kidder and Streets, U. S. N., in Reports of the Surgeon-General of the Navy for 1880 and 1881. See also Bacteria, Sternberg and Magnin, 2d ed., p. 197. » See a case reported in Philadelphia Medical Times, October 21,1882. 38 TEXT-BOOK OF HYGIENE. It is advisable in all cases to exhaust the stagnant air in old wells and privy-vaults before permitting any one to descend. Perhaps the readiest method of exhausting the vitiated air in such places would be to lower heated stones, masses of hot iron or pails of hot water, to near the bottom, which produce a rare- faction of the air and cause it to ascend. Its place will then be occupied by purer air from without. The rarefaction produced by the explosion of gun-powder has also been made use of with success; but this has some objections, because the combustion of powder itself produces gases which are noxious if breathed in large quantity. An animal, such as a cat or dog, should be first lowered into the suspected well for fifteen or twenty min- utes, in order to determine whether the air at the bottom is capable of sustaining life, before permitting the workmen to descend. Similar precautions should be used in old, long- unused mines to prevent fatal effects from the so-called " choke- damp," which is largely composed of carbon dioxide. PRINCIPLES OF VENTILATION. During ordinary respiration an adult human being adds 900 grammes = 455,500 cubic centimetres (14 cubic feet) of carbon dioxide to, and abstracts 744 grammes = 516,500 cubic centimetres (16 cubic feet) of oxygen from, the atmosphere in twenty-four hours. Hence, if the individual were confined in an apartment where the inclosed air could not be intermingled by diffusion with the atmosphere without, the proportion of carbon dioxide would soon become so great that the processes of life could not be sustained, and the individual would die. This result would be reached even sooner than the point here mentioned, for the organic matter exhaled from the lungs and the surface of the body would increase the poisonous condition of the air even more than the carbon dioxide given off. It is easily seen, therefore, how important the study of the principles and practice of ventilation becomes in hygiene. In this chapter only the principles underlying this subject can be definitely PRINCIPLES OF VENTILATION. 39 stated. Practical details will be more fully given in the chapters devoted to dwellings, schools, hospitals, etc. It is generally accepted among sanitarians that the presence of .07 per cent. (7 parts in 10,000) of carbon dioxide in the air indicates the greatest amount of organic impurity (from respira- tion or combustion) consistent with the preservation of health. As each individual gives off from his lungs, in the process of respiration, 316 cubic centimetres of carbon dioxide per minute, the diffusion in the air surrounding him must be sufficiently rapid to keep the air to be breathed at the standard of .07 per cent, above mentioned. Adopting this as the standard of maximum impurity allow- able, 90 cubic metres of fresh air per hour will be needed for each individual to keep him supplied with pure air. This is for a person in a state of health; in cases of disease a more rapid change of air will be necessary to keep that surrounding the patient in a state of purity. Ventilation is defined by Worcester as "the replacement of noxious or impure air in an apartment, mine, or inclosed space by pure, fresh air from without." By Dr. Parkes the term is restricted to " the removal or dilution, by a supply of pure air, of the pulmonary and cutaneous exhalations of men and the products of combustion of lights in ordinary dwellings, to which must be added, in hospitals, the additional effluvia which proceed from the persons and discharges of the sick. All other causes of impurity of air ought to be excluded by cleanli- ness, proper removal of solid and liquid excreta, and attention to the conditions surrounding dwellings." 1 A proper system of ventilation must take into consideration the cubic space of the apartment or building to be ventilated, the number of persons ordinarily inhabiting this space, whether constantly or only temporarily occupied, and certain other col- lateral elements, such as the character of the building to be ventilated, its exposure, necessity for artificial heating, etc. 1 Manual of Practical Hygiene, 6th ed., New York, vol. i, p. 157. 40 TEXT-BOOK OF HYGIENE. The amount of cubic space that must be allowed to each individual is determined by the rapidity with which fresh air must be supplied in order to keep that surrounding the indi- vidual at the standard of less than .07 per cent, of carbon dioxide. For example, in a space of 3 cubic metres, the air must be changed thirty times in an hour, in order to prevent the carbon dioxide exceeding the above proportion; that is to say, to allow 90 cubic metres of air to pass through that space in the time mentioned. This would create an uncomfortable, if not injurious, draught. If the space contained 30 cubic metres, the air would need renewal only three times an hour. A space of 15 cubic metres could be kept supplied with pure air without perceptible movement if all the mechanical arrangements for changing the air were perfect; but such per- fection is rarely attainable, and hence there would be either draughts or insufficient ventilation in such a small " initial air- space," as it is termed. The initial air-space should, therefore, be not less than 30, or, better, 40 cubic metres. The air of this space could be changed sufficiently often to keep it at its standard of purity without creating unnecessary draught. For sick per- sons this should be doubled. In hospitals, therefore, the cubic air-space allowed to each bed should not be less than 60 to 80 cubic metres. As stated, the purposes for which the building or apartment to be ventilated is employed requires differences in the cubic space and in the volume of fresh air supplied. Morin gives the following table:- Fresh Air Required per Hour per Head. Hospital wards for ordinary cases, 60-70 cubic metres. Hospital wards for surgical and obstet- rical cases, ..... 100 " " Hospital wards for contagious diseases, 150 " " Prisons, o 50 " " Table III. PRINCIPLES OF VENTILATION. 41 Workshops, (ordinary occupations, . (unhealthy, " 60 100 cubic u metres. cc Barracks, ( during the day, 30 G Cl ( " " night, . 40-50 IC ll Theatres, 40-50 n u Assembly rooms for long receptions, . 60 Cl ll 44 44 " brief u 30 cc ll Primary schools, ..... 12-15 cc 11 Higher " • • . • • 25-30 cc ll Stables,. ..... 180-200 cc ll These figures are not excessive from a sanitary stand-point, although few buildings meet the requirements here set down. The source of the air supplied must, of course, be capable of yielding pure air. It should not be drawn from damp cellars or basements, or from the immediate vicinity of sewers or drains. Air taken from such places is little better for respiration than that which it replaces in the apartments to be ventilated. Ventilation may be accomplished either with or without artificial aids. In buildings or rooms, used as habitations, natural ventilation (with, perhaps, the simplest mechanical aids) is made use of almost entirely. In large buildings, such as churches, theatres, schools, or in ships and mines, one of the artificial systems must be adopted if efficient ventilation is desired. Natural ventilation takes place by diffusion, by perflation, and in consequence of inequality of atmospheric pressure. By diffusion is meant the slow and equable entrance of air from without and exit from within a room through the walls or ill- made joints without the influence of wind-currents. In an occupied room this is, however, insufficient to keep the air pure, because many of the organic impurities of respired air are mole- cular, and, therefore, incapable of making their way out of the rooms through the walls. Perflation means, literally, " blowing through," and, if the direction and force of air-currents could be regulated, this would, with simple mechanical arrangements, be an efficient means of 42 TEXT-BOOK OF HYGIENE. ventilation. However, the uncertainty of the force and direc- tion of the wind makes this method of ventilation untrustworthy, except in warm weather. Unequal pressure between the air in a room and that without is, within certain limits, an efficient means of ventila- tion, and is usually relied upon in ordinary apartments. When the air in a room is heated above the temperature of the external air, either by a fire, lights, or by the presence of a number of persons in the room, it expands, and part of it finds its way out through numerous crevices and bad joints found in all buildings. The air which remains, being less dense than the external air, the latter enters the room by various openings, until the equality of pressure is re-established. But as the heating of the enclosed air continues, the process is momentarily repeated and becomes continuous. Although the impurities of respired air (carbon dioxide, organic matter) are heavier than the air itself at the same temperature, it is a familiar fact that the most impure air in an occupied room is always found near the ceiling, the impurities being carried upward with the heated air, and that the pure air from without, being colder, fills the lower part of the room. If the cold, outside air were to be admitted at the bottom of the room, and means allowed for the escape of the hot air at the top, the conditions of the old health-maxim, to " keep the feet warm and the head cool," would be reversed, This would be no less uncomfortable than unwholesome. In all plans for natural ventilation, therefore, provision must be made to secure a gradual diffusion of the cold, outside air from above, or to have it warmed before it enters the room. With a large chimney as an aspirating shaft,1 with flues at the top and bottom of the room, and openings in the walls of the room near the ceiling to admit fresh air, sufficient ventilation can be usually secured in cold weather, in a room not overcrowded. 1 Of course there is really no such thing as a real aspiration, or "sucking out" of the air through the chimney or so-called " aspirating shaft." The upward movement of the air in the shaft is due to its displacement by the colder or denser air entering the room. PRINCIPLES OF VENTILATION. 43 When a room is heated by a furnace, the fresh air is warmed before it is introduced, and the foul air escapes either through a ventilating shaft, a ventilator in the window or wall, or through the numerous fissures and other orifices which defective car- pentering always leaves for the benefit of the health of the occupants. • The following rules for the arrangement of a system of natural ventilation are modified and condensed from Parkes1:- The apertures of entrance and of exit for the air should be placed far enough apart to permit thorough diffusion of the fresh air. When the air is brought into a room through slits or tubes in the walls near the ceiling, the current should always be deflected upward by an inclined plane, in order to prevent a mass of cold air from descending over the shoulders of the occupants and chilling them. The air must be taken from a pure source. The inlet-tubes should be short, and so made as to be easily cleansed, otherwise dirt lodges and the air becomes impure. Inlets should be numerous and small, to allow a proper distribution of the entering air. Externally, the inlets should be partially protected from the wind to prevent strong draughts; they should also be pro- vided with valves to regulate the supply of air. If the air cannot be warmed, the inlets must be near the ceiling; if it can be heated, it may enter near the floor. The air may be warmed by passing it through boxes con- taining hot water or steam coils, by passing it through chambers around grates or stoves, or heating it in a furnace. In towns or manufacturing districts the air should be filtered before allowing it to enter the room. Thin flannel or muslin spread over the openings answers very well as filtering material. Outlets should be placed at the highest point of the room 1 Manual of Practical Hygiene, 6th ed., New York, vol. i, p. 177. 44 TEXT-BOOK OF HYGIENE. and should be protected from the weather. An opening into the chimney near the ceiling will answer well in many cases. In one-story buildings, ridge-ventilators make the best out- lets. The entrance of snow and rain must be prevented by suitable arrangements. A small space or slit between the horizontal bars of the upper and lower window-sash will admit sufficient air in a proper direction in small rooms, even when the window is shut. In all rooms, howsoever ventilated, doors and windows should be often opened to permit a thorough flushing of the interior with fresh air. For large buildings, hospitals, schools, theatres, ships, and mines two systems of artificial ventilation are in use. One operates by extracting the foul air by means of fans, the other by forcing in fresh air, allowing the impure air to find its way out as best it may. Further details upon the practical application of these prin- ciples will be given in succeeding chapters of this work. ♦ [In addition to the works mentioned in the text the follow- ing may be referred to as more fully treating of the subjects considered in this chapter:- Flammarion : The Atmosphere.-The Articles on Atmosphere and Climate in the Encyclopaedia Britannica, 9th edition.-Reports of the Chief Signal Officer of the Army.-A paper on Climate and Diseases, by Dr. Cleveland Abbe, in Report of National Board of Health for 1880.- Die Canalgase, by Dr. F. Renk, Munchen, 1884.-Morin : On Warming and Ventilating Occupied Buildings ; translated in Smithsonian Report for 1873 and 1874.-V. Pettenkofer und Ziemssen's Handbuch der Hy- giene, I Theil, 2 Abtheilung. Die Luft, by Dr. F. Renk.] CHAPTER II. Water. Physiologists teach that nearly two-thirds of the tissue of the animal body consists of water. Inasmuch as this water is constantly being lost by evaporation from the skin, exhalation by the lungs, and excretion through various organs, it is evident that the loss must be constantly supplied if the functions of life shall be properly performed. It appears probable that certain diseases are at times spread through tbe agency of insufficient or impure drinking-water. It is, therefore, a matter of very great importance to have a defi- nite notion of what constitutes a pure and sufficient supply of water, and how best to secure it, to be able to detect its condi- tions of purity and impurity, and to know how to maintain the former and avoid the latter. It will be necessary to consider in detail, therefore, the quantity of water required by each indi- vidual for the maintenance of health, the sources whence water is obtained, how it should be collected and stored to the best advantage, the impurities likely to be contained in it, and the methods of keeping it pure, or of purifying it when it has become polluted or vitiated in any manner. THE QUANTITY OF WATER REQUIRED BY HUMAN BEINGS. Dr. Parkes, after a number of experiments, concluded that a man of the English middle class, " who may be taken as a fair type of a cleanly man belonging to a fairly cleanly house- hold," uses about twelve gallons of water per day. This covers all the water needed, including a daily sponge bath. Dr. DeChaumont estimates1 that 16 gallons should be the daily 1 Parkes' Hygiene, 6th ed., New York, vol. i, p. 5. 45 46 TEXT-BOOK OF HYGIENE. allowance. By order of the British War Department, 15 gal- lons of water are allowed to each soldier daily. In very many instances this quantity cannot be furnished, but in such cases there necessarily results some deficiency in cleanliness. It is probable that among the poorer classes, especially where a large supply of water is not convenient, the quantity used is not over one-fourth of the above estimate. In estimating the daily supply of water needed in a com- munity, large or small, other circumstances must be taken into consideration in addition to the demands of the individual. For example, in towns or cities allowances must be made for animals, manufacturing purposes, probable waste, fires, sewerage, etc. In cities an allowance of 50 gallons daily per head would not be excessive. In most American cities the supply is much greater.1 The present daily supply in Baltimore, which is de- rived from an excellent source, is estimated at 60 gallons per head, which could be increased to three times that quantity if necessary. A serious problem, affecting, however, the engineer rather than the sanitarian, is the prevention of waste of water in places where the supply is limited. It is estimated that in Chicago one-half of the water pumped is wasted through negligence and imperfections in the supply apparatus, while in St. Louis the annual cost to the city of the water that is wasted is placed at $400,000. It has been proposed to check this wanton waste by measuring the quantity of water used by each household by means of a meter, as the supply of gas is now measured, and this has been carried into effect in places. There are, however, serious objections to this method. One of the objections is that the very class of persons whom it is desired to induce to use a plentiful supply of water would, from motives of economy, use less than is necessary for cleanliness and health. A system of vigilant inspection of the water service in houses would probably serve to reduce this unnecessary waste to a considerable extent. * Buck's Hygiene and Public Health, vol. i, p. 214. SOURCES OF DRINKING-WATER. 47 SOURCES OF DRINKING-WATER. All water, from whatever direct source obtained, comes originally, by precipitation, from the atmosphere. In many places the rain- or snow- water is the only source of supply. This is usually collected as it falls upon the roofs of buildings and conveyed by gutters and pipes to cisterns, where it is stored until needed. In Venice, the rain falling upon the streets and court- yards is also collected in cisterns after filtering through sand. The cisterns used for the storage of water in New Orleans and other Southern cities in the United States, where the tempera- ture rarely falls below the freezing-point, are generally con- structed of wood and placed above-ground. Farther north, where it is necessary to protect them against the action of frost, they are placed under-ground. These under-ground cisterns are usually built of brick. The water from cisterns above-ground becomes very much heated in summer, and necessitates the use of large quantities of ice to make it palatable. The water from the under-ground cisterns is pleasantly cool in summer, and is also guarded against freezing in winter, There are, however, very serious objections to storing drinking-water in under-ground cisterns. These reservoirs are usually placed within a few feet of privies and cess-pools, and, as neither the retaining walls of the cisterns nor those of the privies are water-tight, it often happens that the drinking-water becomes strongly impregnated with the soluble portions of the excrement, or the products of its decomposition, which have drained into the cistern. Per- sonal observations in Memphis in 1879, as well as the careful chemical analyses made afterward by Dr. Chas. Smart, U. S. A.,1 have convinced the author that the objections to all under- ground cisterns built of brick, stone, or cement are insuperable from a sanitary point of view. Dr. Smart found over one-half of the under-ground cisterns examined by him in Memphis and 1 Report National Board of Health, 1880, pp. 437-441. 48 TEXT-BOOK OF HYGIENE. other cities and towns to be leaky and presenting evidence of organic pollution. The water from 31 out of 80 cisterns ana- lyzed showed decided contamination by sewage. It would seem advisable to prohibit all under-ground cisterns for the storage of drinking-water unless they are constructed of iron, which should be protected against oxidation by a thorough coating of coal- tar. Where any other system of collection and storage is avail- able, however, the under-ground cistern should be unreservedly condemned. Rain-water collected in the country, away from manufac- turing districts, is usually quite pure and wholesome. Its taste is, however, flat and insipid, owing to absence of carbon dioxide and mineral constituents. In cities rain-water frequently con- tains such a large amount of organic matter and other impurities, which have been washed out of the air by the rain, that it may be unfit for drinking. On account of its softness, rain-water is very desirable for washing and other domestic purposes. If the statement made in the last chapter, concerning the presence of organisms in the atmosphere, is remembered, it will be evident on a moment's thought that such organisms, when contained in rain-water, may be the source of disease. The putrefaction which so readily takes place in rain-water upon standing a few days is caused by certain of the organisms carried down out of the lower strata of the air by the descending rain or snow. Precipitation is an exceedingly untrustworthy source of water, and should never be depended upon when other sources of supply are available. Water famines are frequent wherever people are compelled to rely upon such an uncertain source of supply as rain or snow. Rivers and smaller streams probably supply the larger number of cities and towns in this countrv with drinking-water. When care is taken to prevent the pollution of the stream above the point whence the water is taken, this is usually of fair quality for domestic purposes. When the river can be tapped near its source, or before a large number of manufacturing SOURCES OF DRINKING-WATER. 49 establishments can empty their waste products into its current, or before it receives the sewage of a considerable number of inhabitants living on its banks, the water can generally be re- garded as safe. It is very difficult, however, except in the less settled portions of the country, to find these favorable conditions present. Among the minor objections to the use of river-water for domestic purposes are the liability of most streams to become turbid in times of freshet, and the discoloration of the water from dissolved coloring-matters if the stream flows through a marshy or peaty region. These objections are, however, not serious, as filtration will readily remove the suspended matters. The coloring-matter is probably harmless. The organic matter contained in the water of some streams, even when pollution by sewage and manufacturing refuse is absolutely excluded, may, however, be the cause of disease. Dr. Smart has shown1 that the water from streams in Nebraska, Wyoming, and Utah con- tained organic matter varying in amount from .16 to .28 parts per million.2 He thinks the so-called "mountain fever" of the Rocky Mountain region is a malarial fever caused by the large amount of organic matter in the drinking-water. Dr. G. M. Kober, U. S. A., states that he has frequently drunk water from mountain streams which had a perceptible taste of cattle-manure, and suggests that as the origin of the ammonia found by Dr. Smart in the water of mountain streams. Dr. Kober also regards the " mountain fever " as a typhoid fever with malarial complications.3 The most serious objection to the use of ri ver-water for domestic purposes is the employment of streams as carriers of refuse from manufacturing establishments, or of the sewage of cities and towns. In Great Britain and some parts of the con- tinent of Europe, owing to the density of population and the 1 American Journal Med. Sciences, January, 1878, p. 28 et seq. 2 The source of this organic matter seems to be the melted snow which makes up a large portion of the streams. 3 Report of California State Board of Health for 1886, pp. 48 and 177. 50 TEXT-BOOK OF HYGIENE. variety and extent of manufacturing industries, many of the streams are in an extremely filthy condition. In this country, too, especially in the more thickly settled manufacturing districts of New England, the pollution of rivers has increased to a degree to seriously jeopardize the health of the people who are compelled to draw their water-supply from such streams. Several years since a commission was appointed by the State Board of Health of Massachusetts to inquire into the extent of the pollu- tion of the streams in that State, and to devise means for pre- venting such pollution. The commission extended its inquiries and observations over several years, reporting the result to the State authorities at intervals.1 It was found that the water of the Blackstone River, at Blackstone, where it crosses the State line and enters Rhode Island, contained over 10 per cent, of sewage and refuse waters.2 Other streams in Massachusetts show similar pollution. That the presence of such excessive con- tamination renders the water unsuitable for domestic pur- poses must appear evident. It is probable, however, that the most dangerous of the polluting matters are the excreta of human beings, especially those of patients suffering from certain specific diseases, such as typhoid fever or cholera. Only a few years ago it was a generally-accepted theory that running-water, though polluted by sewage, "purified itself" after flowing a distance of twelve miles, and the comforting and reassuring doctrine is still held by many. Recent observations point to the conclusion, however, that the self-purification of rivers is not entirely to be relied upon. A certain proportion of the sewage, it is true, undergoes oxidation in the presence of light and air and minute organisms,3 and so becomes changed into other, possibly innocuous compounds. But at present it is not known what proportion or what kind of organic matter does undergo this change. Another portion of the impurities is deposited upon the bottom and sides of the stream, having 1 Reports State Board of Health of Massachusetts for 1873,1874,1876,1877,1878, 1879,1880. ' Report State Board of Health of Massachusetts, 1876, p. 145. 'Disinfection, in Eulenburg's Realencyclopa'd e d. ges. Heilkunde. vol. iv, p. 68. SOURCES OF DRINKING-WATER. 51 been only held in suspension, and not dissolved in the water. A portion probably forms chemical combinations with other sus- pended or dissolved matters, and is changed into compounds which may be volatile and pass off into the air, or form insoluble precipitates. The remainder is rendered less perceptible or imperceptible to chemical means by dilution. Every stream has sources of inflowing water-feeders-which increase its volume, and thus dilute any foreign admixture. In view of these facts, the theory of the self-purification of streams, as formerly held, can no longer be regarded as true. But it is unquestionably true that running-water does regain its purity if the inflow of sewage and other refuse is not excessive. It cannot be stated with confidence, however, when a stream, once polluted, becomes fit to use again. Moreover, as it is not possible, by any practicable chemical treatment or filtration on a large scale, to make a polluted water absolutely wholesome, it is safer not to use as a source of domestic supply a stream which is known to have been seriously contaminated by sewage matters or other impurities. The water from fresh-water lakes and ponds is generally to be preferred to river-water for domestic use. It is less liable to become turbid from time to time, and, except in the case of small ponds, inflow of sewage is not likely to cause fouling of the water to any serious extent. When the supply can be drawn from large lakes, as is done in Chicago and other cities on the great lakes of the United States, no purer or better source can be desired. In these cases the point whence the water is taken should be far enough from shore to avoid possibility of sewage contamination. When the water-supply is taken from small ponds, all sewage and waste products from houses and factories must be rigidly excluded; otherwise, diseases attribu- table to the polluted water are likely to arise among those using the same. The water in small lakes and storage reservoirs sometimes 52 TEXT-BOOK OF HYGIENE. becomes offensive in taste and odor. The water-supplies of several of the large Eastern cities have within the past seven or eight years at times had a peculiar odor and taste somewhat resembling cucumbers. After considerable study, Prof. Ira Remsen, of Baltimore, found the cause of this odor and taste in a minute fresh-water sponge, the Spongilla fluvlatilis. A still more offensive odor, tersely described as the " pig-pen odor," is given to the water by the decay of certain species of nostoc and other algae. It is not known that either these vegetable or animal organisms, if present, render the water prejudicial to health. Ponds are often used as sources of ice-supply. It was formerly supposed that in the process of freezing, solid matters in the water were not included in the block of ice when con- gelation occurred. Recent observations have shown the falsity of this assumption. In 1875, an outbreak of acute intestinal disease at Rye Beach, New Hampshire, led to an inquiry by Dr. A. II. Nichols, which disclosed the fact that the ice used contained a large percentage of organic matter.1 The use of ice from a different source was followed by an almost immediate disappearance of the disease. Upon further investigation it was discovered that the impure ice had been gathered from a small, stagnant pond into which a small brook carried large quantities of saw-dust from several saw-mills. The water of the pond was loaded with organic matter, and in summer the gases of decay arising from it were very offensive. Chemical exam- ination showed that the ice from this pond contained nearly 6 parts of organic matter in 100,000, while in pure ice the organic matter amounted to only .3 part in 100,000. A similar inves- tigation into the character of the ice furnished to the residents of Newport, R. I., was made under the auspices of the Sanitary Protection Association of that city. The ice, which was cut from ponds in the immediate neighborhood of the city, was found to contain an excessive proportion of organic matter. 1 Report Massachusetts State Board of Health, 1876, p. 467. SOURCES OF DRINKING-WATER. 53 Large quantities of sewage and other impurities were discharged into these ponds.1 A series of experiments recently made by Ur. C. P. Pengra, of Michigan, shows2 that the purification of the water by freezing is in no sense absolute. In experimenting with bacteria, infusoria, and other organisms, he found that from 9 to 11 per cent, re- mained in the ice and retained their vitality, so that when thawed they rapidly multiplied, and there was no apparent loss of numbers. In the ordinary process of freezing the upper portion is the purest, but if snow or rain fall upon the ice and freeze this upper layer will be found much more impure than the lower. Rational conclusions from these experiments are, that ice should not be gathered from an impure source, and that an early harvest of the ice should be encouraged. In a very recent research, Prudden has shown that typhoid bacilli contained in water are not entirely destroyed by freezing, even after remaining in this condition for 103 days. Springs and wells supply the water for most persons not aggregated in large communities, as cities and towns. Even in the latter no inconsiderable quantity of the water used for drinking and domestic purposes is derived from wells. Spring- water usually comes from a source at a considerable depth below the surface; that is to say, the water has percolated through thick strata of soil before re-appearing at the surface. In its passage through the soil it has lost most of its organic matter, and perhaps taken up mineral and gaseous constituents in larger quantities. It may be so strongly impregnated with the latter as to vitiate it for ordinary use and to render it valuable as a medicine. Ordinarily, however, spring-water is clear, cool, and sparkling, with a refreshing taste and uniform temperature, and in all respects an agreeable and wholesome beverage. The character of well-water, on the contrary, is often justly open to grave suspicion. Being derived from those strata of the 1 The Dangers of Impure Ice, in The Sanitarian, May, 1882. 2 Private communication to the author. The memoir of Dr. Pengra has been published in the Report of the Michigan State Board of Health for 1884. 54 TEXT-BOOK OF HYGIENE. soil which are most likely to be contaminated by the products of animal and vegetable decomposition, the wholesomeness of the water is inversely proportional to the degree of saturation of the soil with the products of decay. It has been found by experiment that, when organic matter largely diluted with water is allowed to percolate through soil, it undergoes a gradual decomposition in the presence of certain minute organisms, nitrates and nitrites being formed at the expense of the ammonia and other organic combinations. If, however, the soil is saturated with organic matter in excess, and in a state of concentration, putrefaction takes place, and the conversion of the organic matter into nitrates and nitrites is retarded. Hence, the drain- age of diluted sewage through a stratum of porous soil, not already saturated with putrefying matters, has no especially bad significance, even if the liquid should reach a well used as a source of drinking-water. It is probable that by the time the liquid portion of the sewage reached the well it would have arrived at that point when it could truthfully be termed pure water. At the same time it must be remembered that the puri- fying power of the soil cannot be relied upon if the supply of sewage or other animal or vegetable impurity is too abundant. Distillation is sometimes resorted to for the purpose of pro- curing drinking-water, especially at sea. Vessels now generally carry a still for this purpose. The principal objection to dis- tilled water is its insipidity, due to the absence of carbon dioxide and mineral constituents, which give to good drinking-water its savor. Distilled water may be aerated by passing it in fine streams through holes in the bottom of a cask, elevated so as to allow the water to pass through a considerable stratum of air. Lead is sometimes taken up from the distilling apparatus, and may cause lead poisoning in those using the water. Drinking-water is sometimes procured by melting snow or ice. It is not probable that water derived from these sources is unwholesome, although there is strong popular prejudice against it. Ice and snow may, however, contain large amounts of SOURCES OF DRINKING-WATER. 55 impurities, as already referred to,1 and be for this reason unfit for use. The following qualities are desirable in water for drinking and domestic purposes :- 1. The water should be colorless, transparent, sufficiently aerated, of uniform temperature throughout the year, and with- out odor or decided taste. 2. The mineral constituents (magnesium and lime salts) should not be present in greater proportion than 4 or 6 parts per 100,000. More than this gives to water that quality known as " hardness." 3. There should be but little organic matter present, and no living or dead animal or vegetable organisms. 4. The water should be entirely free from ammonia and nitrous acid, and should contain but very small quantities of nitrates, chlorides, and sulphates. 5. It should contain less than one milligramme of lead per litre. A larger proportion is likely to be followed by lead poisoning. IMPURITIES IN WATER. The transparency and the color of water are affected by the presence of suspended or dissolved mineral or organic mat- ters. If, after standing for a time, the water deposits a sedi- ment, this is dependent upon insoluble matters. If the sediment turns black when heated in a porcelain capsule over an alcohol or gas flame it contains organic matter. If the sediment or residue effervesces upon the addition of hydrochloric acid the presence of carbonates is indicated. Water may be colored by metallic salts or by vegetable matter. It may also contain large quantities of mineral or organic matter, or even living organ- isms, without perceptibly diminishing its transparency. For example, the ova of tape-worms may exist in water in consider- able numbers, and yet remain perfectly invisible except under the microscope. 1 See pages 52 and 53. 56 TEXT-BOOK OF HYGIENE. The presence of sulphur compounds, or of various vege- table and animal organisms (sponges, algae, etc.1), may give to water an unpleasant odor and taste. In the oil regions of this country most of the drinking-water is contaminated with petro- leum, which is very disagreeable to one unaccustomed to it. It is not probable that the small quantities of the oil imbibed with the water have any deleterious influence upon the organism. Many works on hygiene fix a limit to the amount of solid matter allowable in drinking-water. The International Con- gress of Hygiene, at Brussels, fixed the limit at 50 parts in 100,000. It is impossible, however, to say of any particular specimen of water that its content of solid matter, whether or- ganic or mineral, will be prejudicial to health without trial. At the same time it is prudent to reject all waters containing a con- siderable proportion of solid organic matter, as determined by the degree of blackening on heating the sediment or residue after evaporation. The hardness of water is due to the presence of earthy car- bonates, or sulphates, or both. If the hardness is due to car- bonates it is dissipated by heat, as in boiling the water; the carbon dioxide is driven off, and the base (calcium or magnesium oxide) is precipitated upon the bottom and sides of the vessel. This is termed the "removable hardness." The hardness due to the presence of earthy sulphates is not removed upon heating the water, and is termed the "permanent hardness." The hard- ness depending upon both the carbonates and sulphates is called the "total hardness." The proportion of the above-mentioned earthy salts present in a given specimen of water is determined by what is called the soap test. This test depends upon the property which lime and magnesia salts possess of decomposing soap (oleate and stearate of soda). The quantity of a solution of soap of a definite com- position decomposed by a quantity of hard water indicates the amount of the salts present. In this country and England this 1 See page 52. IMPURITIES IN WATER. 57 is generally expressed in degrees of Clark's scale, which are equivalent to grains of carbonate of lime per imperial gallon. Thus, if the chemist says that a certain sample of water has a total hardness of 16 degrees he means that the earthy salts in the sample decompose the same quantity of soap that would be de- composed by 16 grains of carbonate of lime per imperial gallon. In Germany each degree of the scale used expresses the soap decomposed by 1 part of calcium oxide per 100,000. In the scale used in France each degree corresponds to 1 part of car- bonate of lime in 100,000. So much of the hardness of water as is due to carbonates can be dissipated by boiling, which drives off the free carbon dioxide and allows the insoluble oxides to be deposited as an incrustation upon the bottom and sides of the vessel. The standard soap solution for testing the hardness of water is made as follows: Dissolve 10 grammes of Castile soap in a litre of weak (35 per cent.) alcohol. One cubic centimetre of this solution precipitates 1 milligramme of carbonate of lime. The test is made as follows: To a definitely-measured quantity of water (say 100 cubic centimetres) in a graduated burette a quantity of the soap solution is added and the mixture shaken up; so long as there are dissolved lime or magnesium salts in the water the soap is decomposed and no lather is formed. Soap solution is now added gradually and the shaking repeated until there is evidence of saponification by the formation of a more or less permanent lather or froth. The quantity of soap solution used is noted, and the test is repeated. The mean of the quan- tity of soap solution in cubic centimetres used in the two ex- periments will represent approximately the proportion of salts in grains of carbonate of lime per gallon present, or, as it is gen- erally expressed, in "degrees of hardness." The scale on the following page shows the quantity of soap solution required to decompose the proportion of calcium oxide per 100,000.1 1 Uffelmann, Handbuch der Hygiene, p. 94. 58 TEXT-BOOK OF HYGIENE. Table IV. 1 part CaO per 100,000 water requires 5.4 c.cm. standard soap solution. 2 parts 44 44 44 44 44 9.4 44 44 44 44 3 G G G G G G J3 2 44 44 44 g 4 G G G G G G 47 0 44 44 G G 5 G G G G G G 20 8 11 44 44 44 (J G G G G G G 24 4 44 44 il 11 g 5 G G G G G G 26 2 44 44 11 44 7 0 G G G G G G 28 0 44 44 44 44 7 5 G G G G G G 29 8 44 44 44 11 3O44 44 44 44 44 44 3 1 6 44 44 44 44 8 5 44 " 44 44 44 44 33 3 g g g g 9 0 44 44 44 44 44 44 35 0 44 44 44 44 9 5 G G G G G G 30 7 G G G G JO O G G G G G G 3g £ ll ll ll G 4 0.5 44 44 44 44 44 44 40 1 44 44 44 44 44 0 44 44 44 44 44 44 44 8 44 44 44 44 44 5 G G G ll u u 43 4 G G G G 42 o 44 44 44 44 44 44 45 0 44 44 44 44 If there are more than 12 parts of lime in 100,000 the water is diluted with an equal proportion of distilled water and the resultant multiplied by two. Mr. Wynter Blyth has proposed to take the total residue as representing approximately the total hardness of the water, but Dr. Fox points out that there may be a large excess of in- organic solids present in water that is quite soft and originally pure. Hard water is objectionable for domestic use, as it is waste- ful of soap. In cooking certain vegetables, such as peas and beans, the hulls are not thoroughly softened. In making infu- sions of tea and coffee, larger quantities of these materials are needed than where soft water is used. DISEASES DUE TO IMPURE DRINKING-WATER. Hard water is popularly believed to be the cause of calcu- lous diseases, and of goitre and cretinism, but no reliable obser- vations are on record showing that the belief is founded upon DISEASES DUE TO IMPURE DRINKING-WATER. 59 fact. At the same time it is undoubtedly true that calcareous waters produce gastric and intestinal derangements in those unaccustomed to their use. Large amounts of suspended mineral matter are frequently present in river-water, and may give rise to derangements of the digestive organs. If there is carbonate of lime present, the water can be easily clarified by the addition of a small quantity of alum. Sulphate of lime and a bulky precipitate of hydrate of alumina are formed, which carry the suspended matters to the bottom. About 10 centigrammes of crystallized alum are sufficient to clarify a litre of water. This amount of alum is too small to affect the taste of the water perceptibly. This method is frequently used to clarify and render fit for use the water of the Mississippi River, which is usually very muddy. Dr. Parkes quotes the following striking instance of the prac- tical value of clarifying muddy water by means of alum.1 In 1868 the right wing of the Ninety-second Regiment of High- landers, going up the river Indus, suffered from diarrhoea from the use of the water, which was very muddy. The left wing of the same regiment used water from the same source, but pre- cipitated the suspended matters with alum and had no diarrhoea. The right wing then adopted the same plan with like success. Although the opinion is widespread that water containing much mineral matter, either in solution or in suspension, is deleterious to health, there is very little evidence absolutely trustworthy upon this point. The presence of large quantities of organic matter in water, whether these matters be of animal or vegetable origin, must always be looked upon with suspicion. The observation was made by Hippocrates twenty-three centuries ago, that persons using the water from marshes, i.e., water containing vegetable matter, suffer from enlarged spleens. Many physicians, both of ancient and modern times, seem to have held this opinion, but the first positive observation in medical literature is the now 1 Manual of Practical Hygiene, 6th ed., New York, vol i, p. 341. 60 TEXT-BOOK OF HYGIENE. classical one of the ship Argo, reported by Boudin.1 In 1834 the transport Argo, in company with two other vessels, carried 800 soldiers from Bona, in Algiers, to Marseilles. The troops were all in good health when they left Algiers. All three of the vessels arrived in Marseilles on the same day. In two of them there were 680 men, not one of whom was sick. Out of the remaining 120 men who were on the third vessel, the Argo, 13 died during the passage, and 98 of the 107 survivors suffered from paludal fevers of all forms. None of the crew of the Argo were sick, however. The two vessels exempt from sick- ness, and the crew of the Argo, had been supplied with pure water, while the soldiers on the latter vessel had been furnished with water from a marsh. This water was said to have a dis- agreeable odor and taste. The testimony of a large number of East India physicians is also quoted by Parkes in support of the view that malarial fevers are often caused by impure drink- ing-water. The observations of Dr. Charles Smart, upon the production of "mountain fever" of the Western territories, have already been referred to. The author ventures to state it as his opinion, however, that the instances in which malarial fevers are due to impure drinking-water are very rare. The causation of typhoid fever and cholera by impure drinking-water will be presently referred to. Recently the opinion has been expressed by some that yellow fever and diph- theria are also spread by polluted drinking-water, but no strong evidence has yet been adduced in its support. There can be very little doubt that diarrhoea and dysentery are frequently caused by water which has been contaminated with decaying organic matter. The evidence in favor of this amounts practically to demonstration. It must not be forgotten that the ova of certain animal parasites, such as distoma hematobium, filaria sanguinis hominis, and mcdinensis, anchylostoma duodenale, and possibly of round- 1 Quoted in Parkes, op. cit., p. 48; Nowak, Lehr buck der Hygiene, p, 51; and in numerous other publications on Hygiene. DISEASES DUE TO IMPURE DRINKING-WATER. 61 and tape- worms, for example, are taken into the system along with the drinking-water. Organic detritus of various kinds, sewage, decomposing animal and vegetable matter, refuse from manufacturing estab- lishments, may be a source of pollution of water and render it unfit for drinking or other domestic purposes. It is, however, not certain that water thus rendered unclean is prejudicial to health; in fact, Dr. Emmerich, of Munich, has recently put his skepticism on this point to a practical test. For two weeks he drank daily from half' a litre to a litre of very filthy water; in fact, nothing less than sewage. The water was both chemically and physically exceedingly impure. Several of the experi- menter's patients partook of the same water without any ill effect. He even claims that a gastric catarrh, from which he was suffering when the experiment was begun, was improved during its course.1 The results of Emmerich's experiments, and of other well- known observations, seem almost conclusive that the products of animal and vegetable decomposition, taken into the body with the drinking-water, cannot be looked upon as certainly harmful. Should, however, water containing such impurities, or even water apparently pure, contain the germs of one of the specific diseases,-cholera, typhoid fever, or, perhaps, yellow, malarial, or scarlet fevers, or diphtheria,-it is probable that such diseases would be communicated to the consumer of the water. Many instances are on record where outbreaks of typhoid fever have been clearly attributable to pollution of the drinking- water by the germ of the disease from a previous case. One of the most remarkable of these outbreaks is that re- corded by Dr. Thorne.2 About the end of January, 1879, typhoid fever began suddenly in the adjoining towns of Cater- ham and Red Hill. Within six weeks 352 cases occurred. All 1 Wolffhuegel: Wasser versorgung, in Pettenkofer u. Ziemssen's Handbuch der Hygiene, I Abth., II Hlfte, p. 97. 2 Report of the medical officer to the Local Government Board for 1879. Quoted in Fo- dor: Hygienische Untersuchungen, etc., II Abth., p, 261. 62 TEXT-BOOK OF HYGIENE. other sources of the disease were excluded except the drinking- water, to pollution of which it was traced with almost absolute certainty. Caterham contained 558 houses and Red Hill 1700. Of the former 419 and of the latter 924 drew their drinking- water from a common supply, having its source in a well several hundred feet deep. The insane asylum, with 2000 inmates, and the military barracks in Caterham used water from a private well. There was no typhoid fever among the last two commu- nities. During January one of the workmen engaged in some excavation near the public well was taken ill with diarrhoea and fever,-probably typhoid,-but was still able to continue his work. His dejections were often voided where they were cer- tain to become mingled with the water of the common supply. This man's diarrhoea began on January 5th and continued until the 20th of the month, during which time he remained at work. On the latter date he was compelled to quit work and take to his bed. Exactly two weeks from the beginning of the man's sickness, on January 19th, the first case of typhoid occurred in Caterham, and then rapidly increased. The first case occurred, therefore, just fourteen days-the incubative period of typhoid -after the presumed infection of the drinking-water by the de- jections of the sick laborer, who had come from Croydon, where typhoid fever was at the time prevalent. Within two weeks from the appearance of the first case the epidemic had reached its height, and then rapidly declined, disappearing almost entirely in a month after the outbreak. It was shown by Dr. Thorne that nearly all the houses in which the disease appeared were sup- plied with water from the source above mentioned, while other houses in the immediate vicinity of the infected ones remained free from the disease. In 1874 there was an outbreak of typhoid fever in the town of Over Darwen, in which nearly 10 per cent, of the in- habitants were attacked. Here the source of the disease was also traced to an infected water-supply. Dr. Buchanan has shown that an outbreak among the stu- DISEASES DUE TO IMPURE DRINKING-WATER. 63 dents of the University of Cambridge was likewise attributable to an infected water-supply.* In this country the reports of the Boards of Health of the various States teem with accounts of localized outbreaks of typhoid fever, referred to infected or polluted drinking-water. In most instances the evidence furnished by the observers is not conclusive. In many, however, especially of those found in the Massachusetts and Michigan reports, the fact of the communi- cation of the disease in this manner seems unquestionable. One of these is as follows: Out of 40 families, all using water from a certain well, there occurred 23 cases of typhoid fever. Out of 47 families, living in the same neighborhood, but using water from different sources, only 2 had typhoid fever.1 Dr. C. F. Folsom has published a very suggestive account of a house epidemic,2 where 9 persons in a single house, who all drank water from a well which was proven to be infected from a privy, were attacked by this disease. In 1885 an epidemic of typhoid fever began in Plymouth, a mining town of 8000 or 9000 inhabitants, situated in the Wyoming coal region of Pennsylvania, and on the right bank of the Susquehanna River. The epidemic began in April, and lasted until the ensuing September. There were 1104 persons attacked by the disease, of which number 114, or 10.3 per cent., died. The careful inspection made into the history of this epidemic revealed the fact that the public water-supply had unquestionably become polluted by the faecal discharges of typhoid-fever patients, and the entire course of the disease, in this instance, is in complete accord with the view that the origin and spread of the epidemic were due to the pollution of the drinking-water with the typhoid-fever poison. In addition, Chantemesse and Vidal have demonstrated the presence of the bacillus of Eberth, which is now generally rec- ognized as the cause of typhoid fever, in drinking-water from 1 Transactions Mich. Med. Society, p. 401, 1883. 2 Boston Med. and Surg. Journal, vol. cii, pp. 227, 261. 64 TEXT-BOOK OF HYGIENE. a well near Paris, to which a small outbreak of typhoid had been traced. This demonstration has also been furnished by Prof. V. C. Vaughan, in connection with an outbreak of the same disease in the State of Michigan. The numerous cases of typhoid fever which have been attributed to the use of infected milk may be included in this category. It is probable that the milk became infected cither through polluted water used for the purpose of cleansing the milk-vessels or in diluting the milk. Mr. Ernest Hart has re- corded1 50 epidemics of typhoid fever, 15 of scarlet fever, and 7 of diphtheria, the cause of which he has attributed to infected milk. It is probable that typhoid fever is, in the majority of cases, spread through the medium of polluted drinking-water, and, in many of the instances on record, the relations between cause and effect-impure water and typhoid fever-have been so clearly made out as to no longer permit any doubt upon the question. As it is with typhoid fever, so also with cholera. In a later chapter the origin and propagation of typhoid fever and cholera will be discussed more fully. At the present time only the rela- tions of the drinking-water to the spread of these diseases can be considered. In the instance to be presently noted the con- nection between the infected water, on one hand, and the out- break of cholera, on the other, is so clearly shown as to be almost equivalent to a mathematical demonstration. The facts in the case were brought to light after a patient inquiry by a commission, whose report drawn up by Mr. John Marshall has made the occurrence classical. In 1854 the people of a well-to- do and otherwise healthy district in the eastern part of London suffered severely from cholera. Upon inquiry the fact was elicited that a child had died of cholera at No. 40 Broad Street, and that its excreta had been emptied into a cess-pool situated only three feet from the well of a public pump in that street, from which most of the neighboring people took their drinking- 1 Transactions Seventh Int. Med. Congress, vol. iv, p. 391,1881. DISEASES DUE TO IMPURE DRINKING-WATER. 65 water. It was further discovered that the bricks of the cess- pool wall were loose and permitted its contents to drain into the pump-well. (It should be noted that the communication between the cess-pool and well was direct; that there was im- mediate drainage, not percolation through the soil.) In one day 140 to 150 people were attacked, and it was found that nearly all the persons who had the malady during the first few days of the outbreak drank the water from the pump. When the pump was closed to public use by the authorities the epi- demic subsided. The most singular case connected with this outbreak was the following: In West End, Hampstead, several miles away from Broad Street, there occurred a fatal case of cholera in a woman 59 years old. This woman formerly lived in Broad Street, but had not been there for many months. A cart, however, went daily from Broad Street to West End, carrying, among other things, a large bottle of water from the pump referred to. The old lady preferred this water to all others, and secured a daily supply in the manner stated. A niece, who was on a visit to the old lady, drank of the same water. She returned to her home, in a high and healthy part of Islington, was likewise attacked by cholera and died. There were, at this time, no other cases of cholera at West End, nor in the neighborhood of these last two persons attacked. Most of the English medical officers in India hold strongly to the view that cholera is spread by polluted drinking-water, and the evidence in its favor is very strong. Quite recently (in 1885) Dr. Robert Koch discovered the cholera spirillum in a water-tank in Calcutta, used as a source of domestic supply, and in this way furnished another link in the chain of evidence connecting the spirillum, the drinking- water, and the outbreak of the disease. The evidence in favor of the influence of impure drinking- water on the causation of other diseases than those mentioned is not sufficient to justify any conclusions at present. The source of a water-supply may be pure, yet pollution 66 TEXT-BOOK OF HYGIENE. may occur before the water is used by the persons to whom it is distributed. Supply-pipes may become defective, and the water become contaminated with sewage or other deleterious substances. It is a current belief that no impurity can gain access to hydrant-pipes between the reservoir, or source of supply, and the point of discharge of the water. Nevertheless, such contamination may occur very readily. The author and his colleague, Dr. J. W. Chambers, of Baltimore, proved this conclusively a few years ago by establishing an undoubted con- nection between a house-epidemic of typhoid fever and a defect in the hydrant supplying the family with water.1 The hydrant was one of the class known as Clark's patent non-freezing hydrant. The mechanism of these hydrants is as follows: At the lower end of the vertical discharge-pipe is a glazed earthen- ware plunger, which works through a ring of rubber packing into a vacuum chamber. At the bottom of the vacuum chamber is a valve regulating the entrance of the water from the con- ducting-pipe. When the water is shut off this valve is kept closed by a spiral spring. When the crank of the hydrant is turned forward-that is, when the water is " turned on"-the plunger is forced to the bottom of the vacuum chamber, presses on the spring, opens the valve, and allows the water to dis- charge. When the crank is turned back the plunger is raised, releases the spiral spring, which forces the valve into its bed, and shuts off the water. The partial vacuum produced by the raising of the plunger draws the water, which is in the vertical discharge-pipe, into the vacuum chamber, which is so far below the surface as to be unaffected by frost. In course of time, and with use, the rubber packing gets worn and permits gradual leakage into the vacuum chamber of the dirty stagnant water by which this part of the hydrant is always surrounded. Out- breaks of typhoid fever having a similar origin,2 in which the 1 On Preventable Pollution of Hydrant-Water and its Relation to the Spread of Ty- phoid Fever. Maryland Med. Journal, vol. vii, p. 271. 2 Local Causes of Insanitation in Baltimore, by John Morris, M.D. Report Md. State Board of Health, 1878. DISEASES DUE TO IMPURE DRINKING-WATER. 67 connection between cause and effect was clearly shown, have been reported by other physicians of the same city. Aside from the practical question of the causation of disease by polluted water, a more abstract and aesthetic idea is involved in consciously taking any impurity into the system. The in- stincts of man, as well as of most animals, revolt at it. These inborn instincts, which constitute the sanitary conscience, as Soyka says, demand purity of food and water, as they insist on cleanliness of the body, of clothing, and of the dwelling. STORAGE AND PURIFICATION OF WATER. Wherever a large supply of water is needed, unless drawn direct from a well or spring, or pumped directly from its source, arrangements for storage are necessary. Cisterns and large reservoirs are made use of for this purpose. River-water, espe- cially, requires a period of rest in a storage reservoir in order to allow deposition of the large amount of suspended matter in it. Prolonged storage also gives opportunity for the conversion of possibly deleterious organic compounds into simple and perhaps harmless combinations. Usually, in an elaborate system of water-works, a series of reservoirs is built, in which the water is stored successively, so that before its final distribution through the street-mains it has become quite clear and pure. Filtration on a large scale is also used in connection with storage reservoirs in order to secure greater purity of the water. In the distribution of water, care should be taken that nothing deleterious is taken up by the water in its passage through the pipes. Lead poisoning is not infrequent from drinking-water that has passed through a long reach of lead pipe, or which has been standing in a vessel lined with lead. Tanks and storage cisterns should therefore not be lined with lead, and the use of lead pipe in the supply service should be avoided as much as possible. Fortunately, most natural waters possess a considerable propor- tion of carbon dioxide, which forms with the lead an almost insoluble carbonate of lead. This carbonate of lead is deposited 68 TEXT-BOOK OF HYGIENE. on the inside of the pipes, and protects both the pipes against erosive action from other constituents of the water, and also prevents the contamination of the water by the lead. An excess of carbon dioxide in the water renders this deposit soluble, and may cause serious poisoning. Any water which is shown by analysis to contain over 1 milligramme of lead per 100,000 is dangerous, and should be rejected. Owing to the possibility of defilement of the water from improper construction of hydrants, all outdoor hydrants should be discouraged as much as possible, and should be replaced by a simple tap-cock indoors. The pipes should also be laid deep enough under-ground, or otherwise protected against freezing in winter. A number of methods, all more or less efficient, have been introduced to purify water when it needs purification before being fit for use. These methods either comprise filtration or seek to purify the water without the aid of this process. One of the methods of purification without filtration consists in exposing the water to the air in small streams. This was pro- posed by Lind more than a century ago, and has since been frequently revived. The water is passed through a sieve, or a perforated tin or wooden plate, so as to cause it to fall for a distance through the air in finely-divided currents. By this process sulphuretted hydrogen, offensive organic vapors, and possibly dissolved organic matters are removed. This process has been used in Russia on a large scale. By boiling and agitation, carbonate of lime, sulphuretted hydrogen, and organic matter are removed or rendered innocuous. Vegetable germs are usually destroyed, although Tyndall has shown that some bacterial germs withstand a temperature higher than that of boiling water. Pathogenic germs are, however, all destroyed by boiling water acting upon them for ten minutes, as shown by Dr. G. M. Sternberg.1 As has already been mentioned,2 alum is one of the readiest 1 Report of Committee on Disinfectants, 1888. a See page 59. STORAGE AND PURIFICATION OF WATER. 69 and most efficient means of removing suspended matters from water. Permanganate of potassium is sometimes used to purify water containing considerable organic matter. The perman- ganate rapidly oxidizes the organic matter, and is believed to render it harmless. There is no certainty, however, that the germs of specific diseases are destroyed by the action of this salt, in the proportion in which it could be used for the purposes of water purification. A yellow tint is given to the water by the permanganate, which is due to finely-divided peroxide of manganese. This does no harm, but is unpleasant. Water unfitted for use by organic matter is sometimes rendered usable by infusing certain vegetable astringents in it. Thus, it is said that in certain parts of China, where the water contains large quantities of organic matter, the inhabitants drink water only in the form of tea. The tannin of the tea-leaves precipitates the suspended matters and renders the water fit for use. Mixing the water with red wine, which is astringent, has the same effect.1 Filtration is an efficient means of removing suspended matters. Charcoal, sand, gravel, and spongy iron are used as filtering material. A most economical filter is one made of fine, clean sand, above which layers of gravel of a gradually-increasing size are placed. The coarser particles of suspended matter are arrested before the sand, which removes most of the coloring and organic matters, is reached. Filters easily become fouled by the matters arrested in the interstices of the filtering material, and hence require frequent renewal or cleansing. A cheap and efficient filter is made by placing a sheet of druggists' filtering-paper in a glass funnel and filtering the water through it. A new and clean sheet of paper should be used every day. M. Chamberland has invented a filter which is said to be 1 Champouillon, quoted in Med. and Surg. Hist, of the War, part ii med. vol., p. 613. 70 TEXT-BOOK OF HYGIENE. absolutely germ-proof, but this power is not permanent, as after a week micro-organisms pass through the filtering material. The same is true of all other filters hitherto invented. TESTS FOR IMPURITIES IN WATER. Accurate and reliable quantitative analyses of water can only be made by chemists of experience. Every intelligent person should, however, know how to determine the presence or absence of suspected impurities. The following methods are simple, and easily carried out:- The color, transparency, and odor of water are determined by the unaided senses. As a standard for comparison in making the color test, pure, distilled water may be used. Two tubes of clear, white glass, 61 centimetres long, are filled with distilled water and with the specimen to be tested, and placed side by side upon a sheet of white paper. The tops of the tubes are covered with little squares of clear glass. The color is noted by com- paring the tints of the water in the two tubes. The same procedure may be used to determine the transparency of the water. While the color and turbidity show impurities, these are not necessarily prejudicial to health; on the other hand, the clearest and most sparkling water may contain so much poisonous matter as to be positively dangerous. The odor of the water is best ascertained by heating a small quantity in a narrow-necked flask to 40° to 45° C. (104° to 113° F.), and then taking a few strong whiffs at the flask. The odor may or may not indicate the presence of deleterious substances. The chemical examination of a water for sanitary purposes, short of a complete analysis, comprises the determination of the presence or absence of suspected impurities; in other words, it may be termed a qualitative analysis. In some cases an approxi- mate quantitative examination may also be made with little more trouble and skill. TESTS FOR IMPURITIES IN WATER. 71 The examination may be divided into the following pro- cedures :- 1. The determination of the total residue. 2. The determination of the presence of- (a) Organic matter. (b) Chlorides. (c) Nitrogen compounds. (d) Mineral poisons. Determination of Total Solids.-Examination of the public water-supply of eight large cities in the United States shows that the total solid residue varies from 6 to 16 parts in 100,000. The total solids of a good drinking-water should not exceed 25 to 30 parts per 100,000, although a larger quantity may be present without being harmful. The method of determining the total solids is to evaporate a definite quantity-say, 70 cubic centimetres of the water-in a previously-weighed platinum dish to dryness over a water-bath. The dish is then wiped dry and weighed again. The difference in weight between the empty dish and the latter with the dry residue represents the proportion of the latter in grains per gallon. To convert this figure into parts per 100,000 the number of grains per gallon is divided by .7. For example, if the number of grains of solid residue in the specimen examined is 22.4, then 22.4 -r- .7 = 32 parts per 100,000. Determination of Organic Matter.-This is the most difficult test to apply in the sanitary examination of water. While it is comparatively easy to determine the presence of organic matter, its quantity and nature are exceedingly complex problems to solve. The presence of organic impurity in water may be detected by the permanganate-of-potash test, the nitrate-of-silver test, and the incineration test. Neither of these processes is compe- tent to differentiate noxious from inoffensive organic matter. The permanganate test, modified by Dr. DeChaumont, is the 72 TEXT-BOOK OF HYGIENE. one usually adopted. The process is as follows: To 250 cubic centimetres of the water to be examined add 5 cubic centimetres of dilute sulphuric acid (10 per cent.) in a clear, white glass flask. Then add permanganate of potassium solution (395 milligrammes to 1 litre of distilled water) until the water has taken a pink tinge. Heat the water to 140° F. (60° C.), adding permanganate solution if the color disappears. When the tem- perature above mentioned is reached remove the flask from the burner, and add permanganate drop by drop until a faint pink color is obtained, which remains permanent for ten minutes. Read off the number of cubic centimetres of the permanganate solution used as required for total oxidizable matter. As the solution of permanganate yields in presence of an acid 0.1 of a milligramme of oxvgen for each cubic centimetre, it is evident that the number of cubic centimetres of solution decomposed has furnished an equal number of tenths of a milligramme of oxygen which has entered into other combinations. But, inasmuch as all the oxidizable matter in the water may not be organic, the inorganic oxidizable matter (nitrous acid) must be separated. This is done by first boiling the water with sulphuric acid, as above (250 cubic centimetres + 5 cubic centimetres), for twenty minutes, to remove the nitrous acid. Then allow the acidulated water to cool down to 60 degrees and add the permanganate until a pink color is obtained for ten minutes. The amount of permanganate solution used gives the number of milligrammes of oxygen required for oxidizable organic matter. Determination of Chlorides.-Chlorine, or its compounds, when present in drinking-water, represent generally sewage pollution. It is true that chlorine may be in excess in water, and the latter, nevertheless, be entirely free from sewage or urine, but this occurs only where there is a natural deposit of chlorine compounds in the soil from which the supply is drawn. If communication with the sea or salt-deposits is excluded, the chlorine may be assumed to be due to the inflow of sewage. 73 TESTS FOR IMPURITIES IN WATER. Especially is this the case if the test for organic matter has given positive results. The proportion of chlorine may be estimated thus: Place 70 cubic centimetres of the water into an evapo- rating dish, and add a small fragment of neutral chromate of potash. Then, by means of a pipette graduated to tenths of a cubic centimetre, standard solution of nitrate of silver1 should be allowed to drop into the water until the red color produced remains permanent. The number of cubic centimetres of the silver solution required to produce the permanent red tint is equivalent to the number of grains of chlorine per gallon, which, if divided by .7, gives the parts per 100,000. Another method of determining the presence of chlorine or chlorides is as follows: Acidulate about 16 cubic centimetres of the water to be tested with pure nitric acid, and add a few drops of a solution of nitrate of silver (1.5 grammes to 32 cubic cen- timetres of distilled water). A white precipitate, gradually changing to gray, is produced if chlorides are present. The degree of cloudiness produced will indicate approximately the amount of chlorides: "1.5 parts of chlorine per 100,000 give a haze; 5.7 parts per 100,000 give a marked turbidity; 14 parts per 100,000, considerable precipitate." If the chlorine is found by this test to exceed 1.5 parts per 100,000, the source of the contamination should be searched for. If drainage from a cess- pool is suspected, a quantity of salt water may be thrown into it, and the water again tested after an interval of four hours to see whether the chlorine has increased. Determination of Nitrites and Nitrates.-The presence of these nitrogen compounds in drinking-water should excite sus- picion of sewage contamination. They are the resultants of oxidation of nitrogenous organic matter, and, although water containing them is not necessarily dangerous, their presence should render a thorough examination of the source of supply imperative. 1 Standard Solution of Nitrate of Silver.-Dissolve 4.79 grammes of crystallized nitrate of silver in 1 litre of distilled water. One cubic centimetre of this solution precipitates 1 milli- gramme of chlorine. 74 TEXT-BOOK OF HYGIENE. The readiest method of detecting nitrates and nitrites in water is by the pyrogallol test. This may be performed as fol- lows : Put 2 cubic centimetres of pure sulphuric acid in a small test-tube and add 1 cubic centimetre of the water to be tested. To this mixture is added 1 drop of a solution of pyrogallol (65 centigrammes to 30 cubic centimetres) in distilled water, acidulated with 2 drops of sulphuric acid. The water becomes colored a dark amethyst or wine brown if the salts are present. The depth of color indicates approximately the amount of the impurity. The following test for nitric acid or nitrates may also be used: A small quantity of the water is evaporated to dryness, and a few drops of a solution of carbolic acid in 4 parts of con- centrated sulphuric acid and 2 parts of distilled water added to the residue. If nitric acid is present, a brownish-red color results, which turns green and then yellow upon the addition of ammonia. Nitrous acid or nitrites will give a reaction with iodide of potassium and starch; 350 to 600 cubic centimetres of water in a flask are acidulated with a few drops of dilute sulphuric acid, and a little solution of iodide of potassium added. About 2 grammes of freshly-prepared starch are added and the mixture shaken. If nitrous acid is present, the iodide is decomposed, setting free the iodine, which combines with the starch, causing a blue color. The test is a very delicate one. Ammonia.-The presence of this is determined by Nessler's reagent,1 as follows: 100 cubic centimetres of the water to be examined is treated with 0.5 cubic centimetre of caustic soda solution and 1 cubic centimetre of carbonate of soda solution to precipitate the earthy salts. After the precipitate has sub- sided, 1 cubic centimetre of Nessler's reagent is added. If ammonia is present the water takes a yellowish tint. 1 Nessler's Reagent.-Dissolve by heating and stirring 35 grammes of potassium iodide and 13 grammes of mercuric chloride in 800cubic centimetres of distilled water. Add gradually a cold aqueous saturated solution of mercuric chloride until the red color produced just begins to be permanent; 160 grammes of solid caustic potash are then added to the mixture which is to be diluted with distilled water until it exactly measures one litre. TESTS FOR IMPURITIES IN WATER. 75 Determination of Mineral Poisons.-Of these the most important are lead, copper, zinc, and arsenic. The presence of any of these in even the smallest quantity is dangerous, and, if constant, the water so contaminated should not be used for drinking purposes. In order to detect lead 250 cubic centimetres of the water is first treated with hydrochloric acid, and then sulphuretted hydrogen (in aqueous solution) is added. If a brownish or black precipitate results, either lead or copper may be present. On filtering the water, dissolving the residue in hot, diluted nitric acid, and adding a solution of potassium bichromate, a yellow precipitate, soluble in caustic potash, is thrown down if lead is present. If the precipitate produced by sulphuretted hydrogen is dissolved, as above, and ammonia added, a blue color is produced in the presence of copper. To detect zinc the sulphuretted hydrogen precipitate is treated with caustic soda, again filtered, and sulphuretted hydrogen added to the filtering liquid. A white precipitate indicates the presence of zinc. Arsenic is detected by Marsh's test. Mr. A. J. Cooper has prepared the following table showing the accuracy of certain tests employed for the determination of poisonous metals in drinking-water:- Table V. Metal. Reagent. Depth of Liquid, 3% Inches. Depth of Liquid, 14}^ Inches (cylinder inclosed in opaque tube). Copper . . . K4Cy6Fe 1 part of metal detected in 4,000,000 of water. 1 part of metal detected in 11,750,000 of water. Copper . . . nh4ho 1,000.000 " 1,950,000 " Copper . . . h2s 4,150,000 " 15,660,000 " Zinc .... nii4hs 2,500,000 " Arsenic . . . 112s 3,600,000 " 7,520,000 " " Lead .... K2CrO4 4,000,000 " 5,875,000 " Lead .... h2s 100,000,000 " 196,000,000 " In making the tests a tall glass is used, and the formation of the precipitate observed by looking down perpendicularly through the column of liquid of 3f inches (95 millimetres) and 14j inches (368 millimetres) respectively. 76 TEXT-BOOK OF HYGIENE. SIGNIFICATION OF THE VARIOUS IMPURITIES INDICATED BY THE FOREGOING TESTS. The following summary gives, briefly, the inferences that may be drawn from the result of the foregoing tests1:- "If chlorine be present inconsiderable quantity it either comes from strata containing chloride of sodium or calcium, from impregnation of sea-water, or from admixture of liquid excreta of men and animals. In the first case the water is often alkaline from sodium carbonate ; there is an absence, or nearly so, of oxidized organic matters, as indicated by nitric and nitrous acids and ammonia, and of organic matter; there is often much sulphuric acid. If it be from calcium chloride there is a large precipitate with ammonium oxalate after boiling. If the chlorine be from impregnation with sea-water, it is often in very large quantity; there is much magnesia, and little evidence of oxidized products from organic matters. If from sewage the chlorine is marked, and there is coincident evidence of nitric and nitrous acids and ammonia, and if the contamination be recent of oxidizable organic matters. "Ammonia is almost always present in very small quan- tity, but if it be in large enough amount to be detected without distillation it is suspicious. If nitrates, etc., be also present, it is likely to be from animal substances, excreta, etc. Nitrates and nitrites indicate previously-existing organic matters, prob- ably animal, but nitrates may also arise from vegetable matter, although this is probably less usual. If nitrites largely exist it is generally supposed that the contamination is recent; the co- incidence of easily-oxidized organic matters, of ammonia, and of chlorine in some quantity, woidd be in favor of an animal origin. If a water gives the test of nitric acid, but not of nitrous acid, and very little ammonia, either potassium, sodium, or calcium nitrate is present, derived from soil impregnated with animal substances at some anterior date. If nitrites are 1 Parkes' Hygiene, vol. i, p. 79. SIGNIFICATION OF VARIOUS IMPURITIES. 77 present at first, and after a few days disappear, this arises from continued oxidation into nitrates; if nitrates disappear it seems probable this is caused by the action of bacteria or other low forms of life. Sometimes in such a case nitrites may be formed from the nitrates. Lime in large quantity indicates calcium car- bonate if boiling removes the lime, sulphate or chloride or ni- trate if boiling has little effect. Testing for calcium carbonate is important in connection with purification with alum. Sul- phuric acid in large quantity, with little lime, indicate sulphate of sodium, and usually much chloride and carbonate of sodium are also present, and on evaporation the water is alkaline. Large evidence of nitric acid, with little evidence of organic matter, indicates old contamination; if the organic matter be large, and especially if there be nitrous acid as well as nitric present, the impregnation is recent." THE BIOLOGICAL OR BACTERIOLOGICAL EXAMINATION OF DRINKING- WATER. Since the development of the methods of cultivation of micro-organisms by Koch and his pupils, and their employment for the study of water pollution by Meade Bolton, Wolff hugel and Riedel, Percy Frankland, Prudden, and others, and the un- satisfactory results of chemical analysis, some sanitarians have expressed the conviction that the biological method is the only exact one for determining water pollution from a sanitary point of view. While this may be conceded, it is also true that very few health officers are competent to give an expert opinion upon the nature of the organisms which may be found in the water examined. It requires but little technical skill to make cultiva- tions of bacteria from samples of water, but only an expert bacteriologist may safely pronounce upon the nature of the organisms constituting the various colonies which develop upon the nutritive gelatin. Just as the mere presence of organic matter as determined by the chemist is not indicative of a dan- gerous quality in the water unless the kind of organic matter 78 TEXT-BOOK OF HYGIENE. and its derivation be also specified, so likewise the presence of bacteria alone is of small significance; the danger consists not in bacteria, but in certain kinds of bacteria. The differential diagnosis is possible only to the trained bacteriologist. While, as stated, a positive decision as to the sanitary value of a water may often be impossible, there are certain chemical and microscopical features which stamp a water as good or bad. Dr. DeChaumont gives an approximate valuation which may often serve as a useful guide.1 He classifies water under the four heads of Pure and Wholesome Water, Usable Water, Suspicious Water, and Im- pure Water. The characters of these waters are arranged in a series of tables, the essential details of which are given in Table VI. Table VI. Chemical Constituents. Pure Water. Usable Water. Suspicious Water. Impure Water. I. Parts in 100,000. II. Parts in 100,000. III. Parts in 100,000. IV. Parts in 100.000. Chlorine in solution . Under 1.4000 Under 4.2857 4-7 Above 7.1428 Solids " total . " 7.1428 " 42.8571 43-71 " 71.4285 " " volatile " 1.4000 " 4.2857 4-7 " 7.1428 Ammonia, free or sa- line " 0.0020 " 0.0050 0.0050-0.0100 " 0.0100 Ammonia, albuminoid " 0.0050 " 0.0100 0.0100-0.0125 " 0.0125 Nitric acid in nitrates " 0.0323 " 0.5000 0.5-1.0 " 1 0000 " " nitrites Nil. Nil. 0.0500 " 0.0500 Nitrogen in nitrates . " 0.0140 " 0.1129 0.1243-0.2373 " 0 2415 Total nitrogen . . . Oxygen absorbed by " 0.0230 " 0.1252 0.1255-0.2465 " 0.2601 permanganate and acid within half an hour at 140° F. . . " 0.0250 " 0.1000 0.1000-0.1500 " 0.1500 Total hardness . . . " 8.5 " 17.3 Above 17.0 " 28.5 Permanent hardness . Phosphoric acid in " 3.0 " 5.7 " 5.7 " 8.7 phosphates . . . Sulphuric acid in sul- Traces. Traces. Heavy traces. Heavy traces. phates << Under 3.000 Above 3.000 Above 4.2857 Heavy metals . . . Nil. Traces. Traces. ( Any except ( iron. Hydrogen sulphide . Alkaline sulphides if << Nil. << Nil. tt Present. 11 1 Parkes' Hygiene, vol. i, pp. 103-106. EXAMINATION OF DRINKING-WATER. 79 Physical Characters. No. I. Colorless, or bluish tint; trans- parent, sparkling, and well aerated ; no sediment visible to naked eye ; no smell; taste palatable. No. II. Colorless, or slightly greenish tint; transparent, sparkling, and well aerated ; no suspended matter, or else easily separated by coarse filtration or subsidence ; no smell ; taste palatable. No. III. Yellow, or strong, green color ; turbid ; suspended matter con- siderable ; no smell, but any marked taste. No. IV. Color, yellow or brown ; tur- bid, and not easily purified by coarse filtration ; large amount of suspended matter ; any marked smell or taste. Microscopical Characters. No. I. Mineral matter; vegetable forms with endochrome; large animal forms ; no organic debris. No. II. Same as No. I. No. III. Vegetable and animal forms more or less pale and colorless ; organic debris; fibres of clothing, or other evi- dences of house-refuse. No. IV. Bacteria of any kind ; fungi; numerous vegetable and animal forms of low types ; epithelia, or other animal structures ; evidences of sewage ; ova of parasites, etc. [The following works are recommended to those desiring fuller information upon the subjects embraced in the foregoing chapter:- Water Supply, by Wm. Ripley Nichols, N. Y., 1884.-A Guide to the Microscopic Examination of Drinking-Water, by J. D. MacDonald, R.N.F.R.S.-Sanitary Examinations of Water, Air, and Food, by Fox.- Report of the Committee on Water Pollution, Public Health, vol. xiv. Zeitschr. f. Hygiene, vol. i, by Bolton.-Prudden in N. Y. Medical Record, 1887.-Arb. aus d. Reichsgesundheitsamte, I, Wolffhiigel and Riedel.] CHAPTER III. Food. Tn order to preserve health and vigor it is necessary for animal beings to consume at intervals a sufficient quantity of substances known as foods. Alimentary substances, or foods, may, therefore, be briefly defined as materials which, taken into the body and assimilated, sustain the processes of life, promote growth, or prevent destruction of the organized constituents of the body. QUANTITY AND CHARACTER OF FOOD NECESSARY. It has long been known, as the result of the empirical observation of feeding large bodies of people, that the various proximate principles composing the tissues must be combined in certain definite proportions in the food in order to preserve the normal degree of health and vigor of the body. Within a comparatively recent period physiologists have made experi- ments upon animals and human beings which have led to the same conclusions, and have enabled these proportions to be fixed with more or less exactness. Considering man as an omnivorous animal, it may be laid down as an invariable rule that the following four alimentary principles are necessary to his existence.1 Neither of these principles can be dispensed with for a prolonged period without illness or death resulting. 1. Water.-This must be supplied in sufficient quantity to permit the interchange of tissue to be carried on in the body. 2. Salts.-Inorganic compounds of various kinds are 1 Physiologic, Landois, 2te Aufl., p. 448. 81 82 TEXT-BOOK OF HYGIENE. necessary to the preservation and proper construction of the tissues. They are all found in sufficient quantities in the various alimentary substances consumed by man and the lower animals. A deficiency of inorganic constituents in the food is followed by disease. 3. Proteids.-Organic nitrogenous material, either animal or vegetable, is a necessary constituent of the food of man. Continued existence is impossible without a sufficient supply of nitrogenous substances. 4. Fats or Carbohydrates.-The organic non-nitrogenous or carbonaceous principles of food are also necessary to the continuance of health. They are supplied either by fats or by carbohydrates (sugar, starch, etc.), which may, within certain limits, be used as substitutes for each other. Voit has shown that 1 7 parts by weight, of starch, is equivalent as carbonaceous or oxidizable food to 10 parts of fat. The physiology of nutrition has been very carefully studied by a large number of experimental physiologists, who have arrived at conclusions differing widely from those generally accepted twenty-five years ago. The division of foods into plastic and respiratory foods, or, in a general way, into proteids or muscle-builders, and fats and carbohydrates, or oxidizing foods, is now no longer recognized in science. It has been established that proteid tissues are not alone the result of proteid food, and that the accumulation of fat in the body is not altogether due to the excessive consumption of fats and carbohydrates. It has been further shown, contrary to the general belief, that the nitrogenous or proteid tissues are not used up during hard labor any faster than when at perfect rest, but that, on the contrary, increased muscular exertion is attended by increased consump- tion of stored-up fat. These facts have led to a modification of the standard dietaries formerly employed. At present the standards of the quantity of food principles required to maintain equality between bodily income and expenditure are those calculated by Professor QUANTITY AND CHARACTER OF FOOD NECESSARY. 83 Voit, after many experiments upon human beings and the lower animals. These standards are as follow *- Table VII. ADULT MALE OF AVERAGE WEIGHT. At Rest. Moderate Labor. Severe Labor. Proteids .... Fats Carbohydrates . . 110 grammes 50 " 450 " 118 grammes 50 " 500 " 145 grammes 100 " 500 " As the average weight of women is less than that of men, a reduction of from 15 to 20 per cent, in the various food prin- ciples may be made for the female ration. The relative proportion of nitrogenous to non-nitrogenous principles in this ration is about 1 to 5. In the older diet standards, e.g., Moleschott's, the proportion of nitrogenous to non-nitrogenous principles is much larger, being, for a man at moderate labor, proteids, 130 grammes; fats, 84 grammes; and carbohydrates, 404 grammes, or about 1 to 3.75. While from ignorance, or motives of economy, many men sustain life and preserve health at hard labor on rations varying considerably from the standard above given, it is probable that, all things being considered, the most perfect physiological ration would also be the most economical. Thus, Professor Vaughan proposes a daily ration consisting of bread, cod-fish, lard, potatoes, bacon, beans, milk, sugar, and tea in such proportions as to fur- nish 123 grammes proteids, 70 grammes fats, and 550 grammes carbo-hydrates. The total cost or money value of this ration at present prices is about thirteen cents. In actual food value it is not inferior to the daily fare of the habitue of Delmonico's. The above standard diet-tables give the relative proportions of food principles in terms of their proximate chemical composi- tion. In practice it is very necessary to choose such food ma- terials as will represent approximately the proximate principles 84 TEXT-BOOK OF HYGIENE. required. The following tables give the approximate value in proteids, fats, carbohydrates, and salts of a number of articles used as food:- Table VIII. Articles. Water (per cent.). Proteids1 (per cent.). Fats (per cent.). Non-nitrogenous Matters (per cent.). Ash (per cent.). Proportion of Nitrogenous to Non-nitrogenous Matters. Moderately fat beef 72.25 21.39 5.19 1.17 1: 0.4 Ox-heart (fat animal) .... 70.08 21.51 7.47 0.16 0.78 1: 0.6 Fat veal 72.31 18.88 7.41 0.07 1.33 1: 0.7 Moderately fat mutton . . . 75.99 18.11 5.77 1.33 1: 0.6 Lean pork 72.57 19.91 6.81 1.10 1: 0.6 Salt ham 62.58 22.32 8.68 • 6.42 1: 0.7 Hare 74.16 23.34 1.13 0.19 1.18 1: 0 1 Venison 75 76 19.77 1.92 1.42 1.13 1: 0.2 Horse-flesh 74.27 21.71 2.55 0.46 1.01 1: 0.2 Liver-sausage 48.70 15.93 26.33 6.38 2.66 1: 3.3 Beef-extract Chicken (lean) 21.70 76.22 19.72 60 79 1.42 ' 1.27 17.51 1.37 1: 0.2 Pigeon 75.10 22.14 1.00 0.76 1.00 1: 0.1 Wild duck 70.82 22.65 3.11 2.33 1.09 1: 0.3 Haddock 80.92 17.09 0.35 1.64 1: 0.0 Herring (fresh) 80.71 10.11 7.11 2.07 1: 0.0 Roach 75.49 22.23 0.47 1.71 1: 0.0 Mackerel 68.27 23.42 6.76 1.85 1: 0.5 Conger-eel 79 91 13.57 5.02 0.39 1.11 1: 0.7 Salmon 76.38 13.10 4.57 4.67 1.28 1: 1 0 Carp 76.97 20.61 1.09 1.33 1: 0 1 Pike 77.45 20.11 0.69 0.92 0.83 1: 0.1 Sole 86 14 11.94 0.25 0.45 1.22 1: 0.1 Oyster 89.69 4.95 0.37 2.62 2.37 1: 0.7 Caviar 45.05 31.90 14.14 8.91 1: 0.8 Beef-liver 72.02 19.59 5.60 i.io 1.69 1: 0.5 Calf s brains Sweet-bread Fat of pork (salt) 74.14 70.00 9.15 (8 albumen) 27.00 9.72 13.14 0.35 75.75 1L65 1 0 1. 0 5.38 1: 13.6 Hen's egg 73.67 12.55 12.11 0.55 1.12 1: 1.7 White of egg 85.75 12.67 0.25 0.59 1: 0.1 Yelk of egg 50 82 16.24 31.75 0.13 1.09 1: 3 4 Cow's milk 87.41 • 3.31 3.66 4.92 0.70 1: 3.4 Human milk 87.09 2.48 3 90 6.04 0.49 1: 5.2 Cream 66.41 3.70 25.72 3.54 0.63 1: 13.1 Rich cheese 35.75 27.16 30.43 2.53 4.13 1: 2.1 Lean cheese 48.02 32.65 8.41 6.80 4.12 1: 0.7 Butter 14.14 0.86 83.11 0.70 1.19 1: 169.9 Whey 93.31 0.82 0.24 4.98 0.65 1: 6.6 Kumys 87.88 2.83 0 94 7.08 1.07 1: 3.1 Condensed milk 30.34 16.07 12.10 38.88* 2.61 1: 3 7 ANIMAL FOODS. * Containing 16 per cent, nitrogen. a Containing 22.26 per cent, cane-sugar. QUANTITY AND CHARACTER OF FOOD NECESSARY. 85 VEGETABLE FOODS. Table IX. Articles. Water (per cent.). Proteids (per cent.). Fats (per cent.). Sugar (per cent.). Other Non-nitro- genous Mat- ters (per cent.). Woody Fibre (per cent.). Ash (per cent.). Proportion of Nitrogenous to N o n - n itroge- nous Matters. Wheat 13.56 12.42 1.70 1.44 66.45 2.66 1.77 1 5.7 Spelt 12.09 11.02 2.77 66.44 5.47 2.21 1 6.5 Rye 15.26 11.43 1.71 0.96 66.86 2.01 1.77 1 6.2 Barley 13.78 11.16 2.12 65.51 4.80 2 63 1 6.2 Oats 12.92 11.73 6.04 2.22 53.21 10.83 3.05 1 5.6 Indian corn 13.88 10.05 4.76 4.59 62.19 2.84 1.69 1 7.5 Hulled rice 13.23 7.81 0.69 76.40 0.78 1.09 1 9.9 Millet 11.26 11.29 3.56 1.18 66.15 4.25 2.31 1 6.5 Buckwheat 11.36 10.58 2.79 55.84 16.52 2.91 1 5.7 Beans 14.84 23.66 1.63 49.25 7.47 3.15 1 2.2 Peas. 14.31 22.63 1.72 - 53.25 5.45 2.65 1 2.5 Lentils 12.51 24.81 1.85 54.78 3.58 2.47 1 2.3 Wheat-flour 14.86 8.91 1.11 2.32 71.86 0.33 0.61 1 8.5 Rye-flour 14.42 10.97 1.95 3.88 65.86 1.62 1.48 1 6.7 Barley-flour 15.06 11.75 1.71 3.10 67.80 0.11 0.47 1 6.3 Buckwheat-flour .... 14.27 9 28 1.89 1.06 71.40 0.89 1.21 1 8.2 Oatmeal 10.46 15.50 6.11 2.25 61.42 2.24 2.02 1 4.8 Cornmeal 14.00 11.10 8.10 65.10 1.70 1 6.7 Starch 14.84 1.46 83.31 0.39 1 57.1 Macaroni 13.07 9.02 0.28 - 76.79 0.84 1 8.6 Fine wheat-bread. . . . 38.51 6.82 0.77 2.37 49.97 0.38 1.18 1 7.9 Fresh rye-bread .... 44 02 6.02 0.48 2.54 45.33 0.30 1.31 1 8.1 English biscuit 7.45 7.18 9.28 17.02 58.08 0.16 0.83 1 12.7 Potatoes 75.77 1.79 0.16 20.56 0.75 0.57 1 11.6 Beet (red) 87.88 1.07 0.11 6.55 2.43 1.02 0.94 1 8.6 Sugar-beet 83.91 2.08 0.11 9.31 2.41 1.14 1.04 1 5.7 Mangold root 90 51 1.40 4.68 2.14 1.27 1 5.8 Carrot (large) 87.05 1.04 0.21 6.74 2.66 1.40 0.90 1 9.4 " (small) 88.32 1.04 0.21 1.60 7.17 0.95 0.71 1 8.8 Turnip 91.24 0.96 0.16 4.08 1.90 0.91 0.75 1 6.5 Radish 86.92 2.92 0.11 1.53 6.90 1.55 1.07 1 4.5 Horseradish 76.72 2.73 0.35 15.89 2.78 1.53 1 6.0 Kohlrabi 85.01 2.95 0.22 0.40 8.45 1.76 1.21 1 3.1 Onion 70 18 2.68 0.10 5.78 19.91 0.81 0.54 1 9.6 Leek 87.62 2.83 0.29 0.44 6.09 1.49 1.24 1 2.5 Garlic 64.66 6.76 0.06 26.31 0.77 1.44 1 3.9 Cucumber 95.60 1.02 0.09 0.95 1.33 0.62 0.39 1 2.4 Melon 95.21 1.06 0.61 0.27 1.15 1.07 0.63 1 2.4 Pumpkin 90.01 0.71 0.05 1.36 5.87 1.36 0.64 1 10.2 Tomato 92.87 1.25 0.33 2.53 1.55 0.84 0.63 1 3.6 Asparagus 93.32 1.98 0.28 0.40 2.34 1.14 0.54 1 1.6 Green peas . 80.49 5.75 0.50 10.86 1.60 0.80 1 2.0 Snap beans 86.10 4.67 0.30 6.60 1.69 0.64 1 1.5 Cauliflower 90.39 2.53 0.38 1.27 3 74 0.87 0.82 1 2.2 Winter cabbage 80.03 3.99 0 90 1.21 10.42 1.88 1.57 1 3.3 Savoy cabbage 87.09 3.31 0.71 1.29 4.73 1.23 1.64 1 2.2 Red cabbage 85.63 4.83 0.46 6.22 1.57 1.29 1 1.5 Spinach 90.26 3.15 0.54 0.08 3.26 0.77 1.94 1 1.3 Lettuce 94.33 1.41 0.31 . . . 2.19 0.73 1.03 1 1.9 86 TEXT-BOOK OF HYGIENE Table IX (continued) Articles. Water (per cent.). Proteids (per cent.). Fats (per cent.). Sugar (per cent.). Other Non-nitro- genous Mat- ters (per cent.). Woody Fibre (per cent.). Ash (per cent.). Proportion of Nitrogenous to Non -nitroge- nous Matters. Mushrooms (fresh) . . . 91.11 2.57 0.13 1.05 3.71 0.67 0.76 1:19 " (dried) . . . 17.54 23 84 1.21 9 59 34 56 6.21 7.05 1:19 Truffle 72 80 8.91 0.62 7.54 7 92 2.21 1 : 1.0 Apples1 83.58 0.39 7.73 5 17 1.98 0.31 1 :35.2 Pears 83 03 0.36 8 26 3.54 4 30 0.31 1 :33 3 Plums 84.86 0.40 3 56 4.68 4 34 0.66 1 :24 3 Peaches 80.03 0.65 4 48 7.17 6.06 0 69 1 : 19.3 Apricots 81.22 0 49 4 69 6.35 5.27 0.82 1 :24 9 Cherries 80.26 0 62 10.24 1 17 6.07 0.73 1 :19.9 Grapes 78.17 0.59 14 36 1.96 3 60 0 53 1 :29 0 Strawberries 87.66 1.07 0.45 6.28 0.48 2 32 0 81 1:78 Raspberries 86.21 0.53 3.95 1 54 5 90 0 49 1 :13.0 Blackberries 86.41 0.51 4.44 1.76 5 21 0 48 1 :14.5 Mulberries 84.71 0 36 9 19 2 31 0.91 0.66 1 :37.1 Whortleberries 78.36 0.78 5.02 0.87 12 29 1.02 1 : 9.7 Gooseberries 85 74 0.47 7.03 1.40 3 52 0.42 1 :21.0 Currants 84.77 0.51 6.38 0 90 4 57 0.72 1 :18.5 Dried apples 32.42 1.06 41 61 14.68 5 59 1 96 1 :55.6 " pears 29 41 2 07 0.35 29 13 29.67 6 86 1.67 1 :29.1 " prunes 29.83 2 55 0.53 42 65 18.85 1.43 1.39 1 : 25.5 " cherries 49.88 2.07 0 30 31.22 14.29 0.612 1 63 1 :22 2 " raisins 32.02 2.42 0.59 54 56 7.48 1.72 1.21 1 : 26 0 " figs 32.21 5 06 45.28 2.96 1 : 8.9 Sweet almonds 5.39 24 18 53 68 . . • 7.23 6.56 2.96 1:42 Walnut 4.68 16 37 62.86 7.89 6.17 2.03 1:72 Hazel-nut 3.77 15.62 66.47 9.03 3.28 1.83 1 : 8.0 Chestnuts (fresh) . . . 51.48 5 48 1.37 38.34 1.61 1.72 1 : 7.5 Peanut 6.50 28.20 46.40 . . . 15.70 3.20 1 : 2.3 VEGETABLE FOODS In addition to maintaining a proper proportion between the various alimentary principles, it is necessary to vary the articles of food themselves, otherwise they are liable to prove nauseating. The necessity of variety in the food, in order to preserve the appetite, is familiar to every one. By keeping the proportions of the above table in view it will be seen at once that if a man wished to live on beef alone he would be obliged to eat about 2 kilogrammes per day in order to get a sufficient amount of non-nitrogenous food. Of 1 These green fruits all contain in addition from .2 to 2.1 per cent, of free acid. a Without stones. QUANTITY AND CHARACTER OF FOOD NECESSARY. 87 potatoes, in order to get enough nitrogenous food, he would have to eat daily 8 kilogrammes. No human stomach could prove equal to the task of digesting this excess of material. On the other hand, it is to be noted how perfect the combination of the various principles is in human milk. In cows' milk, which is nearest in composition to human milk, the non-nitrogenous principles are deficient. Hence, the important practical point that when ordering milk diet for a patient a small portion of carbonaceous food (bread, rice, or sugar) must be added if the standard of health shall be reached or maintained. Climate has probably very little influence upon the amount of food required by the individual. The actual quantity of food consumed varies little between various races or in different parts of the earth. It is true, however, that a larger proportion of fat is required in cold climates. That fatty articles of food readily undergo oxidation and furnish a large amount of animal heat is proven both by observation and experiment. The albuminoid proximate principles of the food, proteids, are represented by the nitrogenous constituents of organic tissues. These are the vitellin and albumin of eggs, albumin, fibrin, globulin, myosin, syntonin, and other nitrogenized prin- ciples of flesh and blood ; the casein of milk, the gluten, fibrin, and legumin of cereal and leguminous seeds and plants, gelatin, and chondrin. Fat constitutes an integral component of animal tissue, and is found in abundance as a constituent of nerve-tissue, marrow, and subcutaneous connective tissue. In food it is represented especially in the fatty tissue of meat, the yelk of eggs, butter, etc. The carbohydrates are represented especially by various products of the vegetable world, as sugar, starch, dextrin, etc. Water and the various other inorganic proximate princi- ples, chief among which are compounds of calcium, sodium, and potassium, are usually found in sufficient proportion in the other alimentary substances. 88 TEXT-BOOK OF HYGIENE. The food should be taken in appropriate quantities and properly prepared. A larger quantity than necessary may over- tax the digestive organs and thus yield less than the required amount of nutritive material to the body. Physical exertion increases the consumption of fatty prin- ciples. Hence, as in the cases of the athlete or prize-fighter in training, larger quantities of these principles are required to keep the nutrition of the body at the standard of health. During mental work, however, less carbohydrate material is consumed than during physical labor. The greater consumption of carbohydrates during muscular exercise is shown by the following table, which gives the amounts of carbon dioxide and nitrogen excreted by a man at rest and during labor:- Table X. C02 Excreted. Nitrogen Excreted. At rest 2.1 per cent. 1.1 per cent. At work 2.6 " " 1.1 " " In youth the processes of combustion (production of carbon dioxide) go on with greater rapidity than after adult life is reached. For this reason young persons rarely get fat, the fat- producing food being burnt up in the body by the greater meta- bolic activity of the young cell. Hence, fats and carbohydrates should form a larger relative proportion in the diet of the young than in that of grown persons. Low external temperature causes a greater and more rapid consumption of fat than high external temperature. During febrile conditions, however, the destruction of stored-up fat in the body-the wasting away-is one of the most notable phenomena; lienee the importance of supplying fat and fat-producing food in chronic febrile diseases. "Der Mensch ist was er isst" said Ludwig Feuerbach? 1 Gottheit, Freiheit und Unsterblichkeit von Standpunkt der Anthropologic, p. 5. CLASSIFICATION OF FOODS. 89 The pungency of the epigram is somewhat lost in the transla- tion, which is, literally, "Man is what he eats." The intimate relations of mental, moral, and physical conditions of health to the quality and quantity of* food deserve the earnest attention of the educated physician and sanitarian. CLASSIFICATION OF FOODS. Foods and victuals are generally divided into foods proper and so-called accessory aliment. The classification is not exact, however, as the latter, which are commonly regarded as articles of luxury, may under certain circumstances become necessities, and hence should not be considered as forming a separate class. Foods are either of animal or vegetable origin. Those de- rived from animal sources are milk, the flesh of animals, birds, reptiles, and fish, and the eggs of the three last named. The foods derived from the vegetable kingdom comprise the seeds of various plants (cereals, legumes), roots, herbs, ripe fruits, the fleshy envelopes of various seeds (which may prop- erly be classed with the fruits), and various fungi. There are also in common use a number of beverages, e.g., water, alcoholic liquors, alkaloidal infusions (tea, coffee, cocoa), etc. In addition, a number of substances or compounds are in common use as condiments. Their function is either to render victuals more palatable, or to promote digestion and assimilation. Vinegar, mustard, and common salt are familiar examples. FOODS OF ANIMAL ORIGIN. Milk.-Human milk is, so far as known, the one perfect food for man found in nature. It contains, in proper proportion, representatives of all the different classes of proximate principles necessary to nutrition. One hundred parts contain about 2.5 parts of proteids (casein and albumin); 3.9 parts of fat (butter); 6.0 parts of sugar, and .5 of salts. The reaction of human milk is slightly alkaline; that of fresh cows' milk is neutral. 90 TEXT-BOOK OF HYGIENE. In human milk there are 12.9 parts of solid matter to 87.1 of water, while in cows' milk the proportions are: Proteids, 4.0 per cent.; fats, 3.4 per cent.; sugar, 3.8 per cent.; salts, 0.6 per cent., or 11.8 total solids and 88.2 water.1 Of the solids in milk, cows' milk contains more proteids, while human milk is richer in fats and sugar. Hence, in using cows' milk as a substitute for human milk the proteids are di- luted by the addition of water, and the non-nitrogenous com- ponents increased by adding sugar and, under some circum- stances, fat (cream). Goats' and asses' milk are sometimes used as substitutes for human milk, but they do not approach much nearer in com- position to the latter than does cows' milk. On standing, the fatty constituent of milk, the cream, sepa- rates, and on account of its less specific gravity rises to the surface, where it forms a layer of varying thickness. After standing a longer interval the milk undergoes certain physical and chemical changes. Lactic acid is formed at the expense of part of the sugar of milk (a sort of fermentation taking place), and, acting upon the casein, produces coagulation. This is the so-called " bonny-clabber." When the fermentation continues, especially under a slightly elevated temperature, the solid portion becomes condensed (curd), and a sweetish-acid, amber-colored liquid, the whey, separates. The curd, after further fermentation, under appropriate treatment, becomes converted into cheese. Whey is sometimes used alone or mixed with wine as an article of diet for the sick. Butter is made from the cream by prolonged agitation in a churn. The fat-globules adhere to each other and form a soft, unctuous mass, of a yellowish color, solid at ordinary tem- peratures. After the butter is all removed in this way the balance of the cream remains in the churn as buttermilk. This is an article of considerable nutritive value, although its excess 1 Average of a number of analyses. FOODS OF ANIMAL ORIGIN. 91 of acid renders it unsuitable as an article of diet in many cases. The specific gravity of fresh milk should not be below 1030. It should, however, be borne in mind that the richest milk is not always that which has the highest specific gravity. In fact, a sample of rich milk, containing a large proportion of cream, may show, when tested with the lactometer, a lower specific gravity than a specimen of much poorer milk. Hence, the lactometer, although a useful instrument in guarding against excessive dilution of the milk with water, is not a very trust- worthy guide in determining the quality of the milk. Objections are often urged against the use of so-called " skim-milk," i.e., milk from which the cream has been removed. In some cities in this country the police, or representatives of the sanitary authorities, seize and confiscate all skim-milk found in possession of dealers. There appears to be no rational basis for the opinion held by many that skim-milk is not a proper and useful article of food. Before the lactic-acid fermentation has taken place it differs from fresh milk merely in the fatty and other matters removed in the cream. It contains nearly all of the proteids, sugar, and salts of whole milk, and may be used as an article of food with great advantage and entire safety. In certain diseased states it is of exceptional value as an article of diet. The sole objection of any weight to skim-milk is that it may be at times sold fraudulently as fresh milk. This is, how- ever, a question of little sanitary interest, but one principally of commercial ethics. Milk is frequently adulterated by the addition of water. More deleterious substances are rarely found. An excess of water gives the milk a bluish tinge and reduces its specific gravity. The addition of water may become especially dangerous by introducing the virus of some of the acute infectious diseases. Thus, the localized epidemics of typhoid and scarlet fevers have, in quite a number of instances, been traced to mixing the milk with water containing the poison of these diseases. It should, 92 TEXT-BOOK OF HYGIENE. however, be stated that milk which contains the virus of typhoid fever has not necessarily been adulterated by the addition of water. The poison may have been introduced with the water used in washing the can, and adhered to the sides of the latter. In filling the can with milk a good culture medium is supplied in which the typhoid bacillus flourishes. It has long been a mooted question whether acute or chronic infectious diseases of the milk-giving animal may be communi- cated to persons using the milk of such animals. While there is little positive knowledge upon the subject, it would seem prudent to avoid the use of milk from diseased animals, if pos- sible, or to destroy any organic virus the milk may contain by previously boiling the milk. After thorough boiling little fear need be entertained of communicating either acute or chronic infectious diseases through this medium. Demme and Uffel- mann have reported cases which seem to demonstrate the pos- sibility of tuberculous infection through the medium of the milk. Professor Bang, of Copenhagen, has recently made a series of experiments and observations which has led him to the con- clusion that the milk of tuberculous cows and tuberculous women, in which there are no lesions in the mammary gland, only exceptionally contains the contagium. Professor Bang at the same time, however, points out that the milk from tubercu- lous udders is extremely dangerous, and that the tubercle bacilli are to be found not only in the milk itself, but in the cream, buttermilk, and butter made from it; and that such milk is sometimes infective by ingestion, even after exposure to 65° C. of heat, and by injection into the peritoneal cavity after exposure to 80° C. The infectiousness of the milk of cows suffering from splenic fever (milzbrand, anthrax) has been proven by Bollinger and Feser. Anthrax bacilli have been found in such milk by Chambrelent and Moussons. The agency of milk in the spread of scarlet fever is well recognized, but the manner in which the contagium gained 93 FOODS OF ANIMAL ORIGIN. access to the milk was not well understood. Recently, however, an incident happened in England which seems to prove a close connection between this widespread and fatal disease and a dis- order in the milk cattle. The evidence in support of this view is as follows: Mr. W. H. Power, of the English Local Government Board, was detailed to investigate certain outbreaks of scarlet fever which seemed to have especial relation to the milk-supply from a particular dairy-farm. Upon inspection this dairy was found to be in excellent sanitary condition as regards cleanliness, water-supply, sewerage, etc., and for a time considerable difficulty was experienced in locating the cause of the outbreaks. Im- probable as it may at first sight appear, it seems to have been incontestably established that the epidemics of scarlatina were due to the use of milk obtained from cows attacked by a peculiar disease manifested by a vesicular eruption followed by ulceration of the udder. The chain of circumstances connecting the dis- ease in the cows with the outbreaks of scarlet fever in certain districts in London, supplied with milk from the diseased cows, was so strongly forged by the able investigator, into whose hands the work had been committed by the authorities, that hardly a doubt can exist that the one disease owed its origin to the other. The pathological evidence furnished by Dr. Klein lends strong support to the view that the Hendon cow disease and scarlet fever are intimately related to each other. A bacterial organism was found in the material from the ulcerated udders of the sick cows, which presents similar characters to a micro- coccus found by the same observer in the blood of scarlet-fever patients. These results require more extended investigations before they can be unreservedly accepted. The milk of cows fed upon the refuse of breweries and dis- tilleries-"swill-milk"-is believed by many physicians to be unwholesome. If so, it is, probably, only by reason of the un- favorable hygienic conditions under which the animals are kept. If the stables are clean, dry, and well ventilated, and the ani- mals receive plenty of fresh air and exercise, swill-fed cows 94 TEXT-BOOK OF HYGIEXE. should produce as nutritious milk as when they are fed upon different food. Much of the present agitation against "swill- milk" is more prompted by political demagogism than by scientific knowledge. The milk of animals suffering from certain diseases is often dangerous to health. In some of the Western and Southern United States, cows are not infrequently attacked by an acute febrile disease called " the trembles," from one of the prominent symptoms. The milk of cows suffering from this disease pro- duces severe gastro-intestinal disorder, collapse, fever, etc., in the consumer. This disease, called "milk-sickness," is fatal in a pretty large proportion of cases. It is said that the flesh of animals with "the trembles" will, if eaten, produce similar dan- gerous effects. A late writer (Dr. Beach, of Ohio) estimates that 25 per cent, of the Western pioneers and their families died of this disease. For the ready determination of the quality of milk, instru- ments known as lactoscopes, lactometers, and creamometers are used. The lactoscope indicates the opacity of the milk, upon which the proportion of cream depends. One convenient mod- ification of the lactoscope is the little instrument termed the pioscope. This consists of a disk about 6 J centimetres in diam- eter, with a slight depression in the centre. A little milk is placed in the depression and covered with a glass disk, clear in the centre and opaque around the border, which is divided into six divisions of different shades, varying from white to dark gray. The quality of the milk is marked upon the division whose color corresponds with that of the milk in the centre. A better, but still not very accurate, indicator of the quality of the milk is the creamometer. This consists of a cylindrical glass vessel with the upper half divided up into hundredths. The glass is filled up to the zero mark with milk, and allowed to stand until all the cream has separated. The thickness of this layer is then read off on the scale. In Chevallier's instru- FOODS OF ANIMAL ORIGIN. 95 ment, 10 per cent, of cream is the minimum proportion that should be furnished by the milk. The specific gravity, which is a fair guide to the quality of the milk, with the reservations above mentioned, is measured by means of the lactometer or lactodensimeter. The specific gravity of good cows' milk should not be less than 1029. In order to prevent the rapid fermentation of milk various methods of preservation have been adopted. The addition of alkalies, or antiseptics, retards the lactic-acid fermentation, while the abstraction of a portion of the water and addition of sugar (condensed milk) preserves it for an indefinite time. The mere addition of vyater restores it to nearly its original condition. Tyrotoxicon in Milk.-This substance, first found in poison- ous cheese, and later in milk, ice- cream, custards, etc., is believed by Professor Vaughan to be the cause of true cholera infantum, and many of the clinical phe- nomena of this disease lend strong support to such a view. The conditions under which the poison is developed have not yet been sufficiently studied to enable correct conclusions to be drawn. Butter.-Butter is of especial value as food on account of the large amount of easily digestible fat which it contains. It is almost always used as accessory to other articles of food, to ren- der them more palatable. When pure and fresh, it is one of the most delicious of creature comforts. It soon undergoes the butyric-acid fermentation, however, becoming " rancid," as it is termed, when it is unfit for food. The great demand for butter and its consequent high price Fig. 3.-Chevallier's Creamometer. 96 TEXT-BOOK OF HYGIENE. have led to its extensive sophistication. Butter is now very largely substituted by an artificial product termed oleo-margarine, or butterine. This artificial butter is made from beef-suet by the following process: Fresh beef-fat is melted at as low a temperature as possible, never higher than 52° to 53° C. [126° to 128° F.]. All membrane and tissue are then removed, and the resulting clear fat is put into presses, where the stearine is extracted. The liquid fat, free from tissue, and with nearly all its stearine removed, is known as "oleo-margarine oil." The next step in the process is " churning." The oil is allowed to run into churns containing milk and a small quantity of coloring material (annatto), where, by means of rapidly-revolving pad- dles, it is churned for about an hour. When this part of the process is complete, the substance is drawn off from the bottom of the churn into cracked ice. When cool it is taken from the ice, mixed with a proper quantity of salt, and is then worked like butter and put into firkins for the market. It is also molded into attractive prints in imitation of dairy-butter.1 When the materials from which oleo-margarine is made are sweet and clean, and when the process of manufacture is prop- erly conducted, the resulting product is an entirely harmless article, and probably differs very little in nutritive value from butter itself. Cheese.-The value of cheese as a food depends upon the large amount of proteids and fat which it contains. The rich varieties of cheese, such as Fromage de Brie and Roquefort, con- tain on an average 30 per cent, of fat and 27 per cent, of proteid compounds. Parmesan contains only about 8 per cent, of fat and nearly 33 per cent, of proteids, while Edam and Chester cheese, which may be considered as standing about midway between the above, contain 20 per cent, of fat and nearly 28 per cent, of proteids. From these figures it appears that cheese is one of the most nutritious aliments obtainable, but it cannot 1 Dr. W. K. Newton, Fifth Annual Report of the State Board of Health of New Jersey, 1881, p. 107. 97 FOODS OF ANIMAL ORIGIN. be eaten in large quantities at a time, as it is exceedingly liable to cause disturbances of the digestive organs. The constipating property of cheese is well known to the public. The relative value of different kinds of cheese in alimentary principles is given in the following table:- Table XI. Kind of Cheese. Proteids (per cent.). Fats (per cent.). Sugar (per cent.). Salts (per cent.). Cheshire . 27.68 27.46 5.89 5.01 Edam . . 24.07 30.26 4.48 4.91 Holland 29.48 26.71 2.27 4.62 Roquefort. 27.69 33.44 3.15 5.35 Neufchatel 17.44 40.80 5.21 2.05 Parmesan . 41.19 19.52 1.18 6.31 Cheese is not often adulterated. The only articles used with success in its sophistication are lard and oleo-margarine, which are incorporated with the casein during the process of manufacture. It sometimes undergoes chemical changes which render it intensely poisonous when eaten. Prof. V. C. Vaughan, of the University of Michigan, has ascertained that the substance causing the poisonous symptoms is a chemical compound termed by him tyrotoxicon. This same poison has also been found by Professor Vaughan and other chemists in ice-cream and fresh milk, which produced poisonous symptoms when consumed. The poison is supposed to be a ptomaine produced by the agency of a micro-organism, which has, however, not yet been isolated. Meat.-The flesh of mammals, reptiles, birds, fish, and invertebrate animals is used as food by man. Falck1 has classi- fied the varieties of animals which furnish food to the inhabitants of Europe. There are 47 varieties of the mammalian class, 105 of birds, 7 of amphibia, 110 of fish, and 58 of invertebrates. 1 Das Fleisch, Gemeinverstsendliches Handbuch der Wissenschaftlichen und Praktischen Fleiscbkunde. 98 TEXT-BOOK OF HYGIENE. Meat is the most important source of proteids in the food. In the more commonly used varieties of meat the proteids and fats constitute from 25 to 50 per cent, of the entire bulk, the proportion depending largely upon the age of the animal and its bodily condition. The following table shows the influence of these two factors upon the relative proportions of the fats and proteids contained in the meat:- Proteids (per cent.). Fats (per cent.). Moderately fat beef 21.39 5.19 Lean beef 20.54 1.78 Veal 10.88 7.41 Very fat mutton 14.80 36.39 Fat pork 14.54 37.34 Lean pork 19.91 6.81 Hare 23.34 1.13 Lean chicken 19.72 1.42 Table XII.1 The flesh of animals, which is neutral in reaction immedi- ately after death, soon becomes acid in consequence of the formation of lactic acid. The acid, acting upon the sarcolemma and the muscular fibre, renders it softer and more easily per- meable by fluids when cooking, and more susceptible to the action of the gastric juice when the meat is taken into the stomach. Certain kinds of meat-mutton and venison, for example- are often kept so long before being eaten that a considerable degree of putrefaction has taken place when they are brought upon the table. The wisdom of this practice is questionable from a hygienic point of view. Meat is sometimes eaten raw, but it is usually first cooked. The methods of cooking in general use are boiling, frying, roasting, broiling, and baking. By either of these methods of 'Abridged from Loebisch; article "Fleisch" in Realencyclopaedie d. ges. Heilkunde, vol. V, p. 340. Fuller details will be found in Table VIII. FOODS OF ANIMAL ORIGIN. 99 cooking, when properly carried out, the nutritious properties of the meat are preserved, and it is rendered digestible. The culinary art deserves the closest attention of students of hygiene. A number of soluble preparations of meat (beef-extract, beef-essence, beef-juice) are found in the market, and highly recommended as containing all the nutritious qualities of the meat from which they are prepared. These, and similar products of domestic preparation (broths and teas), contain in reality very little nutritive material, but are of use almost solely as stimulants to the appetite and digestion. They have a place in the dietary of the sick, but their nutritive value is small. On the other hand, a number of partly or wholly predi- gested (peptonized or pancreatized) preparations of meat are offered for sale, many of which have a high nutritive value. They cannot, however, be used as articles of diet except for a short time, or as a temporary succedaneum for meat in diseases attended with weakness or derangement of the digestive organs. Meat may be unfit for food from various causes. Thus the flesh of animals dying from certain diseases-splenic fever, pleuro* pneumonia, tuberculosis in its advanced stages, cow- or sheep- pox-should not be used as food when it can be avoided. Cases are on record proving the poisonous character of meat from animals which suffered, at the time of death, from some of the above-mentioned diseases. The most important condition to be borne in mind is that certain parasites (trichina spiralis, echinococcus, cysticercus), which frequently infest the flesh of animals, especially hogs, not infrequently give rise to serious or even fatal diseases in persons consuming such meat. Any meat containing these parasites, or suspected of containing them, should therefore not be used as food unless precautions be first taken to destroy the life of the parasite. Of the parasites mentioned the trichina spiralis is the most important in this connection, as it frequently occurs in the flesh of hogs, rats, dogs, cats, and other carnivorous animals. Rats are said to be infested with the parasite more frequently than 100 TEXT-BOOK OF HYGIENE. any other animals. The trichinae are found in two forms, one, the mature form, inhabiting tlie intestinal canal. The immature form, or muscle trichinae, are found in striped muscle, coiled into spirals and encysted in a fibrous capsule. They gain access to their host in the following manner: Flesh containing living trichinae is taken into the stomach, where the muscular tissue and the fibrous envelope are dissolved, and the inclosed worms set free. These mature in the intestinal canal, where sexual reproduction takes place, and the young embryos pass through the intestinal walls and other tissues until they become imbedded in striated muscle. Localized epidemics of trichinosis have been reported in this country and Europe, and in nearly every instance the source of the disease has been traced to the inges- tion of uncooked pork. Meat known to be trichinous should not be used unless in times of great scarcity. It may, however, be rendered innocuous by thorough cooking. A temperature of 60° to 70° (140° to 160° F.) destroys the life of the parasite and renders the meat safe. On account of the frequent occur- rence of trichinae in pork, this meat should never be eaten unless thoroughly cooked. It has been ascertained that salted and smoked pork is not free from danger, as the parasites are not killed in the process of curing the meat. Hence, ham and sausage should not be eaten raw, as the danger from these articles is almost equally as great as from fresh pork. Cysticercus cellulosa, the transition form of one variety of tape-worm, and which is the parasite in measly pork, may also gain entrance to the human body, and, failing to undergo devel- opment, cause very serious lesions of various organs and tissues. The frequency of tape-worm is evidence that pork is often thus diseased. The use of partially decayed meat or fish has often been the cause of serious or fatal illness. Sometimes the illness par- takes of the character of septic infection. In these cases it is probable that the morbid process is due to the action of the organisms of putrefaction. In other cases the symptoms are FOODS OF ANIMAL ORIGIN. 101 widely different. These cases have been the source of much perplexity to physicians and toxicologists until very recently. Within the past six years, however, Selmi, Husemann, Brouardel, Casali, and others have drawn attention to certain intensely poisonous chemical compounds found in decomposing flesh, and which have been named by Selmi ptomaines. While there is still much uncertainty concerning the nature of these compounds, it seems pretty well established that when flesh undergoes de- composition, in the absence of oxygen, certain unstable chemical combinations are formed which act as violent poisons. Selmi, followed by most toxicologists, believes these compounds to be alkaloids, analogous to the vegetable alkaloids, such as morphine, atropine, etc. Casali, on the other hand, disagrees with this opinion, and believes the ptomaines to be amido compounds. Husemann regards Casali's hypothesis as plausible, inasmuch as the formation of amido compounds in animal and vegetable bodies during decomposition is well established. The form of poisoning due to the organisms of putrefaction is not infrequent. An extensive outbreak of this nature occurred at Andelfingcn, in Switzerland, in 1839. A musical festival was held, at which there were over 700 present. Out of these 4-14 were suddenly attacked by violent gastro-enteric and nervous symptoms. Ten of the patients died. The illness was traced to roast veal, which had been kept in a warm place for two days after roasting, and which was probably in a state of partial decomposition. The class of cases which seem more probably due to the action of ptomaines or related poisons, have been frequently observed after eating sausages or canned meats. Sausage poi- soning is not rarely observed in Germany. It has been ascer- tained that the internal portions of the sausage are the most poisonous. It is supposed that the ptomaines, which are formed in the absence of oxygen, are the active agents in the pro- duction of the train of symptoms. Poisoning by canned meat seems to be due to a similar poison. 102 TEXT-BOOK OF HYGIENE. In July, 1885, an outbreak of disease, due to eating un- wholesome beef, was caused at Momence, Illinois. Chemical examination of specimens of the meat showed the presence of an alkaloidal body, which was believed to be a ptomaine, but its nature was not definitely determined. Fish, oysters, crabs, and lobsters frequently give rise to symptoms of poisoning. In most of these cases the poisoning is probably due to partial decomposition, but it is a well-known fact that oysters and crabs are unfit for food at certain seasons. Some persons, however, are subjects of a peculiar idiosyncrasy, in consequence of which shell-fish always produce certain un- pleasant symptoms, among which nettle-rash and a choleraic attack are most prominent. That form of fish-poisoning known among the Spaniards in the West Indies as siguatera is, however, very grave. The mortality is large, and in many cases death succeeds rapidly upon the attack. The symptoms are as follow: Sometimes suddenly, sometimes preceded by dizziness and indistinct vision, great prostration and paralysis occur. Often death follows the onset of the symptoms in two and three hours; exceptionally in less than twenty minutes. In most cases consciousness is totally lost; in others it persists, with interruptions, until death. Sensa- tion and the powers of speech and deglutition fail. The jaw- muscles become paralyzed, the pulse is slowed, and the tem- perature diminished. There is sometimes vomiting, but no purging. The secretion of the kidneys is also checked. Dr. McSherry states1 that he has seen all these symptoms produced by eating oysters, lobsters, and crabs unseasonably. In Russia a form of poisoning has often been observed which results from eating salted sturgeon. In the fresh state these fish are perfectly wholesome, but when salted and eaten raw they produce a very fatal illness. The mortality is said to reach 50 per cent, of those attacked. No cases traceable to this cause have been observed in this country. 1 Health and How to Promote it, p. 143. FOODS OF ANIMAL ORIGIN. 103 It has been shown, beyond question, that the flesh of beeves suffering, when killed, from splenic fever, will produce this disease in the human subject. In 1874 an extensive and violent outbreak of an acute disease, characterized by vomiting and purging, fever and dizzi- ness, occurred at Middelburg, in Holland. Three hundred and forty-nine persons were attacked, of whom 6 died. The out- break was traced to eating liver-sausage (Leberwurst), in which the characteristic bacillus of splenic fever was found on micro- scopic examination. In July, 1877, an outbreak of choleraic disease, from eating carbuncular meat, occurred in the town of Wurzen. In the latter epidemic the bacillus of splenic fever {Bacillus antliracis') was found in the intestinal canal and in the blood of those attacked. In Detmold, in Germany, an outbreak of violent gastro- intestinal inflammation, accompanied by high fever, occurred. Among the 150 persons attacked 3 died. The disease was traced to eating the meat of a cow suffering, before death, from pleurisy (probably pleuro-pneumonia). In view of the somewhat extensive prevalence of this disease among cattle in this country at the present time, the record of this outbreak may suggest to sanitary authorities some measures for the prevention of similar epidemics on this side of the Atlantic. In July, 1880, 72 persons who had eaten of certain beef and ham-sandwiches in Welbeck, England, were attacked by choleraic diarrhoea; 4 of the cases died. Inflammation of the lungs and small intestines were the most prominent pathological conditions found post-mortem. The smaller blood-vessels of the kidneys were filled with finger-shaped bacilli, which, when cul- tivated and inoculated into guinea-pigs, rats, and white mice, produced similar pathological conditions. At Nottingham, England, in 1881, a number of persons were attacked by a similar train of symptoms after eating baked pork. One case terminated fatally out of the 15 attacked. It is uncertain whether the meat in these two instances was from diseased 104 TEXT-BOOK OF HYGIENE. animals or whether it had undergone partial decomposition. The former is the more probable supposition, although the organisms found were neither those of splenic fever nor swine plague, but resembled those of symptomatic anthrax (black leg or black quarter). Whether the flesh of tuberculous animals can communicate tuberculosis to the consumer is still an unsettled question. Foreign veterinarians and hygienists who have studied the question incline to the view that there is danger of such trans- mission. At the International Sanitary Congress of 1883, at Brussels, the subject was discussed, and M. Lydtin, the chief veterinary surgeon of the Grand Duchy of Baden, submitted the following propositions, which were adopted by the Congress: 1. That the flesh and viscera of tuberculous animals may be used as food, provided the disease is only commencing, the lesions extending but to a small part of the body, the lymphatic glands being still healthy; provided the tubercle centres have not undergone softening, and provided the carcass is well nour- ished and the flesh presents the characters of meat of the first quality. 2. That the flesh of animals showing very pronounced tuberculous infection should be saturated with petroleum, and afterward burned under the direction of the police. 3. That the milk from cows affected with pulmonary phthisis, or suspected of having it, should not be consumed by man or other animals, and the sale of it should be strictly prohibited. The congress for the study of tuberculosis, which met in Paris in 1888, adopted resolutions of a more decided character against the use of meat and milk from tuberculous animals. Certain animals can devour with impunity substances which are intensely poisonous to human beings. The flesh of the animals may be impregnated with these poisons, and cause serious and fatal illness in persons partaking of it. In this way may, perhaps, be explained the cases of poisoning sometimes following the eating of partridges and other birds. The prevention of disease from tainted meat is one of the FOODS OF ANIMAL ORIGIN. 105 most important problems of public hygiene. Food animals should be inspected by qualified inspectors before slaughtering, to exclude animals suffering from diseases that would vitiate the meat. When the meat is exposed for sale upon the dealer's stall it should be again inspected, and all found unfit for use as food confiscated and destroyed. Meat, in which the presence of trichinae or other parasites is suspected, should be examined microscopically.1 Eggs.-Although eggs contain a large amount of the pro- teid and fatty alimentary principles,2 their value as food has probably been greatly overrated. The savory taste and ready digestibility of eggs has, however, rendered them a popular article of food. For obvious reasons, the eggs of the common barn-yard fowl are most frequently used, those of ducks and geese being far inferior in flavor to the first named, and being likewise less easily obtained. The method of cooking eggs is generally supposed to have considerable influence upon their digestibility. According to Dr. Beaumont's experiments made on Alexis St. Martin, raw es^s are digested in one and a half to two hours, fresh-roasted in two hours and fifteen minutes, soft-boiled or poached in three hours, and hard-boiled or fried in three and a half hours. These experiments are, however, of very little value as a basis for general conclusions. It is probable that a hard-boiled egg is quite as easily digested in the healthy stomach as a raw one, if care be taken to masticate it well and eat bread with it, so that it is introduced into the stomach in a finely-divided state. Eggs readily undergo putrefaction, when sulphuretted hydrogen is formed in them in large quantities. When this has taken place they are manifestly unfit to be used as food. 1 The prevention of the diseases of animals by National and State authorities is one of the most logical and thorough-going means of preventing disease from unwholesome meat. The American Public Health Association has for some years devoted considerable attention to the investigation of the diseases of animals and means for their prevention. The Department of the Interior of the National Government has likewise made the diseases of cattle and hogs a subject of study and published some valuable reports thereon. 2 See analysis in Table VHI. 106 TEXT-BOOK OF HYGIENE. FOODS OF VEGETABLE ORIGIN. Bread.-The various cereal grains, when ground into flour, are used in making bread. The flours of wheat, rye, barley, buckwheat, and Indian corn are almost exclusively used in bread- making. The bran or cortical portion of grain contains a larger percentage of proteid principles than the white internal portion; hence, flours made from the whole grain (bran-flour, Graham flour) if finely ground are more nutritious than the white flours. The latter are, however, more digestible, and hence furnish a larger proportion of nutriment, because the principles contained in white flours are absorbed and assimilated to a greater degree. Good bread should be light, porous, and well baked. The lightness and porosity are due to carbon-dioxide gas imprisoned in cavities of the dough during the process of bread-making. By adding yeast to the dough a fermentation is caused in the latter, in consequence of which a portion of the starch is con- verted into sugar, and then into alcohol and carbon dioxide. During the process of mixing the dough the entire mass becomes permeated by the gas, which, on heating, expands and leaves the numerous large and small cavities throughout the loaf which indicate properly-made bread. Instead of yeast some persons use leaven, which is simply a portion of fermenting dough, saved from previous baking. A small quantity of this added to a mass of* dough starts up the fermentation in a similar manner to that of yeast. The production of carbon dioxide by fermentation in the dough goes on at the expense of part of the starch. It has been proposed, therefore, to supply the carbon dioxide from without, thus saving the entire amount of the carbohydrates present in the flour. This is accomplished in two ways- first, by the use of some alkaline carbonate or bicarbonate (bicarbonate of sodium, carbonate of ammonium), the carbon dioxide being set free on the application of heat; or, secondly, by forcing the gas, previously prepared, into the dough by means of machinery. FOODS OF VEGETABLE ORIGIN. 107 Flour is not infrequently adulterated with chalk, gypsum, pipe-clay, and similar articles. These are easily detected by adding a mineral acid, which produces effervescence when it comes in contact with the alkaline carbonate used as adulterant. Potato- and bean- meals are also used as adulterants of the higher grades of flour. Bakers often mix alum with inferior grades of flour. This imparts a greater degree of whiteness to the bread, and, in .addition, enables it to retain a large proportion of water, thereby increasing the weight of the loaf. Formerly diseased grain (ergotized rye) often caused out- breaks of disease when the flour made from the diseased grain was used in bread-making. At the present time such accidents rarely occur. In some parts of Italy it is said that an endemic disease-pellagra-is caused by the consumption of diseased Indian corn. The evidence in favor of this view is, however, not unquestioned. Potatoes and rice are often used with satisfaction as substi- tutes for bread. They both contain a large proportion of carbo- hydrates. Indian corn (hominy) and oatmeal are likewise wholesome and nutritious foods of this class. The leguminous seeds (beans, peas, lentils) furnish a food containing a large percentage of proteids. According to the analyses of Koenig1 the average composition of the most fre- quently used legumes in the dried condition is as follows:- Table XIII. Beans. Peas. Lentils. Ground-nuts.2 Water, per cent. . . . 13.6 14.3 12.5 6.5 Solids, per cent. . . . 86.4 85.7 87.5 93.5 Proteids, per cent. . . 23.1 22.6 24.8 28.2 Fats 2.3 1.7 1.9 46.4 Carbohydrates, per cent. 53.6 53.2 54.7) 15 7 Cellulose, per cent. . . 3.9 5.5 3.6 j Ash 3.5 2.7 2.5 3.2 1 Die Menschlichen Nahrungs and Genussmittel, ii, p. 288. 8 The American pea-nut, the fruit or nut of Arachis hypogcea. 108 TEXT-BOOK OF HYGIENE. Beans, peas, and lentils are often added to other articles of food with advantage. In recent years an important article of food for armies has been made of various legumes ground into flour and mixed with fat, dried and powdered meat, salt, and spice. This constitutes the so-called " Erbswurst," or pea-sausage, which formed such an important part of the dietary of the German army in the Franco-German war of 1871. Bean- and pea- meals are also used sometimes as additions to other flours in bread- making. The dried leguminous fruits cannot be used as regular articles of diet, however, as they soon pall upon the taste, and produce indigestion, nausea, and other intestinal derangements. Green Vegetables.-The plants usually classed together as " vegetables," the products of the market-garden or truck-farm, comprise cabbages, turnips, parsnips, onions, beets, carrots, tomatoes, lettuce, green peas and beans, and similar articles. They all contain a large proportion of water, a variable propor- tion of sugar, and a small percentage of proteid principles. Much of their palatability and digestibility depend upon the methods by which they are prepared for the table. All garden vegetables should be used soon after being gathered, as they rapidly undergo decomposition, and are liable to produce derangements of the digestive organs if used under these conditions. Fruits and nuts generally contain large quantities of sugar and fats. They form agreeable additions to other articles of diet, but are insufficient to sustain life. The use of fruits usually produces copious intestinal evacuations, and they are, therefore, especially to be recommended to persons of sedentary occupations, in whom torpidity of the bowels is so frequently present. Condiments.-Various aromatic herbs and seeds are used as additions to other articles of food, to increase their sapidity and to promote a larger flow of saliva and gastric juice, and so assist digestion. Mustard, pepper, allspice, and vinegar are the principal condiments. Within certain limits they are not in- jurious, but the tendency in the use of all stimulants is to COOKING. 109 exceed a healthful limit. Condiments, as well as other stimu- lants, should be used in moderation. COOKING. Much more attention than is generally given should be paid by physicians to the culinary art. The manner in which food is cooked has no little influence upon its digestibility. There can be no question that the extreme prevalence of functional indi- gestion in this country is almost exclusively dependent upon bad cooking. The various methods of cooking are boiling, frying, roast- ing, broiling, and baking. By either of these methods food can be cooked so as to be palatable as well as digestible; on the other hand, the choicest article can be utterly spoiled and rendered unfit to be taken into the human stomach. It depends, therefore, not so much upon the method of cooking, as upon the knowledge and art of the cook. Boiling.-Meats of all kinds are rendered tender and di- gestible by boiling. In order to retain the flavor of meat, the water should be boiling when the meat is put into it. By the heat of the boiling water the albumen on the outside of the meat is coagulated and the juices and flavor retained within. After a few minutes the temperature of the water should be re- duced to 71° to 77° C. (160° to 170° F.), and maintained at that height until the meat is tender. By this process a much more savory piece of beef, mutton, or fowl can be obtained than where the meat is put into cold water and thus gradually heated. The latter method is, however, the proper one to be followed when good soup or broth is desired. In boiling vegetables, as much care is necessary as in boil- ing meat or fish. Potatoes and rice should be steamed, rather than boiled. The difficulty of obtaining a good cup of coffee, especially in the northern portion of the United States, illustrates the pre- vailing ignorance upon one of the simplest points in the art of 110 TEXT-BOOK OF HYGIENE. cooking. Coffee should never be served in the form of a de- coction; that is to say, it should never be boiled. Properly made it is an infusion, like tea, which no one ever thinks of boiling. The difference between an infusion (especially if made by per- colation) and a decoction of coffee can only be appreciated by those who have enjoyed the one and endured the other. Frying.-Frying, if properly done, is really nothing less nor more than boiling in oil or fluid fat of some kind. Olive- oil is preferable, but is not essential; butter, beef-drippings, lard, or probably cotton-seed oil may be substituted for it without disadvantage. The principle of frying depends upon the fact that the temperature of oil can be raised to such a height as to produce instant coagulation of the surface of meat, fish, or other object immersed in it while hot; this film of coagulated albu- men imprisons the juices and flavors of the meat or fish, and pre- vents the fat entering and soaking the fibres with grease. Small fish or birds, properly fried, are justly regarded as delicacies by connoisseurs, but the process of saturating these objects with fat while gradually heating them produces a dish that is anything rather than grateful to the palate, or conducive to good digestion. Roasting.-The fame of "the roast beef of Old England" has passed into song, but, at the present day, beef and other meats are rarely roasted, either in this country or abroad. As Sir Henry Thompson well expresses it,1 "the joint, which for- merly turned in a current of fresh air before a well-made fire, is now half stifled in a close atmosphere of its own vapors, very much to the destruction of the characteristic flavor of a roast." It is probable that the old method of roasting before an open fire produced not only the most savory, but likewise the most nu- tritious and digestible, meat. It is much to be regretted that the process has fallen so greatly into disuse. Broiling and Baking.-These methods of cooking are modifications of the process of roasting. Meats or fish, care- fully broiled or baked, preserve their natural juices and flavors * Food and Feeding, p. 45. London, 1880. ALIMENTARY BEVERAGES. 111 to a great extent, and retain their digestibility and nutritious properties. Of all methods of cooking these are probably best known and most satisfactorily applied in this country.1 ALIMENTARY BEVERAGES. The alimentary beverages may be divided into two classes, -those depending for their effects upon the alcohol they contain, and those whose active principles reside in certain alkaloids. They are used chiefly as digestive and nervous stimulants. BEVERAGES CONTAINING ALCOHOL. The physiological action of alcohol has been pretty fully worked out by Binz and his pupils, and by other experimenters. From these researches, it appears that the first effect of taking alcohol, sufficiently diluted, into the stomach, is to increase the flow of the saliva and gastric juice. This effect is probably re- flex, and results from a stimulation of nerve terminations in the stomach. The alcohol is rapidly absorbed, and is carried in the blood, without undergoing chemical change, to the nervous centres, lungs, and tissues generally. In the brain the alcohol probably enters into combination with the nervous tissue, modifying the normal activity of the various centres, either increasing the activity, if the alcohol is in small quantity (stim- ulating effect), or diminishing it if in larger quantity (depressing effect), or entirely suspending the activity of the centres, if in sufficiently large quantity (paralyzing effect). Alcohol stimulates the vasodilator nerves, causing dilata- tion of the smaller vessels; in consequence of this the blood is largely sent to the periphery of the body; the blood-pressure diminishes, and heat-radiation is increased. At the same time a portion of the alcohol is used up in the lungs in the produc- tion of animal heat, thus economizing the expenditure of fats 1 Every one interested in the proper application of the principles of cookery should study the Lomb prize essay of the American Public Health Association, by Mary Hinman Abel, upon "Practical, Sanitary, and Economic Cooking." This little book can be obtained of Dr. I. A. Watson, Secretary, Concord, N. H.; price, 25 cents. See, also, an essay on "The Art of Cook- ing," by Edward Atkinson, LL.D., in Popular Science Monthly, November, 1889. 112 TEXT-BOOK OF HYGIENE. and proteids, and acting as a true respiratory food. Alcohol docs not contribute nutritive material to the body; it only per- mits that which is stored up to be saved for other uses, by fur- nishing easily-oxidizable (combustible) material for carrying on the respiratory process, and supplying animal heat. During the use of alcohol the excretion of urea is dimin- ished. This shows that waste of tissue is retarded in the body. Regarding the statement of some authorities that alcohol does not undergo any change in the body, but is excreted unchanged, Binz asserts1 that alcohol appears in the urine only when exceptionally large quantities have been taken, and then in very small proportion. It is not excreted by the lungs, the peculiar odor of the breath being due not to the alcohol, but to the volatile aromatic ether, which is oxidized with greater difficulty, and so escapes unchanged. While alcohol produces subjectively an agreeable sensation of warmth in the stomach and on the surface of the body, the bodily temperature is not raised. The subjective sensation is due to the dilatation of the blood-vessels and the sudden hyper- semia of those parts. During fevers and other exhausting diseases, alcohol is invaluable to prevent waste of tissue and sustain the strength. It does not act merely as a stimulant to the circulation and nervous system, but, as above pointed out, saves the more stable compounds by furnishing a readily oxidizable respiratory food. When taken in small doses by healthy persons, alcohol diminishes the temperature by increasing heat-radiation. When large quantities are taken, the bodily temperature is reduced by diminishing heat production, as well as by increased radiation. This is shown in the condition known as dead-drunkenness, in which the temperature is sometimes depressed as much as 20 0 F. below the normal. Cases in which the temperature sank to 75°, 78.8°, and 83° F. have been reported, with recovery in all cases. 1 Realencyclopaedie d. ges. Heilk., Bd. I, p. 183. 113 BEVERAGES CONTAINING ALCOHOL. The constant use of alcohol produces in all the organs an excess of connective tissue, followed by fatty degeneration and the condition known as cirrhosis. The organs most frequently affected are the stomach, liver, and kidneys. Serious pathological alterations also occur in the circulatory, respiratory, and nervous systems. Alcohol is not necessary to persons in good health. Prob- ably most persons, regardless of their state of health, do better without it. Its habitual use in the form of strong liquors is to be unreservedly condemned. The lighter wines and malt liquors, if obtained pure, may be consumed in moderate quanti- ties without ill effects. Even in these forms, however, the use of alcohol should be discouraged or, perhaps, prohibited in the young. Neither in hot nor in cold climates is alcohol necessary to the preservation of health, and its moderate use even produces more injury than benefit. The Polar voyager and the East India merchant are alike better off without alcohol than with it. It has long been a prevalent belief that the use of alcohol enables persons to withstand fatigue better than where no alcohol is used. A large amount of concurrent testimony absolutely negatives this belief.1 The predisposition to many diseases is greatly increased by the habitual use of alcohol. Sun-stroke, the acute infectious diseases, and many local organic affections attack, by preference, the intemperate. A recent collective investigation by the British Medical Association brought out the fact that croupous pneu- monia is vastly more fatal among the intemperate than among those who abstained from the use of alcoholic liquors. A further investigation by Baer has shown that the average expectation of life among users and dealers in alcoholic liquors is very much shortened. The following table gives a compara- tive view of the expectation of life in those who abstained from and those who used alcohol:- 1 See Parkes' Hygiene, 6th ed., vol. i, pp. 315-327. 114 TEXT-BOOK OF HYGIENE. Table XIV. EXPECTATION OF LIFE. Age. Abstainers. Alcohol Users. At 25 32.08 years. 26.23 years. "35 25.92 " 20.01 " "45 19.92 " 15.19 " "55 14.45 " 11.16 « "65 9.62 " 8.04 " Table XV shows the influence of alcohol upon the mortality from various diseases:- Table XV. General Male Popu- lation (per cent.). Alcohol Venders (per cent.). Brain disease 11.77 14.43 Tuberculosis 30.36 36.57 Pneumonia and pleuritis .... 9.63 11.44 Heart disease 1.46 3.29 Kidney disease 1.40 2.11 Suicide 2.99 4.02 Cancer 2.49 3.70 Old age . 22.49 7.05 Alcohol as a beverage is consumed in the various forms of spirits, wines, and fermented liquors. The varieties of spirits most frequently used are brandy, whisky, rum, and gin. They are all procured by distillation. Brandy is distilled from fermented grape-juice, and has a characteristic aromatic flavor. When pure and mellowed with age it is the most grateful to the palate of all distilled spirits. Whisky is distilled from barley, rye, oats, corn, or potatoes. Each of these has a peculiar flavor, depending upon the par- ticular volatile ether formed during the distillation. Rye-, barley-, and corn- whiskies are almost exclusively used in this country. 115 BEVERAGES CONTAINING ALCOHOL. Rum is distilled from molasses, and is a favorite ingredient in hot punches. It is often used with milk, eggs, and sugar, in the preparation of eggnog, a highly-nutritious, stimulating drink, which is often prescribed with great benefit in acute and chronic wasting diseases. Gin is an ardent distilled spirit, flavored with oil of juniper. It has a widely-spread popular reputation as a cure for kidney diseases, but is probably oftener responsible for the production of these diseases than for their cure. All of the above-mentioned liquors contain from 40 to 60 per cent, of alcohol, and should always be diluted before being taken into the stomach, in order to prevent the local irritant effects of the alcohol upon the gastric mucous membrane. Wine is the product of the alcoholic fermentation of the saccharine constituents of fruits. Wine is usually derived from the grape, though other fruits may also furnish it. The stronger wines (sherry, port, madeira) contain from 16 to 25 per cent, of alcohol. The lighter wines (hock, red and white Bordeaux and Burgundy wines, champagnes) contain from 6 to 15 per cent, of alcohol. Some also contain considerable free carbonic acid (sparkling wines), of which the champagnes are types. The red and white Bordeaux and Rhine wines are probably the least objectionable of these beverages for habitual use. They contain sufficient alcohol to be lightly stimulant, have a pleasant acid flavor, and are least likely to produce the bad effects which usually follow in the wake of the habitual use of the stronger wines or ardent spirits. Preference should be given to the wines of domestic manu- facture, on account of the great probability of adulteration of the favorite brands of foreign wines. Many of the California, Vir- ginia, New York, and Ohio wines compare very favorably in flavor with those imported from abroad. The more reasonable cost of these domestic wines is also a point in their favor. Cider is the fermented juice of apples. It frequently pro- duces unpleasant gastric and intestinal disturbances when drunk, 116 TEXT-BOOK OF HYGIENE. on account of the large quantity of malic acid contained in it. Although it is usually ranked as a " temperance drink," it is quite capable of causing intoxication when consumed in large quantities. Beer is the fermented extract of barley, mixed with a decoction of hops and boiled. It should be prepared only of malt, hops, yeast, and water, and should contain from 3 to 4 per cent, of alcohol, 5 to 6 per cejit. of extract of malt and hops, 2 to 4 per cent, of lactic and acetic acids, and from | to per cent, of carbonic acid. This ideal is, how- ever, rarely attained in the article sold by the liquor dealer. Numerous adulterations are practiced on the unsuspecting con- sumer. The hops are frequently substituted by aloes, calamus, and ginger, or by the more deleterious picric acid or picrotoxin. The rich brown color, sweetness, body, and creamy foam are produced by caramel and glycerin. The more expensive barley- malt is substituted by starch and rice, or grape-sugar and molasses. Ale, porter, and brown-stout are merely varieties of beer- some containing more sugar, others more extractive matter. Beer and its correlatives have considerable dietetic value, owing not merely to the alcohol they contain, but largely to the sugar and acids entering into their composition. When used to excess they often cause a considerable accumulation of fat. Kumys is the national beverage of the nomadic tribes of Tartary. It consists of the milk of mares which has undergone fermentation, partly lactic and partly alcoholic in character. Recently it has been introduced into Europe and also into this country, where it is made of cows' milk. It is a palatable, nutritious stimulant, and is often very useful as a dietetic article in disease. Kefyr is a product of the fermentation of milk which bears some resemblance to kumys. The following table (Table XVI) gives a comparative view of the composition of true kumys, the same prepared from cows' milk, and kefyr:- ALKALOIDAL BEVERAGES. 117 True Kumys (per cent.). Cows' Milk Kumys (per cent.). Kefyr (per cent.). Proteids 2.20 2.35 3.12 Fats 2.12 2.07 1.95 Sugar 1.53 1.81 1.62 Lactic acid 0.90 0.40 0.83 Alcohol 1.72 1.90 2.10 CO2 0.85 0.80 0.92 Table XVI. The virtues of the alkaloidal beverages depend upon certain alkaloids which differ very little in their chemical composition or physiological effects, and upon certain volatile aromatic con- stituents of the various articles used. The principal articles employed in the preparation of these beverages are coffee, tea, chocolate, mate, and coca. It is estimated that 500,000,000 people drink coffee, 100,000,000 tea, 50,000,000 chocolate, 15,000,000 mate or Paraguay tea, and 10,000,000 coca. All of these are active nervous stimulants and retarders of tissue- waste. They are all liable to produce serious functional dis- turbances of the nervous, digestive, and circulatory systems if used to excess. Anaemia, digestive derangements, constipation, pale, sallow complexion, loss of appetite, disturbed sleep, nervous headaches and neuralgias are the most marked of these effects. On the other hand, when taken in moderate quantity, the alkaloidal beverages enable the consumer to withstand cold, fatigue, and hunger; they promptly remove the sensation of hunger, and diffuse a glow of exhilaration throughout the body. Coffee.-Coffee is the ripe fruit (seed) of the Caffea Arabica, a native of Arabia and Eastern Africa, but now cultivated in other tropical regions of the world. The fruit consists of two flat-convex beans, the flat surfaces of which are apposed to each other. These are enclosed in a fibrous envelope which is some- times used as a cheap substitute for the coffee-bean. The beverage, coffee, is an infusion of the roasted and THE ALKALOIDAL BEVERAGES. 118 TEXT-BOOK OF HYGIENE. ground bean in hot water. Its virtues depend upon the alkaloid, caffein, and an aromatic oil. The latter, being volatile, is driven off by long-continued heat. Hence boiled coffee lacks the grateful aroma of that which is made by simply infusing the ground bean in hot water. The great demand for coffee and its comparatively high price have caused it to be extensively adulterated and substituted by other natural and artificial products. Artificial coffee-beans have been made of clay, dough, or extract of chicory, colored to imitate the natural bean. The fraud is easily detected by placing the beans in water, when the artificial product soon falls to pieces, while the natural beans undergo no change of shape or consistence. Ground coffee as found in the stores is usually adulterated. The materials used for sophistication are: The grounds of coffee previously used, the roasted root of chicory, acorns, rye or barley, carrots, sunflower-seeds, caramel, and a number of articles of similar value, generally harmless. Tea.-The plants which furnish the tea-leaves are natives of China, Indo-China, and Japan. The tea-leaves contain a crystalline alkaloid, them, identical in composition and proper- ties with caffein. The various sorts of tea found in the market (green and black teas, etc.) differ only in the relative proportion of tannin and thein contained in each. The aromatic principle also varies somewhat in the different sorts. Tea is adulterated to quite as great an extent as coffee, the leaves of various plants bearing more or less resemblance to tea- leaves being added to the latter. Much of the tea found in the market is colored artificially with Prussian blue and iron oxide. These additions are harmless, as they are not soluble in water. Chocolate.-Cocoa, from which chocolate is derived, is widely different in composition from tea and coffee. In addi- tion to its active principle, theobromin, which is identical with caffein and thein, it contains nearly 50 per cent, of fat, which renders it an article of high nutritive value. TOBACCO. 119 Mate, or Paraguay tea, guarana, and coca are used to a considerable extent in some parts of South America as substi- tutes for coffee and tea. Their composition is not well known, but their effects are believed to depend upon alkaloidal princi- ples similar to caffein and them. TOBACCO. Closely connected with the subjects treated in this chapter are the effects of the constant use of tobacco upon the human system The depressing effects of tobacco, due principally to the nicotine upon the nervous and digestive systems, have long been recognized. Recently, however, it has been found that very serious symptoms are produced upon the sense of vision by the constant or excessive use of tobacco. A special form of amaurosis, termed tobacco amaurosis, has been frequently noticed since attention was first called to it by Mackenzie. [The following additional works are recommended to the student:- Thos. K. Chambers, on Diet in Health and Disease.-Edward Smith, on Foods.-Forster, Ernahrung, in Pettenkofer u. Ziemssen's Handbuch der Hygiene.-Munk und Uffelmann, Die Ernahrung des Gesunden und Kranken Menschen.] CHAPTER IV. Soil. Hippocrates treated at length, in one of his works, of the sanitary influences of the soil. Others of the older writers, especially Herodotus and Galen, called attention to the same subject, and Vitruvius, the celebrated Roman architect, who flourished about the beginning of the Christian era, taught that a point of first importance in building a dwelling was to select a site upon a healthy soil. From this time until the beginning of the eighteenth cen- tury, very little of value is found in medical literature bearing upon this subject. In 1717, however, Lancisi published his great work on the causes of malarial fevers, in which he laid the foundation for the modern theory of malaria, and pointed out the relations existing between marshes and low-lying lands and those diseases by common consent called malarial. Other authors of the eighteenth and the early part of the nineteenth centuries refer to the connection between the soil and disease, but exact investigations have only been made within the last thirty years. When it is considered that the air that human beings breathe, and much of the water they drink, are influenced in their composition by the matters in the soil, the great importance of possessing a thorough knowledge of the physical and chemical conditions of the soil becomes evident to every one. PHYSICAL AND CHEMICAL CHARACTERS OF THE SOIL. In the hygienic, as in the geological sense, rock, sand, clay, and gravel are included in the consideration of soils. The soil, as it is presented to us at the surface of the earth, 121 122 TEXT-BOOK OF HYGIENE. is the result of long ages of disintegration of the primitive rocks by the action of the elements, of the decomposition of organic remains, and, possibly, of accretions of cosmical dust. The principal factor, however, is the action of water upon rock, in leveling the projections of the earth's surface produced by volcanic action. Soils vary considerably in physical and chemical constitu- tion. A soil may, for example, consist exclusively of sand, of clay, or of disintegrated calcareous matter. Other soils may consist of a mixture of two or more of these, together with vegetable matter undergoing slow oxidation. In forests, a layer of this slowly-decomposing vegetable matter of varying thick- ness is found, covering the earthy substratum. This organic layer is called humus, and when turned under by plough or spade, and mixed with the sand or clay base, it constitutes the ordinary agricultural soil. THE ATMOSPHERE OF THE SOIL, OR GROUND-AIR. The interstices of the soil are occupied by air or water, or by both together. The soil's atmosphere is continuous with, and resembles in physical and chemical properties, that which envelops the earth. Its proportion to the mass of the soil depends upon the degree of porosity of the soil, and upon the amount of moisture present. In a very porous soil, such as, for example, a coarse sand, gravelly loam, or coarse-grained sand- stone, the amount of air is much greater than in a clayey soil, granite, or marble. So, likewise, when the soil contains a large proportion of water, the air is to this extent excluded. The porosity of the various soils, as evidenced by the amount of air contained in them, is much greater than would, at first thought, be supposed. Thus it has been found that porous sandstone may contain as much as one-third of its bulk of air, while the proportion of air contained in sand, gravel, or loose soil may amount to from 30 to 50 per cent. The ground-air is simply the atmospheric air which has THE ATMOSPHERE OF THE SOIL, OR GROUND-AIR. 123 penetrated into the interstices of the soil and taken part in the various chemical decompositions going on there. In consequence of these chemical changes the relative proportions of the oxygen and carbonic acid in the air are changed-oxygen disappearing and giving place to carbon dioxide. It is well known that during the decay of vegetable matter in the air carbon dioxide is formed; one constituent of this compound, the carbon, being- derived from the vegetable matter, while the oxygen is taken from the air. Hence, if this action takes place where there is not a very free circulation of air, as in the soil, the air there present soon loses its normal proportion of oxygen, which enters into combination with the carbon of the vegetable matter to form carbon dioxide. Thirty years ago, MM. Boussingault and Levy, two dis- tinguished French chemists, exammed the air contained in ordinary agricultural soil, and found that the oxygen was diminished to about one-half of the proportion normally present in atmospheric air, while the carbon dioxide was enormously increased. The exact results obtained by Boussingault and Levy were as follow:- In 100 volumes of ground-air there were 10.35 volumes of oxygen, 79.91 volumes of nitrogen, 9.74 volumes of carbon dioxide. In atmospheric air, on the other hand, there are in 100 volumes 20.9 volumes of oxygen, 79.1 volumes of nitrogen, 0.04 volume, or about of 1 per cent, of carbon dioxide. In spite of the striking results obtained by these two chemists, very little attention was paid to them by sanitarians, as very few seemed to have any clear notion of the relations exist- ing between the motions of the air above-ground and that under- ground. In 1871, however, Professor von Pettenkofer, of Munich, published the results of his own examinations into the constitu- tion and physical conditions of the ground-air, and the relations of the latter to the propagation of epidemic diseases. These re- searches, which created a wide-spread interest in the subject, 124 TEXT-BOOK OF HYGIENE. were extended by other observers in all parts of the world. These observers, prominent among whom were Professors Fleck, Fodor, and Soyka, in Germany; Drs. Lewis and Cunningham, in India; Prof. William Ripley Nichols, in Boston; and Sur- geons J. H. Kidder and S. H. Griffith, of the U. S. Navy, in Washington, demonstrated that the increase of carbon dioxide in the ground-air is due to increased vegetable decomposition and to lessened permeability of the soil. A permeable, that is to say, a sandy or gravelly soil is likely to contain less carbon dioxide in its atmosphere than a dense, less permeable clay, although the amount of decomposition going on and the pro- duction of carbon dioxide in the former may considerably ex- ceed the latter. In the loose, sandy soil the circulation of the air is less obstructed, and the carbon dioxide may easily escape and be diffused in the superincumbent air, while the close-pored clay imprisons the carbon dioxide and prevents or retards its escape into the air above. The disappearance of oxygen from the ground-atmosphere is coincident with the production of an equivalent amount of carbon dioxide. It appears from this that in the soil an ox- idation of carbonaceous substances takes place, the product of which is found in the excess of carbon dioxide in the ground-air. Professor Nichols has found the proportion of carbon di- oxide in the air taken from a depth of 3 metres below the surface in the "made-land" of Boston to amount to 21.21 per thousand, the observation having been made in August. In December, at a depth of 2 metres, the proportion was 3.23 per thousand. Fodor, in Buda-Pesth, found the proportion of carbon dioxide to be 107.5 per thousand (over 10 per cent.), the air having been taken from a depth of 3 metres. The ground-air also teems with micro-organisms of various kinds, these being occasionally pathogenic. While in the great majority of instances the micro-organisms found are ordinary mold or fermentation fungi and bacteria of decay and putrefac- tion, disease-producing bacilli have also been observed in a THE ATMOSPHERE OF THE SOIL, OR GROUND-AIR. 125 number of instances. Among the latter are the bacillus of tetanus (Nicolaier), of anthrax (Frank), of malaria (Klebs and Tommasi-Crudeli),1 of malignant oedema (Koch and Gaffky), and of typhoid fever (Tryde). It may not be inappropriate to refer here to the claim of Professor Domingos Freire, of Brazil, to the discovery of the germ of yellow fever in the soil of a burial ground near Bio Janeiro. The exhaustive investigations of Dr. G. M. Sternberg, of the U. S. Army, under the direction of the government, have disposed effectually of the claims and pretensions of the Brazilian scientist, and established the fact that Freire's organism has no pathological significance whatever,-at all events, that it has no relation to yellow fever. Cholera bacilli have not been found in the soil, but C. Frankel has shown experimentally that they can grow and multiply in the soil at various depths. At a depth of 11 metres their development was constant and progressive throughout the year. When the soil is dry, these organisms may be carried hither and thither in the movements of the ground-air, and thus infect the air of contiguous localities, or be transported to a distance. Movements of the ground-atmosphere are principally due to differences of pressure and temperature in the air above- ground. Owing to such differences the air from the soil fre- quently permeates houses, entering from cellars or basements. In winter, when the air of houses is very much more heated (and consequently less dense) than the air out-of-doors, the difference of pressure thus caused draws the ground-air up through the house, while the cold, external atmosphere pene- trates the soil and occupies the place of the displaced ground- air.2 A similar effect occurs in consequence of heavy rains. 1 While the pathogenic significance of Klebs' bacillus malarice is not generally accepted, it is thought proper, for the sake of completeness, to include it among the organisms sometimes found in the soil. ' It is, of course, not strictly correct to say that the air is drawn up through the house by the diminution of pressure; it being rather forced out of the soil by the colder and denser outside air; but the phrase is sufficiently exact and will be readily understood. 126 TEXT-BOOK OF HYGIENE. The water fills up the interstices of the soil near the surface, and forces the ground-air out at points where the pores remain open. These places are the dry ground under buildings, where the air escapes and passes through floors and ceilings into the house above. Heavy rains may thus be the cause of pollution of the air in houses. The greater the porosity of the soil, the more likely is this to happen. This pollution of the house-air may be prevented by having impervious floors and walls to cellars and basements, or by interposing a layer of charcoal between the ground and the floor of the house. The latter does not prevent the passage of the ground-air, but the charcoal layer absorbs or arrests the noxious matters,-filters the ground-air, as it were. In the spring and early summer the ground being colder than the air above it, and the ground-air consequently heavier and denser, the latter is not easily displaced. It is, perhaps, due to this fact that those infectious diseases which are proba- bly dependent upon the movements of the ground-air are less prevalent in the spring and early summer than in the latter part of the summer, autumn, and early winter. In the autumn the ground-air being warmer than the air above ground is easily displaced by the latter and forced out into the streets and houses to be inspired by men and animals. The same conditions may explain the greater likelihood of infection at night, which is proven for such diseases as malarial and yellow fevers. The colder outside air penetrates the interstices of the soil and forces out the impure ground-air. The researches of Fodor have demonstrated that the pro- portion of carbon dioxide in the ground-air may be taken as an approximative measure of the impurity of the soil whence the air is taken. The influence of the permeability of the soil, as before pointed out, must, however, not be overlooked in esti- mating the signification of the carbon dioxide. Fodor has shown that the proportion of carbon dioxide in the ground-air, and consequently the amount of organic decomposition, is THE ATMOSPHERE OF THE SOIL, OR GROUND-AIR. 127 greatest in July and least in March. That the carbon dioxide is derived from the decomposition of vegetable matter has been proven by Pettenkofer. This observer examined specimens of air brought from the Lybian desert, and found that the propor- tion of carbon dioxide in the ground-air was exactly the same as in the air collected above-ground. There being no vegetable growth in the desert there can, of course, be no vegetable decomposition going on in the soil. The excess of carbon dioxide in the ground-air is an indi- cation of the deficiency of oxygen, as has been shown. The air at a depth of 4 metres below the surface was found to contain only from 7 to 10 per cent, of oxygen-one-half to one- third of the normal proportion. Many basements occupied by people as living-rooms extend from 1 to 3 metres under-ground, and hence are liable to be supplied with an atmosphere approach- ing in impurity that just mentioned. It requires no very vivid imagination to appreciate the dangers to health that lurk in such habitations. THE WATER OF THE SOIL, OR GROUND-WATER. At a variable depth below the surface of the ground, a stratum of earth or rock is found through which water passes with difficulty, if at all. Above this there is a stratum of water which moves from a higher to a lower level, and which varies in depth at different times according to the amount of precipita- tion (rain- or snow- fall), and according to the level of the nearest body of water toward which it flows. This stratum of water is termed the ground-water, and has within the last few years assumed considerable importance from its apparently close rela- tions to the spread of certain of the infectious diseases. The direction of horizontal flow of ground-water is always toward the drainage-area of the district. Thus, it is usually toward lakes, rivers, or the sea. Rains, or a rise in the river, cause a rise in the ground-water, while long-continued dry weather, or a low stage of the river which drains off the ground-water, 128 TEXT-BOOK OF HYGIENE. causes a fall in the latter. On the sea-coast the ground-water oscillations probably correspond with the tides. The writer is not aware of any observations made to determine this point, with the exception of a single instance mentioned by Dr. De Chaumont. In Munich, where the ground-water flows toward the river Isar, which divides the city, it has been found that the annual range or oscillation (the difference between the highest and lowest level during the year) is 3 metres, while the hori- zontal movement amounts to 5 metres per day. In Buda-Pesth the annual range was found by Fodor to be less than 1 metre, while in some portions of India it amounts to more than 12 metres. As it is from the ground-water that the greater portion of the supply of drinking-water in the country and in villages and small towns is drawn, it becomes at once manifest how important it is to prevent, as far as possible, pollution of this source. Cess-pools and manure-heaps and pits, of necessity, contaminate the soil and also ground-water for a distance below and around them, and such water is clearly unfit for drinking and other domestic purposes. Hence, the reason why wells should not be placed too near privies and manure-heaps or pits becomes apparent. Between the level of the ground-water, or that portion of the soil where its pores are entirely occupied by the water- where, in other words, the ground is saturated-and the surface, is a stratum of earth more or less moist; that is to say, the interstices of the soil are partly filled with water and partly with air. It is in this stratum that the processes of organic decay or putrefaction are most rapidly going on, in consequence of which the pollution of the ground-air occurs. The oxidation of non- nitrogrenous matter in the soil results in the formation of carbon dioxide. On the other hand, nitrogenized compounds are oxidized into nitric acid and nitrates. When, however, putre- faction occurs, nitrous acid, or nitrites and ammonia, are formed, the oxidation not proceeding far enough to result in nitric acid. Recent observations seem to show that these processes of THE WATER OF THE SOIL, OR GROUND-WATER. 129 decomposition are initiated and kept up by minute organisms termed bacteria, just as fermentation in liquids containing sugar can only take place in the presence of the yeast-plant. It has been found that when non-putrefactive decomposition goes on, there are always present multitudes of one variety of these minute organisms; while if putrefactive decomposition is going on, a number of other varieties of these organisms are present. Just as, when a fermenting liquid becomes putrid, the yeast-plant disappears and its place is taken by the ordinary bacteria of putre- faction, so in the soil, if the access of oxygen, which is necessary to the life of the bacteria of decay, is prevented, these organisms die and are succeeded by the organisms of putrefaction. It has been found that in a soil saturated with water the bacteria of decay cannot live, while those of putrefaction may flourish, because these latter organisms can sustain life and develop in the absence of oxygen. Professor Fodor's researches indicate that the most prominent organism of non-putrefactive decomposition or decay is that which is termed by Cohn bacterium lineola; and that the bacterium termo is the principal organism of putrefaction. DISEASES SPREAD BY SOIL IMPURITIES. Given now an area of soil, say the ground upon which a house or city is built, with a moist stratum in which the pro- cesses of decay are active, and imagine a rise in the ground- water. The ground-air, charged with carbon dioxide and other products of decomposition, is forced out of the pores of the soil by the rising ground-water, and escapes into the external air, or through cellars and basements into houses, and may there produce disease. But the saturation of the soil with water pre- vents the further development of the bacteria of decay, and this is checked, or putrefaction may take place. If now the ground- water sinks to its former level or below, the processes of decay again become very active in the moist stratum, and large quan- tities of carbon dioxide and other inorganic compounds are produced. If the germs of infectious or contagious diseases 130 TEXT-BOOK OF HYGIENE. have been introduced into the soil, they also multiply and may escape with the movements of the ground-air into the external atmosphere, and there produce their infective action. This, it is held by Pettenkofer and his followers, is what actually occurs in cholera and typhoid fever. Professor DeChaumont has laid down the rule that a soil with a persistently low stage of ground- water, say 5 metres below the surface of the ground, is healthy; a persistently high stage of ground-water, less than 1| metres below the surface, is unhealthy; while a fluctuating level of the ground-water, especially if the changes are sudden and violent, is very unhealthy. This would lead us to expect that places where this fluctuation is very great would show a large mortality from such diseases as are attributed to impurities in the soil. And this we And especially true in India. In certain localities in India, cholera, for example, is endemic; that is to say, the disease is never entirely absent in such localities. Calcutta is one of these places. The rainy season begins about the first of May and continues until the end of October. During the next six months there is very little rain. It is fair to assume that the ground-water rises during the rainy season and checks decay and the multiplication of the germs of the disease in the soil, and that these processes become more active as the dry season advances and the ground-water level falls. If we note the death-rate from cholera in Calcutta it will be found that it bears a distinct relation to the movement of the ground-water. The deaths from cholera begin to increase from October and reach their height in April. Dr. Macpherson, who has written a very elaborate history of Asiatic cholera, shows this relation very clearly. For twenty-six years the average rain-fall was 157 cen- timetres. From May to October 142 centimetres fell, while the remaining 15 centimetres fell from November to April. The average number of deaths from cholera annually was 4013. Of these, 1238 died in the rainy season, while 2775, nearly three-fourths, died during the period of dry weather. In the cholera epidemics of 1866 and 1873 in Buda-Pesth, 131 DISEASES SPREAD BY SOIL IMPURITIES. the same relations existed between the ground-water and the cholera. As the level of the ground-water rose the cholera diminished, while the disease increased upon the sinking of the ground-water. Exactly the same behavior was exhibited by the disease in Munich in 1873. There seems good reason to believe that typhoid fever is propagated in consequence of movements of the ground-water, in the same way as above explained for cholera. This does not exclude the infection of drinking-water by the disease-germ, since much of the drinking-water used, as before stated, is drawn from the ground-water. Pettenkofer, Buhl, and Virchow have shown that the death-rate from typhoid fever has a distinct and definite relation to the ground-water oscillations. This has been incontestably proven for two cities, Munich and Berlin. When the level of the ground-water is above the average, typhoid fever decreases; when it is below the average, the number of cases becomes greater. Dr. H. B. Baker has demonstrated that the fluctuation of the ground-water level in the State of Michigan is similarly followed by a change in the morbility and mortality from typhoid fever.1 Hence, it may be regarded as an established law that the rise and fall of the ground-water bears a definite relation to the morbility rate of typhoid fever. Nearly thirty years ago Dr. Henry I. Bowditch, of Boston, called attention to the frequent connection between cases of pulmonary consumption and dampness of the soil upon which the patients lived. After a very extended and laborious investi- gation Dr. Bowditch formulated these two propositions:- " First.-A residence in or near a damp soil, whether that dampness be inherent in the soil itself or caused by percolation from adjacent ponds, rivers, meadows, or springy soils, is one of the principal causes of consumption in Massachusetts, probably in New England, and possibly other portions of the globe. " Second.-Consumption can be checked in its career, and *The Relation of the Depth of Water in Wells to the Causation of Typhoid Fever, Public Health, vol. x, p. 184-213. 132 TEXT-BOOK OF HYGIENE. possibly-nay, probably-prevented in some instances by atten- tion to this law."1 Dr. Buchanan, of England, about the same time showed that the thorough drainage of certain English cities had mark- edly diminished the deaths from consumption in the drained cities. So far as the writer is aware, not a single fact has been established which militates against the law laid down by Dr. Bowditch, and so strongly supported by the statistical researches of Dr. Buchanan, yet hardly any notice has been taken of these results by physicians. Few know anything of them, and still fewer seem to have made practical use of such knowledge in advising patients. As corroborative of the views of Dr. Bow- ditch, the rarity of consumption in high and dry mountainous districts or plateaus may be cited. A recent study of the topographical distribution of con- sumption in the State of Pennsylvania, by Dr. William Pepper, apparently confirms Dr. Bowditch's conclusions in nearly every particular. It is now known that the direct cause of consump- tion is the bacillus tuberculosis, discovered by Dr. Robert Koch. The relation between soil-moisture and the increase of consump- tion will probably be found in the more favorable conditions of development of the tubercle bacillus furnished by a moist medium. DISEASES OF ANIMALS PROBABLY DUE TO SIMILAR CONDITIONS OF THE SOIL. The modern study of the sanitary relations of the soil is still in its infancy. Whatever definite knowledge has been gained relates merely to physical or chemical conditions of the soil and its atmosphere and moisture, or possibly the relations of these to the spread of certain diseases in human beings. But there is, perhaps, a wider application that may be made of such knowledge than has been heretofore suggested. The domestic animals which form such a large portion of the wealth of this * Consumption in New England and Elsewhere, 2d ed., p. 87. Boston, 1866. DISEASES OF ANIMALS DUE TO SIMILAR CONDITIONS OF SOIL. 133 country-horses, cattle, sheep, and hogs-are liable to infectious and contagious diseases, as well as are human beings, and many millions of dollars are lost annually by the ravages of such diseases. Now, from what is known of such diseases as splenic fever among cattle, and of the so-called swine plague, it does not appear improbable to the writer that the source of infection is a soil polluted by the poisonous germ of these diseases, just as it seems demonstrated that cholera and typhoid fever and possibly malarial fevers are so caused. The laborious investiga- tions of M. Pasteur in France have shown that the cause of splenic fever, when once introduced into a locality, will remain active for months, and even years, and it seems probable that a study of the soil in its relations to the diseases of domestic animals is a subject to which attention may profitably be given. It is well known that milch-cows frequently suffer from a disease identical in its nature with consumption in human beings. It is believed by many that the milk of such animals is not only unfit for food by reason of its poor quality, but that it may convey the disease to human beings when used as food. The observations of Bowditch and Buchanan, quoted above, show that consumption in man may be, and doubtless is, frequently caused by soil-wetness. It seems probable that the same cause should produce similar effects in the lower animals, and it is the writer's firm conviction that an examination into the circumstances under which cows become attacked by con- sumption would prove this probability a fact. DRAINAGE. In many soils drainage is necessary in order to secure a constant level of the ground-water at a sufficient depth below the surface. Drainage and sewerage must not be confounded with each other. Drainage contemplates only the removal of the ground-water, or the reduction of its level, while sewerage aims to remove the refuse from dwellings and manufactories, 134 TEXT-BOOK OF HYGIENE. including excrementitious matters, waste-water, and other products, and in some cases the storm-water. Sewers should never be used as drains, although for economy's sake sewer- and drainage- pipes may be laid in the same trench. Sewer-pipe must be perfectly air-tight and water- tight to prevent escape of its liquid or gaseous contents into the surrounding soil and rendering it impure. Drainage-pipe, on the other hand, should be porous and admit water freely from without. Escape of the contents of the drain-pipe into the surrounding soil will not produce any pollution of the latter. The best material for drains is porous earthenware pipe, or the ordinary agricultural drain-tile. Coarse gravel or broken stones may also be used, and prove efficient if the drains are properly constructed. Referring again to the aphorism of Professor DeChaumont, that a persistently low ground-water, say 5 metres down, or more, is healthy; that a persistently high ground-water, less than metres from the surface is unhealthy; and that a fluctuating level, especially if the changes are sudden and violent, is very unhealthy, the necessity appears obvious that in the construction of drainage-works the drains should be placed at a sufficient depth to secure a level of the ground-water consistent with health. This depth should never be less than 3 metres, and, if possible, not less than 5 metres. Care must be taken that the outflow of the drain is unobstructed, in order that the soil may be kept properly dry at all times. In the absence of a proper mechanical system of drainage, the planting of certain trees may efficiently drain the soil. It has been found that the eucalyptus tree has produced drying of the soil when planted in sufficient numbers in marshy land. The roots absorb a prodigious quantity of water, which is then given off by evaporation from the leaves. Sunflower-plants have a similar effect upon wet soils. CHAPTER V. Removal of Sewage. In all larger communities certain arrangements are neces- sary to secure a prompt and efficient removal of excreta and the refuse and used water of households and manufacturing establishments, the sweepings of streets, and rain-water. The total quantity of excrementitious products-faeces and urine-for each individual, including men, women, and children, has been estimated by Professor von Pettenkofer as 90 grammes of faecal and 1170 grammes of urinary discharge daily. This would give for a population of 1000 persons 34,000 kilogrammes of faeces and 428,000 litres of urine per year. If to this is added a minimum allowance of 159 litres of water per day to each individual, a complete sewerage system for a population of 1000 persons would require provision for the discharge of 160,000 litres of sewage passing through the sewers every day. In this estimate storm-water and such accessory feeders of the sewage are omitted. The organic matters contained in sewage, even if free from the specific germs of disease, give rise to noxious emanations, which, when inhaled, probably produce a gradual depravement of nutrition that renders the system an easier prey to disease. For this and other reasons it is important that such measures be adopted as will secure the removal of sewage matters from the immediate vicinage of houses as quickly as possible after they have been discharged. The impregnation of the soil with sewage produces a con- tamination of ground-air and ground-water, which may become a source of grave danger to health. By polluting the ground- water it eventually vitiates the well-water, which is nearly always derived from that source. 135 136 TEXT-BOOK OF HYGIENE. The system of removal of excremcntitious matters which any community will adopt depends to a considerable extent upon financial considerations. Although the sanitarian must insist upon the pre-eminent importance of the cause of public health, his suggestions will receive little attention from municipal or state legislatures unless they can be carried out without involv- ing the community too deeply in debt. For this reason it is a matter of great practical importance that the student of sani- tary science should make himself familiar with the relative cost as well as with the hygienic significance of the various methods of sewage removal in use. The different systems in use for the removal of sewage matters may be considered in detail under the following five heads:- 1. The common privy, or privy-vault systems. 2. The Rochdale or pail system, and its modifications. 3. The earth- or ash- closet system. 4. The pneumatic system of Liernur. 5. The water-carriage systems. 1. The Privy and Privy-well Systems.-While from a sanitary point of view privies of all kinds, whether wells or cess-pits, are to be unreservedly condemned, it is not likely that they will cease to be built for many years to come. It becomes necessary, therefore, to point out by what means the objections against them may be diminished, and their evil consequences in some measure averted. In the first place, a privy-vault should be perfectly water- tight in order to prevent pollution of the surrounding soil by transudation of the contained excremental matters. The walls should be of hard-burned brick laid in cement. The cavity should be small in order that the contents may be frequently re- moved, and not allowed to remain and putrefy for months or years. A water-tight hogshead sunk in the ground makes an economical privy-tank or receiver. A privy must not be dug in a cellar, or in too close proximity to the house-walls. Unless REMOVAL OF SEWAGE. 137 these last precautions are taken the offensive gases from the mass of decomposing faecal matter in the privy will constantly ascend into and permeate the air of the house. All privies should be ventilated by a pipe passing from just under the privy-seat to a height of about a metre above the roof of the house. A gas-flame, kept burning in the upper portion of this pipe, will increase its ventilating power by creating a strong and constant upward current. Deodorization of the contents of privies may be secured in a measure by means of sulphate of iron, phenyle, carbolic acid, or dry earth. The first named is probably the most economical, most easily applied, and very effective. A solution containing from | to 1 kilogramme of the salt in 4 litres of water is poured into the privy as often as necessary to prevent offensive odors. This solution may be conveniently prepared by suspending a basket or bag containing about 25 kilogrammes of the sulphate in a barrel of water. In this way a saturated solution will be maintained until the salt has been entirely dissolved. Phenyle is likewise a good deodorizer as well as an excellent disinfectant. The most rigid deodorization by chemicals will, however, be less effective than thorough ventilation, for it must be re- membered that the mere destruction of an offensive odor is not equivalent to removing all the deleterious properties that may be present. It is not at all certain that those elements of sew- age which are the most offensive to the sense of smell are most o detrimental to health. Privies should be emptied of their contents at stated inter- vals. A strict supervision should be exercised over them by the municipal authorities in cities and towns to prevent overflowing of their contents. In many places the method of removing the contents of privies is the primitive one with shovel, or dipper and bucket. In most cities and large towns, however, the privy-vaults or tanks are now emptied by means of one of the so-called odorless excavat- ing machines, of which there are a number of different patents. 138 TEXT-BOOK OF HYGIENE. The process is rarely entirely odorless, however, as the careless- ness of the workmen frequently permits offensive gases to escape and pollute the air for a considerable distance. All the different forms of the apparatus act upon the pneumatic principle. One end of a large tube is carried into the cess-pool or vault to be emptied and the other attached to a pump, by means of which the material is pumped into a strong barrel-tank carried on wheels. At the top of the tank is a vent, over which is placed a small charcoal furnace to consume the foul gases escaping from the vent. In some cities and many of the smaller towns and villages in this country the primitive midden or pit system is still in use. A shallow pit is dug in the ground, over which is erected the privy. When the pit is full another is dug close by the side of it, and the earth from the new pit thrown upon the excrement in the old one. The privy is then moved over the new pit, and this is used until it too becomes full. The proceeding is re- peated as often as the pit becomes filled up with the excreta, until in the course of a few years all the available space in a yard has been honey-combed with the pits. Then the custom adopted in overcrowded cemeteries is followed, namely, the first pit is dug out again and the cycle is repeated. In other cities the privy-well system is largely in use. This is-next to the midden or shallow pit just described-the most pernicious system for the disposal of excreta that can be imagined. The wells are dug to such a depth as to reach the subterranean flow of water, in which the excremental matters are constantly carried off. Hence these receptacles never fill up, and never need cleaning. For this reason they are popular with property owners; for, next to the primitive midden, they are the most economical of all the various methods adopted. The utter perniciousness of the system is, however, plain, because the soil for a considerable distance around each of these wells becomes a mass of putrid filth, contaminating the ground-water which feeds the drinking-water supplies in the vicinity; polluting also REMOVAL OF SEWAGE. 139 the ground-air, which eventually reaches the surface, or the in- terior of houses, when the pressure of the outside atmosphere diminishes or the ground-water level rises. It must, therefore, be evident that the best ventilating arrangements, or the most thorough and consistent disinfection, can have very little, if any, effect in removing the very grave objections to this baneful system. The privy-well system for the removal of excreta cannot be recommended for adoption by any sanitarian. 2. The Rochdale, or Pail-closet System.-The Rochdale system of removal of excreta has won the support of many dis- tinguished sanitarians on account of its simplicity, its economy, and its compliance with most sanitary requirements. The ex- creta, both solid and liquid, are received into a water-tight pail, either of w'ood or metal, and removed once or oftener a week, a clean and disinfected pail being substituted for the one removed. In Rochdale, Manchester, and Glasgow in Great Britain, in Heidelberg in Germany, and in other cities abroad, where this system has been introduced, it has worked satisfac- torily. In this country a modification of the pail system, known as the Eagle Sanitary Closet, has been introduced by a firm in Charleston, S. C. The receptacle consists of an enameled-iron reservoir, with a neck just large enough to fit under the seat of the privy, and a quantity of disinfectant solution is put into the receptacle to prevent putrefaction of the excreta. The recep- tacles are replaced by clean ones every week. Mr. James T. Gardner, Director of the New York State Sanitary Survey, says, in a special report on methods of sewerage applicable in small towns and villages, concerning the pail system1:- "Rochdale is a city of some 70,000, and Manchester of between 400,000 and 500,000 inhabitants. The higher class of houses are allowed to have water-closets, but four-fifths of the people are obliged to have ' pail-closets ' in their yards built 1 Second Annual Report of New York State Board of Health, pp. 322, 323, 140 TEXT-BOOK OF HYGIENE. according to plans of the Health Department. Their essential features are: A flag-stone floor, raised a few inches above the level of the yard; a hinged seat, with a metal rim underneath for directing urine into the pail, which stands on the flag directly beneath the seat; a hinged front and back to the seat, so that the pail or tub may be easily taken out and the place cleaned; and a 6-inch ventilating pipe from under the seat to above the roof. In Rochdale they use a wooden pail or tub made of half of a disused paraffine cask, holding about 40 kilogrammes; in Manchester the ' pail ' is of galvanized iron and holds 40 litres. Under the direction of the authorities, they are removed once a week in covered vans, which bring clean tubs to be put in the place of the full ones taken away. Each tub is covered with a close-fitting double lid before removal. The tubs are taken to a depot, where their contents are deodorized and prepared as manure by mixing with ashes and a small proportion of gypsum to fix the ammonia. Subsequently, street-sweepings and the refuse of slaughter-houses are added. At Manchester there is by the side of each closet a very simple ash-sifter, from which the ashes fall into the tub and help to deodorize its contents. " The manure at Rochdale sells for about four-fifths of the cost of the collection and preparation. " In 1873 the net cost to the town of removing and dispos- ing of the house dry refuse and excrement was only about $95 per annum per 1000 of population,-less than 10 cents a person per annum. " The system has been in operation more than twelve years. " The tubs are removed in the day-time without offensive odor. " Where ashes are frequently thrown into the tubs at Man- chester, very little odor is to be perceived in the closets. " For the villages of the State, which can have no general water-supply, I would unhesitatingly advise the use of the ' pail ' or tub system as practiced in Manchester, England, as being, from a sanitary point of view, an immense improvement REMOVAL OF SEWAGE. 141 over the death-breeding privy-vaults in common use. The cheapness of the plan and the smallness of the original outlay of brains and money, in comparison with that needed to build a good sewer system, will make it possible to introduce a tub- privy system into most villages half a century before sewers would meet with any consideration. " At a small cost the existing privy-vaults can be cleaned and filled, and the privies altered into healthful tub-closets. The town authorities must then arrange for the removal of the tubs once a week, and for their thorough cleansing and disinfecting. Any isolated house, or group of houses, can use the tub system, taking care of it themselves. If the plan is adopted in villages it will doubtless spread into the country, and become the most powerful means of abolishing the fatal privy-vaults which are poisoning the farm-wells." 3. Earth- and Ash- Closets.-The earth- and ash- closets are devices in use to a large extent in England, and to a less degree in this country, for the purpose of rendering human ex- creta inodorous by covering them immediately after they are voided with dry earth or ashes. The earth-closet is the inven- tion of the Rev. Henry Moule, of England, and consists of an ordinary commode or closet, the essential feature of which is a reservoir containing dried earth or ashes, a quantity of which, amounting to about twice the quantity of feces voided, is thrown upon the evacuation either by hand or by means of an auto- matic apparatus called a "chucker." Just as in the ordinary water-closet, by raising a handle a supply of water is thrown into the hopper to wash down the faeces into the soil-pipe, so, in the usual form of the earth-closet, raising the handle projects a quantity of earth upon the evacuated faeces and urine. By this means the excreta are rendered entirely inodorous and dry. The contents of the closets may be collected into a heap in a dry place. In the course of a few months the organic constit- uents have become oxidized, and the earth may be used over again for a number of times. A well-known sanitarian states 142 TEXT-BOOK OF HYGIENE. that he has used sifted anthracite coal-ashes ten or twelve times over in the course of three years. During this time the material under no circumstances gave any indication that it was " any- thing but ashes, with a slight admixture of garden soil."1 Dr. Buchanan, of England, comparing the advantages of the earth-closet with those of the water-closet, says: "It is cheaper in original cost; it requires less repairs; it is not in- jured by frost; it is not damaged by improper substances being Fig. 4.-Pull-up Handle Commode, SHOWING THE DOOR OPEN FOR REMOV- ING Pail. The Flap of the Seat and Earth-Reservoir are also Par- tially Raised to show the Con- struction. Fig. 5.-Showing the Apparatus Mounted on Bearers as when Fixed. Seat Removed, showing Me- chanical Arrangement. thrown down it; and it very greatly reduces the quantity of water required by each household."2 In cities and towns the removal of the excreta should be carried out by or under the immediate direction of the mu- nicipal sanitary authorities. If this is neglected, abuses are liable to creep in which will vitiate the performance of any system, however faultless, if properly managed. Many advocates of the pail, dry earth, or privy systems urge the advantage of the large quantity of valuable manure which 1 The Sanitary Drainage of Houses and Towns, Waring, p. 250. 2d ed., 1881. 2 Quoted in Waring, above cited, p. 264. REMOVAL OF SEWAGE. 143 can be realized by converting the excremental matters into pou- drette and other fertilizing compounds. Experience has shown, however, that the cost of preparing a satisfactory fertilizer from human excrement is much greater than can be realized from its sale. In all places in Great Britain and the continent of Europe where it has been tried the decision is against its practicability. The agricultural consideration should, however, be a secondary one, if the systems mentioned are economical and meet the sanitary requirements (which the privy system certainly does not). The adoption of one or other of them may be secured where more perfect but more complicated and expensive systems may be out of the question. 4. The Pneumatic System of Liernur.-A system which seems to be useful in larger cities, especially where the topo- graphical conditions are such as to render necessary mechanical aid in overcoming obstacles to natural drainage, is the pneu- matic system devised by Captain Liernur, of Holland, and generally known as the Liernur system. It consists of a set of soil-pipes running from the water-closets to central district reservoirs, from which the air is exhausted at stated intervals. When a vacuum is created in the reservoir the contents of the water-closets and soil-pipes are driven forcibly into the reservoir by the pressure of air. The district reservoirs are connected by a separate system of pipes with a main depot, and the transfer of the faecal matter from the former to the latter is also accom- plished with the aid of pneumatic pressure. The complete system of Liernur provides that at the main depot the faecal matter shall be treated with chemicals, evaporated, and con- verted into a dry fertilizer-poudrette. It appears from the published reports that while the system has been partially adopted in three Dutch cities, in only one of them, Dortrecht, has the machinery for manufacturing poudrette been established. With reference to this Erismann1 says: "It seems never to have 1 Von Pettenkofer und Ziemssen. Handbuch der Hygiene. II Th., II Abth, 1 Hlfte, p. 140. 144 TEXT-BOOK OF HYGIENE. been in regular working order, for the faecal masses are mixed with street-sweepings and ashes into a compost-mass, which causes no little discomfort in the neighborhood by the offensive odors. In Amsterdam the faecal matters, which frequently do not find a ready sale, are partly made into a compost with sweepings, partly used to fertilize meadows, or simply discharged into the water." As to the practical working of the system the opinions differ widely. While the majority of sanitarians, including Virchow, von Pettenkofer, and Mr. Rawlinson, object to it as not fulfilling the demands of hygiene, the system has also been criticized by engineers as not being in accordance with the well- known principles of their science.1 Two other plans for the removal of faecal matter by pneu- matic pressure have been invented, namely, the Shone and the Berber systems. Neither of these has been adopted to any considerable extent. Both seem to the author to fall far short even of the merits of the Liernur system. 5. The Water-Carriage System of Sewerage.-Two sys- tems of removal of sewage by water-carriage are in use at the present time. They are technically known as the "combined" and the " separate " systems. In the former, which is the sys- tem upon which the most of the sewers in this country are constructed, all excreta, kitchen-slops, waste-water from baths and manufacturing establishments, as well as storm-water, are carried off in the same conduits. In the separate system, on the other hand, the removal of the storm-water is provided for, either by surface or under-ground drains, not connected with the sewers proper, in which only the discharge from water-closets and the refuse-water from houses and factories are conveyed. In the separate system the pipes are of such small calibre that a constant flow of their contents is maintained, preventing 1 Papers by Maj. C. H. Latrobe and Col. Geo. E. Waring, Jr., in Fifth Biennial Report Md. State Board of Health. See also, in favor of system, a paper by Dr. C. W. Chancellor, in same publication, and an elaborate description by the same author in Trans. Med. and Chir. Faculty of Md., 1883. 145 REMOVAL OF SEWAGE. deposition of suspended matters and diminishing decomposition and the formation of sewer-gas. In the combined system, on the other hand, the sewers must be made large enough to receive the maximum rain-fall of the district. This requires a calibre greatly in excess of the ordinary needs of the sewer, and furnishes favorable conditions for the formation of sewer-gas and the development of minute vegetable organisms. The ordinary flow in a sewer of large calibre is usually so sluggish as to promote the deposition of solid matters and the gradual obstruction of the sewer. It is the opinion of the most advanced sanitarians that the separate system fulfills the demands of a rational system of sewerage better than any other at present in use. The objec- tions to the combined system are so many and so great that it does not seem advisable for sanitary authorities to recommend the construction of sewers on this principle in the future. The separate system of sewerage, indorsed as it is by high engineering and sanitary authorities, and by a satisfactory, prac- tical test of nine years in the city of Memphis and of six years in the town of Keene, N. H., seems to the author to possess merits above any other plan for the removal of excreta and house-wastes. The following description is from a paper by Col. George E. Waring, Jr.: "A perfect system of sanitary sewerage would be something like the following: No sewer should be used of a smaller diameter than 6 inches (15 centi- metres) : a, because it will not be safe to adopt a smaller size than 4-inch (10 centimetres) for house-drains, and the sewer must be large enough to surely remove whatever may be de- livered by these; b, because a smaller pipe than 6-inch would be less readily ventilated than is desirable; c, and because it is not necessary to adopt a smaller radius than 3 inches (5 centi- metres) to secure a cleansing of the channel by reasonably copious flushing. "No sewer should be more than 6 inches (15 centimetres) in diameter, until it and its branches have accumulated a 146 TEXT-BOOK OF HYGIENE. sufficient flow at the hour of greatest use to fill this size half full, because the use of a larger size would be wasteful, and because when a sufficient ventilating capacity is secured, as it is in the use of a 6-inch pipe, the ventilation becomes less complete as the size increases, leaving a larger volume of contained air to be moved by the friction of the current, or by extraneous in- fluences, or to be acted upon by changes of temperature and of volume of flow within the sewer. "The size should be increased gradually, and only so rapidly as is made necessary by the filling of the sewer half full at the hour of greatest flow. " Every point of the sewer should, by the use of gaskets or otherwise, be protected against the least intrusion of cement, which, in spite of the greatest care, creates a roughness that is liable to accumulate obstructions. " The upper end of each branch sewer should be provided with a Field's flush-tank of sufficient capacity to secure the thorough daily cleansing of so much of the conduit as from its limited flow is liable to deposit solid matters by the way. " There should be sufficient man-holes, covered by open gratings, to admit air for ventilation. If the directions already given are adhered to, man-holes will not be necessary for cleans- ing. The use of the flush-tank will be a safeguard against deposit. With the system of ventilation about to be described, it will suffice to place the man-holes at intervals of not less than 1000 feet (305 metres). "For the complete ventilation of the sewers it should be made compulsory for every householder to make his connection without a trap, and to continue his soil-pipe above the roof of his house. That is, every house connection should furnish an uninter- rupted ventilation-channel 4 inches (10 centimetres) in diameter throughout its entire length. This is directly the reverse of the system of connection that should be adopted in the case of storm-water and street-wash sewers. These are foul, and the volume of their contained air is too great to be thoroughly ven- REMOVAL OF SEWAGE. 147 tilated by such appliances. Their atmosphere contains too much of the impure gases to make it prudent to discharge it through house-drains and soil-pipes. With the system of small pipes now described, the flushing would be so constant and complete and the amount of ventilation furnished, as compared to volume of air to be changed, would be so great, that what is popularly known as ' sewer-gas ' would never exist in any part of the public drains. Even the gases produced in the traps and pipes of the house itself would be amply rectified, diluted, and removed by the constant movement of air through the latter. "All house connections with the sewers should be through inlets entering in the direction of the flow, and these inlets should be funnel-shaped so that their flow may be delivered at the bottom of the sewer, and so that they may withdraw the air from its crown; that is, the vertical diameter of the inlet at its point of junction should be the same as the diameter of the sewer. "All changes of direction should be on gradual curves, and, as a matter of course, the fall from the head of each branch to the outlet should be continuous. Reduction of grade within this limit, if considerable, should always be gradual. " So far as circumstances will allow, the drains should be brought together, and they should finally discharge through one or a few main outlets. "The outlet, if water-locked, should have ample means for the admission of fresh air. If open, the mouth should be pro- tected against the direct action of the wind. " It will be seen that the system of sewerage here described is radically different from the usual practice. It is cleaner, is much more completely ventilated, and is more exactly suited to the work to be performed. It obviates the filthy accumulation of street-manure in catch-basins and sewers, and it discharges all that is delivered to it at the point of ultimate outlet outside the town before decomposition can even begin. If the discharge is of domestic sewage only, its solid matter will be consumed by 148 TEXT-BOOK OF HYGIENE. fishes if it is delivered into a water-course, and its dissolved material will be taken up by aquatic vegetation. "The limited quantity and the uniform volume of the sewage, together with the absence of dilution by rain-fall, will make its disposal by agricultural or chemical processes easy and reliable. "The cost of construction, as compared with that of the most restricted storm-water sewers, will be so small as to bring the improvement within the reach of the smaller communities. "In other words, while the system is the best for large cities, it is the only one that can be afforded in the case of small towns. " Circumstances are occasionally such as to require extensive engineering works for the removal of storm-water through very deep channels. Ordinarily, the removal of storm-water is a very simple matter, if we will accept the fact that it is best carried, so far as possible, by surface gutters, or, in certain cases, by special conduits, placed near the surface. " It is often necessary, in addition to the removal of house- waste, to provide for the drainage of the subsoil. This should not be effected by open joints in the sewers; because the same opening that admits soil-water may, in dry seasons and porous soils, permit the escape of sewage matters into the ground, which is always objectionable. " Soil-water drains may be laid in the same trench with the sewers, but preferably, unless they have an independent outlet, on a shelf at a higher level. When they discharge into the sewer they should always deliver into its upper part, or into a man-hole at a point above the flow-line of the sewage."1 The establishment of a system of sewerage presupposes a constant and abundant supply of water to keep all closets clean and all house-drains and street-sewers well flushed. Where this cannot be obtained, sewers would be likely to prove greater evils than benefits. In such cases one of the methods of removal 1 The Sewering and Drainage of Cities, Waring, Public Health, vol. v, p. 35. REMOVAL OF SEWAGE. 149 of excreta before mentioned, either the pail- or earth- closet system, should be adopted. The final disposal of sewage is a problem that depends for its solution partly upon the agricultural needs of the country around the city to be sewered, partly upon the proximity of large bodies of water or running streams. When the city is situated upon or near large and swiftly-flowing streams, the sewage may be emptied directly into the stream without seriously impairing the purity of the latter, although the principle of thus disposing of sewage is wrong. Dilution, deposition, and oxida- tion will soon remove all appreciable traces of the sewage of even the largest cities. Where, on the other hand, the stream is inadequate in size to carry off the sewage, or where, as in the Seine and Thames, the current is sluggish, some other method of final disposal must be adopted. In many cities of Great Britain and the continent of Europe the disposal of the sewage by irrigation of cultivated land has been practiced for a number of years. The reports upon the working of the system are generally favorable, although some sanitarians express doubts of the efficiency of the system. In using sewage for the irrigation of land, two objects are secured: first, the fertilization of the land by the manurial constituents of the sewage, and, second, the purification of the liquid portion by filtration through the soil. The organic matters which have been held back by the soil undergo rapid oxidation in the presence of air and the bacteria of decay, and are converted into plant- food, or into harmless compounds. Sewage irrigation, as prac- ticed in Europe, must make provision for the disposal of a very large proportion of water in the sewage (street-wash, storm- water), which requires much larger areas of land than would be needed if only sewage material proper (water-closet and kitchen- waste) was to be thus disposed of. In this country a practical experiment has recently been made at Pullman, Illinois, delivering only the sewage materials above mentioned upon the irrigation area. The success of the experiment is said to be satisfactory. 150 TEXT-BOOK OF HYGIENE. All land used for sewage irrigation should be drained with drain-tile at a depth of 3 to 6 feet (1 to 2 metres) below the surface, in order to promote a rapid carrying off of the watery portion of the sewage, purified by filtration through the soil. A sandy loam is the best soil for irrigation. Clay is not sufficiently permeable to air and water, while pure sand allows the sewage to pass through too readily, before the organic matters in it have been sufficiently oxidized. It has been shown that the roots of plants assist largely in the oxidation of organic matter. The entire process of collecting and finally disposing of sewage matters, from the moment they are received in the house- receptacles until discharged into the swiftly-flowing stream or on the sewage farm, should be void of offense to the senses of sight or smell. With a proper construction and management of sewerage works, on the lines indicated in this chapter, it is believed these residts can be attained. During the past two or three years a number of experi- ments have been made in this country with various processes for the disposal of excreta and garbage by cremation. In a general way the principle may be pronounced a success, although its proper application in practice is still under discussion. [The following works give fuller details upon the matters treated in the two foregoing chapters:- Erismann, Entfernung der Abfallstoffe. Hdbch. d. Hygiene, etc., IT Th., I Abth., 1 Hlfte.-C. F. Folsom, Seventh Report Mass. State Board of Health, 1876, p. 276.-Soyka, Stadte-reinigung, in Realency- clopredie d. ges. Heilk.,Bd. xiii, p. 14 et seq.-Pettenkofer, The Sanitary Relations of the Soil, in Pop. Sci. Monthly, vol. xx, p. 332, 468.-Rohe, Address on State Medicine, in Journ. Am. Med. Ass'n, July, 1887.-Cor- field and Parkes, The Treatment and Utilization of Sewage, 1887.-Re- ports of the Committee on Destruction of Garbage and Refuse, Public Health, vols. xiv and xv.] CHAPTER VI. Construction of Habitations. The importance of observing the principles of hygiene in the construction of habitations for human beings is not suffi- ciently appreciated by the public. Architects and builders them- selves have not kept pace with the sanitarian in the study of the conditions necessary to be observed in building a dwelling-house which shall answer the requirements of sanitary science. In an investigation conducted by Dr. Villerme1 it was found that in France, from 1821 to 1827, of the inhabitants of arron- dissements containing 7 per cent, of badly-constructed dwellings, 1 person out of every 72 died; of inhabitants of arrondissements containing 22 per cent, of badly-constructed dwellings, 1 out of 65 died; while of the inhabitants of arrondissements containing 38 per cent, of badly-constructed dwellings, 1 out of every 45 died. Inseparable from the question of the defective construction of dwellings is that of overcrowding in cities, because the most crowded portions of a city are at the same time those in which the construction of dwellings is most defective from a hygienic stand-point. The following tables show the relations of the death-rate to density of population in various large cities of Europe, and also the relations between overcrowding in dwell- ings and the mortality from contagious diseases :- RELATION OF DEATH-RATE TO DENSITY OF POPULATION, Table XVII City. Mean Number of Inhab- itants to each House. Average Death-rate per 1000 Inhabitants. London 8 24 Berlin 32 25 Paris 35 28 St. Petersburg 52 41 Vienna 55 47 1 Quoted in Realencyclopaedia d. ges. Heilk, Bd. ii, 71. 151 152 TEXT-BOOK OF HYGIENE. In Glasgow, the death-rate in apartments with 1.31 occu- pants is 21.7 per 1000, while in apartments with 2.05 occupants the rate is 28.6 per 1000. In Buda-Pesth, in 1872-73, it was found that out of every 100 deaths from all causes there were, from contagious diseases:- 20 deaths in dwellings with 1 to 2 persons in each room. 2g « « « " 3 « 5 " ii a it 32 " " " " 6 11 10 " " 11 u 79 " " " " over 10 " " " " Dr. Jose A. de los Rios gives the following statistics, bear- ing upon the mortality of cholera, in relation to the number of persons occupying one room when attacked by it:- Of 10,000 persons attacked by cholera, and living 1 person to the room, 68 died. Of 10,000 persons attacked by cholera, from 1 to 2 to the room, 131 died. Of 10,000 persons attacked by cholera, living 2 to 4 to the room, 219 died. Of 10,000 persons attacked by cholera, living 4 or more to the room, 327 died. These figures show very clearly the vital importance of the application of sanitary laws in the construction and occupation of dwellings. Another curious and suggestive point is presented by some statistical researches on the mortality of Berlin, in regard to the death-rate among persons living in different stories of houses. It was found, for example, that the mortality in fourth-story dwell- ings is higher than in the lower stories. Even basement dwell- ings furnish a lower death-rate. Still-births, especially, occur in a larger proportion among the occupants of the upper stories of houses. This may be explained by the unfavorable effects of frequent stair-climbing, especially in pregnant women. It is in the death-rate among young children that the effects of overcrowding and unsanitary construction of dwellings are especially manifest. The mortality returns from all the large CONSTRUCTION OF HABITATIONS. 153 cities of the world give mournful evidences of this every summer. The researches of Dr. H. I. Bowditch upon soil-wetness, to which reference has already been made in a previous chapter, show conclusively that persons living in houses situated upon or near land habitually or excessively wet, are especially prone to be attacked by pulmonary consumption. Dr. Buchanan1 has corroborated the truth of Dr. Bowditch's observations by show- ing, from the records of a number of cities and towns of Great Britain, that, with the introduction of a good drainage system, bringing about a depression and uniformity of level of the ground-water, the mortality from consumption and other dis- eases very markedly diminished. The following table, showing the proportionate amount of this diminution, is abridged from the official reports2:- Table XVIII. RESULTS OE SANITARY WORK. Name of Place. Population in 1861. Average Mortality per 1000 beifore Construction of Works. Average Mortality per 1000 since Com- pletion of W orks. Saving of Life (percent.). Reduc- tion of Typhoid Fever Rate (per cent.). Reduc- tion in Rate of Phthisis (per cent.). Banbury . . 10,238 23.4 20.5 121 48 41 Cardiff . . . 32,954 33.2 22.6 32 40 17 Croydon . . 30,229 23.7 18.6 22 63 17 Dover . . . 23,108 22.6 20.9 7 36 20 Ely ... . 7,847 23.9 20.5 14 56 47 Leicester . . 68,056 26.4 25.2 4| 48 32 Macclesfield . 27,475 29.8 23.7 20 48 31 Merthyr . . 52,778 33.2 26.2 18 60 11 Newport . . 24,756 31.8 21.6 32 36 32 Rugby . . . 7,818 19.1 18.6 10 43 Salisbury . . 9,030 27.5 21.9 20 75 49 Warwick . . 10,570 22.7 21.0 52 19 The following points must be taken into account in building a house in accordance with sanitary principles:- i.-SITE. The building-site should be protected against violent winds, although a free circulation of air all around the house 1 Ninth and Tenth Reports of the medical officer to the Privy Council. 2 Sanitary Engineering, Baldwin Latham, p. 2. Chicago, 1877. 154 TEXT-BOOK OF HYGIENE. must be secured. Close proximity to cemeteries, marshes, and injurious manufacturing establishments or industries must be avoided if possible. A requisite of the highest importance is the ability to command an abundant supply of pure water for drinking and other purposes. A neglect of this precaution will be sure to result to the serious inconvenience, if not detriment, of the occupants of the house. II. CHARACTER OF THE SOIL. The soil should be porous and free from decomposing ani- mal or vegetable remains, or excreta of man or animals. It should be freely permeable to air and water, and the highest level of the ground-water should never approach nearer than 3 metres to the surface. The fluctuations of the ground-water level should be limited. In this connection, attention is again called to the aphorism of Dr. DeChaumont.1 It is impossible to say positively that any kind of soil is either healthy or unhealthy, merely from a knowledge of its geological characters. The accidental modifying conditions above referred to, viz., organic impurities, moisture, the level and fluctuations of the ground-water, are of much greater importance than mere geological formation. The late Dr. Parkes, however, regarded the geological structure and conforma- tion as of no little importance, and summarized the sanitary relations of soils, variously constituted, as follows2:- "1. The Granitic, Metamorphic, and Trap Rocks.-Sites on these formations are usually healthy; the slope is great, water runs off readily; the air is comparatively dry; vegetation is not excessive; marshes and malaria are comparatively infrequent; and few impurities pass into the drinking-water. " When these rocks have been weathered and disintegrated they are supposed to be unhealthy. Such soil is absorbent of water; and the disintegrated granite of Hong Kong is said to 1 Chapter iv, p 130. 3 Practical Hygiene, 6th ed., vol. i, p. 359. CHARACTER OF THE SOIL. 155 be rapidly permeated by a fungus; but evidence as to the effect of disintegrated granite or trap is really wanting. "In Brazil the syenite becomes coated with a dark sub- stance and looks like plumbago, and the Indians believe this gives rise to 'calentura,' or fevers. The dark granitoid, or metamorphic trap, or hornblendic rocks in Mysore, are also said to cause periodic fevers; and iron hornblende, especially, was affirmed by Dr. Heyne, of Madras, to be dangerous in this respect. But the observations of Richter on similar rocks in Saxony, and the fact that stations on the lower spurs of the Himalayas on such rocks are quite healthy, negative Heyne's opinion. "2. The Clay Slate.-These rocks precisely resemble the granite and granitoid formations in their effect on health. They have usually much slope, are very impermeable, vegetation is scanty, and nothing is added to air or drinking-water. "They are consequently healthy. Water, however, is often scarce, and as to the granite districts, there are swollen brooks during rain, and dry water-courses at other times swelling rapidly after rains. "3. The Limestone and Magnesian Limestone Lochs.- These so far resemble the former that there is a good deal of slope and rapid passing off of water. Marshes, however, are more common, and may exist at great heights. In that case, the marsh is probably fed with water from some of the large cavities which in the course of ages become hollowed out in the limestone rocks by the carbonic acid in the rain, and form reservoirs of water. "The drinking-water is hard, sparkling, and clear. Of the various kinds of limestone, the hard oolite is best and magnesian is worst; and it is desirable not to put stations on magnesian limestone if it can be avoided. " 4. The Chalk.-The chalk, when mixed with clay, and permeable, forms a very healthy soil. The air is pure, and the water, though charged with calcium carbonate, is clear, 156 TEXT-BOOK OF HYGIENE. sparkling, and pleasant. Goitre is not nearly so common, nor apparently calculus, as in the limestone districts. "If the chalk be marly, it becomes impermeable, and is then often damp and cold. The lower parts of the chalk, which are underlaid by gault clay, and which also receive the drainage of the parts above, are often very malarious; and in America some of the most marshy districts are in the chalk. " 5. The Sandstones.-The permeable sandstones are very healthy; both soil and air are dry; the drinking-water is, how- ever, sometimes impure. If the sand be mixed with much clay, or if clay underlies a shallow sand-rock, the site is sometimes damp. " The hard millstone-grit formations are very healthy, and their conditions resemble those of granite. "6. Gravels of any depth are always healthy, except when they are much below the general surface, and water rises through them. Gravel hillocks are the healthiest of all sites, and the water, which often flows out in springs near the base, being held up by the underlying clay, is very pure. " 7. Sands.-There are both healthy and unhealthy sands. The healthy are the pure sands, which contain no organic matter, and are of considerable depth. The air is pure, and so is often the drinking-water. Sometimes the drinking-water con- tains enough iron to become hard, and even chalybeate. The unhealthy sands are those which, like the subsoil of the Landes, in southwest France, are composed of silicious particles (and some iron) held together by a vegetable sediment. "In other cases sand is unhealthy from underlying clay or laterite near the surface, or from being so placed that water rises through its permeable soil from higher levels. Water may then be found within 3 or 4 feet of the surface; and in this case the sand is unhealthy and often malarious. Impurities are retained in it and effluvia traverse it. " In a third class of cases the sands are unhealthy because they contain soluble mineral matter. Many sands (as, for ex- CHARACTER OF THE SOIL. 157 ample, in the Punjab) contain magnesium carbonate and lime- salts, as well as salts of the alkalies. The drinking-water may thus contain large quantities of sodium chloride, sodium carbon- ate, and even lime and magnesian salts and iron. Without examination of the water it is impossible to detect these points. "8. Clay, Dense Marls, and Alluvial Soils Generally.- These are always regarded with suspicion. Water neither runs off nor runs through; the air is moist; marshes are common; the composition of the water varies, but it is often impure with lime and soda salts. In alluvial soils there are often alterations of thin strata of sand, and sandy, impermeable clay. Much vegetable matter is often mixed with this, and air and water are both impure. " The deltas of great rivers present these alluvial characters in the highest degree, and should not be chosen for sites. If they must be taken, only the most thorough drainage can make them healthy. It is astonishing, however, what good can be effected by the drainage of even a small area, quite insufficient to affect the general atmosphere of the place; this shows that it is the local dampness and the effluvia which are the most hurtful. "9. Cultivated Soils.-Well-cultivated soils are often healthy; nor at present has it been proved that the use of manure is hurtful. Irrigated lands, and especially rice-fields, which not only give a great surface for evaporation, but also send up organic matter into the air, are hurtful. In Northern Italy, where there is a very perfect system of irrigation, the rice- grounds are ordered to be kept 14 kilometres (8.7 miles) from the chief cities, 9 kilometres (5.6 miles) from the lesser citiesand the forts, and 1 kilometre (1094 yards) from the smaller towns. In the rice countries of India [and America] this point should not be overlooked." Where a wet, impermeable, or impure soil must, of neces- sity, be chosen as a building-site, it should be thoroughly drained. The minimum depth at which drains are laid should 158 TEXT-BOOK OF HYGIENE. be not less than 1| metres below the floor of the cellar or base- ment. Such a soil should be covered with a thick, impervious layer of asphaltum or similar cement under the house, in order to prevent the aspiration of the polluted ground-air into the building. It is a frequent custom in cities to fill in irregularities of the building-site with street-sweepings and garbage, which always contain large quantities of decomposing organic jnatters. This is a gross violation of the plainest principles of hygiene. It is almost equally reprehensible to use such decaying or putrefying organic material for the purpose of grading streets or sidewalks in cities and towns.1 It should be the constant endeavor of all sanitary authorities to prevent pollution of the soil as much as possible in villages, towns, and cities. Where houses are built on the declivity of a hill, the upper wall should not be built directly against the ground, as it would tend to keep the wall damp. A vacant space should be left between the wall and the ground to permit free access of air and light. In addition to, or in default of, drainage, the drying of soil can be promoted by rapidly-growing plants, which absorb water from the soil and give it out to the air. The sunflower and the eucalyptus tree are the most available for this purpose. III. THE MATERIAL OF WHICH THE HOUSE IS BUILT. The nature of the most appropriate building material de- pends upon so many collateral circumstances that definite rules cannot be laid down. As a general rule, moderately hard burned brick is the most serviceable and available material. It is easdy permeable by the air, and so permits natural ventila- tion through the walls, unless this is prevented by other means. 1 During the very fatal epidemic of yellow fever in New Orleans, in 1878, it was ascer- tained that a contractor for street-work used the garbage and street-scrapings to grade the bed of the streets. Even though in this case it may not have intensified the epidemic in these localities, the practice is so contrary to the simplest sanitary laws that it should nowhere be tolerated. The author is aware, however, that the "made-ground" of nearly every city in this country is composed largely of just such material. All sanitarians should protest against a continuance of this pernicious practice. 159 MATERIAL OF WHICH THE HOUSE IS BUILT. It does not absorb and hold water readily; hence, damp walls are infrequent if brick is used. It is probably, of all building material, the most durable. On account of its porosity a brick wTall is a poor conductor of heat. It therefore prevents the rapid cooling of a room in cold weather, and likewise retards the heating of the inside air from without in summer. Another very great advantage is its resistance to a very high degree of heat, brick being probably more nearly fire-proof than any other building material. In hot climates light wooden buildings are advantageous, because they cool off very rapidly after the sun has disappeared. On account of the numerous joints and fissures in a frame building, natural ventilation goes on very readily and to a con- siderable extent. Next to brick, granite, marble, and sandstone are the most serviceable building materials. Very porous sandstone is, how- ever, not very durable in cold climates, as the stone absorbs large quantities of water, which, in consequence of the expansion accompanying the act of freezing, produces a gradual but progressive disintegration. The application of paint to the walls, either within or with- out, almost completely checks the transpiration of air through the walls, thus limiting natural ventilation. Calcimining, on the other hand, offers very little obstruction to the passage of air. Wall-paper is about midway between paint and lime- coating in its obstructive effect on atmospheric transpiration. Newly-built houses should not be occupied until the walls have become dry. Moisture in the walls is probably a not infrequent source of ill health; it offers favorable conditions for the development of fungi (possibly of disease-germs), and, by filling up the pores of the material of which the walls are composed, prevents the free transpiration of air through them. Moisture of the walls is sometimes due to the ascent of the water from the soil by capillary attraction. This can be 160 TEXT-BOOK OF HYGIENE. prevented by interposing an impervious layer of slate in the foundation-wall. Where the moisture is due to the rain beating against the outside walls, and thus saturating them if composed of porous materials, a thorough external coating of impervious paint will prove a good remedy. IV. INTERIOR ARRANGEMENTS. A. Size of Rooms, and Ventilating and Heating Arrange- ments.-The rooms in dwelling-houses should never be under 2 J metres in height from floor to ceiling. In sleeping-rooms the initial air-space should never be less than 35 cubic metres for adults, and 25 cubic metres for children under 10 years of age. Provision must be made for changing this air sufficiently often to maintain it at its standard of purity; i.e., less than 7 parts of carbon dioxide per 10,000. The details for accomplish- ing this will vary with the architects' designs, the material of which the house is constructed, the climate, and the season. The principles laid down in the section on ventilation (Chapter I) should be adhered to. In cold weather the air should be warmed, either before its entrance into the room or afterward, by stove or fire-place. Galton's jacketed stove, or fire-place, seems to answer this purpose admirably. The details of the heating apparatus must be left to individual taste, or other circum- stances. It may be noted, however, in passing, that the pre- vailing method of heating houses by means of hot air is objec- tionable for various reasons; partly, because the air is usually too dry to be comfortable to the respiratory organs; partly, because organic matter is frequently present in large proportions, and gives the air an offensive odor when the degree of heat is high enough to scorch the organic matter. Both these objections are, however, removable; the first, by keeping a vessel of water constantly in the furnace, so that the hot air can take up a sufficient proportion of vapor in passing through, and, the second, by having the furnace made large enough so that the tempera- 161 INTERIOR ARRANGEMENTS. ture need never be raised to a very high degree. Heating by hot water or steam is preferable to the hot-air furnace. Both of these methods are, however, more expensive. Where special ventilating arrangements are necessary, air- a, a, sash; b, b, window-jambs; c, c, window- sill. This cut represents the view from within the Bury Ventil,ator, in operation. It is broken away at one end to show the sash raised above the outer holes to admit the air. Fig. 6. a, a, sash. This cut represents the view from without the Bury Ventilator, in operation. The sash is broken away to show the ven- tilator behind, with the fresh air passing in. Fig. 7. inlets may be inserted at appropriate points in the walls of the room, facing toward the air. A simple arrangement is that known as the Bury Ventilator, shown in Figs. 6 and 7. It consists of a wooden block interposed between the bottom of the lower 162 TEXT-BOOK OF HYGIENE. window-sash and the window-frame. The air passes into the room through the openings in the block, as shown in the illustration. The separation of the upper and lower sashes, when the ventilator Fig. 8.-Ventilation of a Room Containing an Open Fike-place. is in place, also adds to the efficiency of the ventilation, as the air passes in through the space so formed. A cheaper ventilator can be made by simply tacking a strip INTERIOR ARRANGEMENTS. 163 of canvas, binders' board, or manilla paper, 20 to 25 centimetres wide, across the lower portion of the window-frame, and then raising the sash 10 to 15 centimetres. The air will pass in under the lower and between the lower and upper sashes and pass upward toward the ceiling and then gradually diffuse itself through the room. In summer a counter-opening may be ob- tained for the escape of foul air by lowering the upper sash, while in winter a stove or fire-place will furnish a good exit. Fig. 8 shows the probable course of the air-currents in a room ventilated by means of a fresh-air inlet near the ceiling and an open fire-place. A is the inlet; C the fire-place; G the floor; F, ceiling; E E, flues. B. Internal Wall-Coating.-A point of considerable im- portance in the outfitting of dwelling-houses is the material used for coating or decorating the inside of the walls. Green paint and green-colored wall-papers should be rejected. The reason for avoiding this color is the following : Bright-green pigments and dyes are largely composed of some compound of arsenic, which becomes detached from the wall or paper when dry. and, being inhaled, produces a train of symptoms which have been recognized as chronic arsenical poisoning. Many cases have been reported in which serious and even fatal poison- ing has been produced in this way.1 It would be advisable, therefore, to discard all bright-green tints in paints and orna- mental paper-hangings. C. Lighting.-Provision should be made in all dwelling- houses for an abundant supply of sunlight. Every room should have at least one window opening directly to the sun. It is not sufficient to give an ample window-space, which should be in the proportion of one to five or six of floor-space, but the im- mediate surroundings of the house must be taken into account. Thus, close proximity of other buildings, or of trees, may pre- vent sufficient light entering a room, although the window- 1 Arsenic in Certain Green Colors, F. W. Draper. Third Annual Report Mass. State Board of Health, 1872, pp. 18-57. 164 TEXT-BOOK OF HYGIENE. space may be in excess of that required under ordinary circumstances. Some form of artificial light will also be needed in all dwellings. Certain dangers are necessary accompaniments of all available methods of artificial illumination. The danger from fire is, of course, the most serious. This danger is prob- ably least where candles are used, and greatest where the more volatile oils (kerosene, gasolene) are employed. The use of candles results in pollution of the air by carbon dioxide and other products of combustion to a greater degree than when other illuminating agents are used; they also give out a larger amount of heat in proportion to their power of illumination. Kerosene gives a good light when burned in a proper lamp, and is cheap, but the dangers from explosion and fire are consider- able. The danger from explosion can be greatly reduced by always keeping the lamp filled nearly to the top, and never fill- ing it near a light or fire. The danger of explosion is increased when the chimney of the lamp is broken, as then the tempera- ture of the metal collar, by which the burner is fastened to the lamp, is rapidly raised1 and the oil vaporized. If, at the same time, the lamp is only partially filled with oil, the space above it is occupied by an explosive mixture of air and the vapor of the oil. If this is heated to a sufficient degree an explosion will take place.2 The use of coal-gas is probably attended by less danger than the lighter oils, but by more than other means of illumina- tion. In addition to the dangers from fire and explosions, which are inevitable accompaniments of defects in the fixtures, the escaping gas is itself exceedingly poisonous from the large amount of carbon monoxide it contains. It is, in fact, a very frequent occurrence in large cities that persons are killed by the inhalation of gas which has escaped from the fixtures or was 1 H. B. Baker, in Report Mich. State Board of Health, 1876, p. 48. 2 See an instructive paper by Prof. R. C. Kedzie, in Report Mich. State Board of Health for 1877, p. 71 et seq. 165 INTERIOR ARRANGEMENTS. allowed to escape from the burner through ignorance. That variety of illuminating gas known as "water-gas" is more dan- gerous to inhale than coal-gas owing to the larger proportion of carbon monoxide contained in it. The "natural gas" used as a fuel and illuminant in some places in the United States is espe- cially dangerous from the total absence of odor. The gas may escape in large quantity and fail to give notice of its presence except by an explosion, if ignited, or by producing asphyxia in those who incautiously venture into the air permeated by it. The electric light (Edison's incandescent system) is prob- ably open to less objection on the score of danger than any other of the illuminating systems mentioned. There is no trust- worthy evidence that the electric light has any unfavorable in- fluence on the vision, although Regnault supposed it would have a bad effect upon the ocular humors on account of the large proportion of the violet and ultra-violet rays it contained. In order to remove this objection Bouchardat advised the wearing of yellow glasses by those compelled to use this light for close work. The advantages of the incandescent light, besides the brilliant white light it gives, are that it is steady and does not produce any heat, nor does it pollute the air with carbon dioxide and other products of combustion. Professor von Pettenkofer has recently shown experimentally that the pollution of the air by the products of combustion is very much greater when gas is used than where the electric light is employed. The electric arc-lights are extremely dangerous on account of the high poten- tial maintained in the wires, and the difficulty of thoroughly insulating the latter. Many deaths have occurred from this source, and, unless a method is discovered and adopted by which the voltage of the arc-light current can be greatly dimin- ished without decreasing the efficiency of the light, this method of lighting must soon be given up in cities, owing to its danger, not only to those directly brought in contact with the conductors, but to others who may indirectly get in the way of the errant current. 166 TEXT-BOOK OF HYGIENE. In writing, sewing, reading, or other work requiring a con- stant use of accurate vision, the light, whether natural or artifi- cial, should fall upon the object from above and on the left side. Hence, windows and burners should be at least at the height of the shoulder and to the left of the person using the light. Increased ventilation facilities must be provided where arti- ficial light (except the electric light) is used to any extent. It has been calculated that for every lighted gas-burner 12 to 15 cubic metres of fresh air per hour must be furnished in addition to the amount ordinarily required in order to maintain the air of the room at the standard of purity. V.-WATER-SUPPLY. The water-supply of a dwelling-house should be plentiful for all requirements, and its distribution should be so arranged that the supply for every room is easily accessible. Where prac- ticable, water-taps should be placed on every floor, both for convenience and for greater safety in case of fire. It is also a result of observation that personal habits of cleanliness increase in a direct ratio with the ease of obtaining the cleansing agent. The inmates of a house where water is obtainable with little exertion are much more likely to be cleanly in habits than where the water-supply is deficient or not readily procured. VI.-HOUSE-DRAINAGE. Provision must be made for the rapid and thorough removal of waste-water and excrementitious substances from the house. This is most easily and completely accomplished by well-con- structed water-closets and sinks. Water-closets should, however, not be tolerated in any room occupied as a living- or bed- room. It would doubtless be very much more in accordance with sani- tary requirements to have all permanent water-fixtures, water- closets, and bathing arrangements placed in an annex to the dwelling proper. In this way the most serious danger from water-closets and all arrangements having a connection with a HOUSE-DRAINAGE. 167 cess-pool or common sewer-permeation of the house by sewer- air-could be avoided. Water-closets, however, presuppose an abundant supply of water. Unless this can be obtained and rendered available for flushing the closets, soil-pipe, and house-drain, the dry-earth or pail system should be adopted. Privies should not be coun- tenanced. Experience in several large cities of Europe has demonstrated1 that the pail system can be adopted with advan- tage and satisfactorily managed even in large communities. As house-drainage may be considered the first and most important link in a good sewerage system, a brief description will be here given of the details of the drainage arrangements of a dwelling-house. The rapid and complete removal of all faecal and urinary discharges, lavatory- and bath- wastes, and kitchen-slops must be provided for. For these purposes are needed, first, water-closets and urinals, wash-basins and bath- tubs, and kitchen- or slop- sinks; second, a perpendicular pipe, with which the foregoing are connected, termed the soil-pipe; and, third, a horizontal pipe, or house-drain, connecting with the common cess-pool or sewer. A. Water- Closets -There are five classes of water-closets in general use. They are the pan-, valve-, plunger-, hopper-, and washout- closets. Pan-closets are those found in most old houses containing water-closet fixtures. Just under the bowl of the closet is a shallow pan containing a little water, in which the dejections are received. On raising the handle of the closet, the pan is tilted and the water at the same time is turned on, which washes out the excrement and sends it into or through the trap between the closet and the soil-pipe. It will be readily understood that the space required for the movement of the pan-the " container," as it is termed-is rarely thoroughly cleansed by the passage of water through it. Faecal matter, paper, etc., gradually accumu- late in the corners of the container, and, as a consequence, pan- 1 See Chapter v, p. 139. 168 TEXT-BOOK OF HYGIENE. closets are always, after a brief period of use, foul. There are other defects in the construction of the pan-closet which render it untrustworthy, but the one especially pointed out-the impos- sibility of keeping it clean-is enough to absolutely condemn its use, from a sanitary point of view. It is decidedly the worst form of closet that can be used. Valve-closets are merely modifications of the pan-closet. The bottom of the bowl is closed by a flat valve, which is held in its place by a weight. By moving a lever the valve is turned down, allowing the excreta to drop into the container. The only differences between the pan- and valve- closets are that in the latter a flat valve is substituted for the pan of the former, and that this allows the container to be made smaller. Otherwise, there are no advantages in the valve-closet. Considered from a sanitary stand-point, the valve-closet is no worse than the pan- closet, and but very little, if any, better. The third variety, or plunger-closet, has several marked advantages over the two just described. The characteristic feature of the closets of this class is that the outlet, which is generally on one side of the bowl, is closed by a plunger. This bowl is always from one-third to one-half full of water, into which the excreta fall. On raising the plunger, the entire contents of the bowl are rapidly swept out of the apparatus into the soil- pipe, the bowl thoroughly washed out by a sudden discharge of water, and, on closing the outlet with the plunger, the bowl is again partly filled with water. An overflow attachment prevents accumulation of too large a quantity of water in the bowl. This overflow, however, sometimes becomes very foul and objection- able. The Jennings, Demarest, and Hygeia are types of this class. The principal objection is that the plunger sometimes fails to properly close the outlet, allowing the water to drain out of the bowl, and thus destroying one of its principal advantages. The mechanism is also somewhat complicated and likely to get out of order. The hopper-closet consists of a deep earthenware or enameled HOUSE-DRAINAGE. 169 iron bowl, with a water-seal trap directly underneath. The excreta are received directly into the proximal end of the trap, and when the water is turned on the sides of the bowl are washed clean and everything in the bowl and trap swept directly into the soil-pipe. There is no complicated mechanism to get out of order, the trap is always in sight, and the entire appa- ratus can always be kept clean and inoffensive, as there are no hidden corners or angles for filth to lodge. This form of closet is, all things considered, one of the best for general use. Fig. 9.-The "Dececo" Closet. (New Form.) The " wash-out " closets are of various shapes, some having the trap in the bowl itself, others having a double water-trap. They are generally simple in construction, and not likely to get out of order. They do not present any decided advantages over the simple hopper, although at the present time they are more used than any other form of closet. Of the recent improvements in this form of closet may be mentioned the "A. G. M.,"1 shown 1 Manufactured by the Myers Sanitary Depot, New York. 170 TEXT-BOOK OF HYGIENE. Fig. 10.-The "A. G. M." Closet. HOUSE-DRAINAGE. 171 in view with cistern in Fig. 10, and in section in Fig. 11, and the " Dececo," Fig. 9, invented by Col. George E. Waring. In the latter the automatic siphon principle, so ingeniously used by Rogers Field in the construction of the automatic flush-tank, is applied to the scouring of a water-closet. Practical experi- ence for six or seven years has demonstrated the great usefulness of this closet. If the delivery of water from the flushing-cistern is properly regulated, at first rapid to thoroughly wash out the Fig. 11.-Sectional View of "A. G. M." Closet. closet and connections, and then slow to re-establish the proper depth of seal in the trap, the closet should be thoroughly satis- factory in its working. Water-closets should not be inclosed in wooden casings, as is almost universally done. Everything connected with the closet, soil- and drain- pipes, water-supply, and all joints and fix- tures should be exposed to view so that the defects can be imme- diately seen and easily corrected. By laying the floor and back of the closet in tiles or cement, such an arrangement can even 172 TEXT-BOOK OF HYGIENE. be made ornamental, as suggested by Waring,1 who says that a closet " made of white earthenware, and standing as a white vase in a floor of white tiles, the back and side walls being similarly tiled, there being no mechanism of any kind under the seat, is not only most cleanly and attractive in appearance, but entirely open to inspection and ventilation. The seat for this closet is simply a well-finished hard-wood board, resting on cleats a little higher than the top of the vase, and hinged so that it may be conveniently turned up, exposing the closet for thorough cleansing, or for use as a urinal or slop-hopper." Where the arrangement here described is adopted, extra urinals are unnecessary and undesirable. Where they are used they should be constantly and freely flushed with water, other- wise they become very offensive. The floor of the urinal should be either of tiling or enameled iron. B. Water-Supply for Closets.-The water-supply for flush- ing water-closets should not be taken directly from the common house-water supply, but each closet should have an independent cistern large enough to hold a sufficient quantity of water for a thorough flushing (20 to 30 litres) every time the closet is used. The objections to connecting the water-closet directly with the common house-supply are, that there is often too little head of water to properly flush the basin; and, secondly, if the water be drawn from a fixture in the lower part of the house, while the valve of a water-closet in an upper floor is open at the same time, the water will not flow in the latter (unless the supply- pipe is very large), but the foul air from the closet will enter the water-pipe, and may thus produce dangerous fouling of the drinking-water. Hence, separate cisterns for each water-closet should always be insisted upon. The arrangement of these cisterns is often difficult to com- prehend. Fig. 12 shows the interior arrangement of one form. The ball-shaped float, a, cuts off the supply when the tank is full, while opening the valve, b, by means of the crank, c, dis- » Sanitary Condition of New York City, Scribner's Monthly, vol. xxii, No 2, June, 1881. HOUSE-DRAINAGE. 173 charges the water. The rounded annex, d, contains enough water to partly fill the closet-bowl and trap after the contents have been washed out by the rapid flush. C. Traps.-Every water-closet, urinal, wash-basin, bath- tub, and kitchen-sink should have an appropriate trap between the fixture and the soil-pipe. The trap should be placed as near the fixture as practicable, as pointed out above; in the best forms of water-closet the bottom of the closet itself forms part of the trap. Fig. 12.-Flushing Cistern for Water-Closets. Traps differ in shape and mechanism. The simplest and usually efficient is the ordinary S-trap (Fig. 13). This trap is of uniform diameter throughout, and has no angles for the lodg- ment of filth. A free flush of water cleanses it perfectly, and it rarely fails to furnish a sufficient obstruction to the passage of sewer-air from the soil-pipe, unless the water has evaporated, or been forced out under a back-pressure of air in the soil-pipe, or been siphoned out, and thus the seal broken. 174 TEXT-BOOK OF HYGIENE. The D-trap and bottle-trap are objectionable on account of the great liability of becoming fouled by filth lodging in the corners, while in the mechanical traps, like Bowers' ball-valve trap, CudelTs trap, and others of this class, there is always danger of insufficient seal by filth adhering to the valve, and thus preventing its exact closure. Most of the traps now furnished by the dealers in plumbers' supplies have an opening in the highest part for attaching a vent-pipe. It has been found that the seal in most traps can be broken by siphonage, if the pressure of air on the distal side (the side toward the soil-pipe) of the trap is diminished, or, on the other hand, by increase of pressure in the soil-pipe the water in the trap may be forced back into the fixture, and thus sewer-air enter the room. By providing for a free entrance and exit of air to the trap this breaking of the seal can be prevented. The ventilation of traps is, however, an evil, as it furnishes an additional means of evaporation, and when the fixture is not in frequent (daily) use the seal is sooner broken. The elaborate extra system of ventilation of traps, so generally insisted upon by plumbers and sanitary engineers, is unnecessary. If the soil-pipe is of the proper size and height, siphonage of traps will not be likely to occur. The waste-pipe connecting the fixture and the soil-pipe should be as short as possible; in other words, all water-closets, urinals, baths, and lavatories should be placed as near the soil-pipe as practicable, in order to have no long reaches of foul waste-pipe under floors or in rooms. Dr. E. S. McClellan has recently invented a trap which obviates many of the objections urged against all previous de- vices, and is intended to meet the defects of the S and other traps. It consists of a body containing a light, inverted cup, with its edges resting in an annular groove containing mercury, which forms an absolute seal against the escape of sewer-air. When Fig. 13.-S-Trap. HOUSE-DRAINAGE. 175 a slight diminution of pressure occurs on the sewer side of the cup, the greater external pressure lifts the cup out of the mercury and permits a free inflow of air until the wonted equilibrium is re-established, when the cup drops back into the mercury by gravity, and effectually closes the trap against any outflow. With this trap siphonage of the seal is impossible. Fig. 14 shows this trap with the cup down, and Fig. 15 with the cup raised, allowing inflow of air. For an ordinary wash-bowl or bath-waste (which should Fig. 14.-Sectional View of Vent, with Cup in Normal Position. Fig. 15.-Sectional View of Vent, with Cup Lifted Out of the Mercury by the Inflowing Current of Air Indicated by the Arrows. always be trapped), the Connolly globe-trap, shown in Figs. 16 and 17, is an excellent fixture. It is impossible, under ordinary circumstances, to break the seal by siphonage. D. The Soil-Pipe.-The vertical pipe connecting the water-closets and other fixtures with the house-drain is called the soil-pipe. It should be of iron, securely jointed, of an equal diameter (usually 10 centimetres) throughout, and extend from the house-drain to from II to 2 metres above the highest point of the house. The connections of all the waste-pipes from water-closets, baths, etc., should be at an acute angle, in order 176 TEXT-BOOK OF HYGIENE. that an inflow at or nearly at right angles may not produce an obstruction in the free passage of air up and down the soil-pipe. The diameter of the soil-pipe, at its free upper end, should not be narrowed; in fact, according to Col. Geo. E. Waring, the up-draught is rendered more decided if the upper extremity of the soil-pipe is widened.1 The internal surface of the pipe should be smooth, and especial care should be taken to prevent projections inward at the joints; otherwise, paper and other Fig. 18.-Connolly Globe-Trap. Fig. 17.-Globe-Trap Attached to Basin. matters will adhere to the projections, and gradually obstruct the pipe. E. The House-Drain.-The horizontal or slightly inclined pipe which connects the lower end of the soil-pipe with the sewer or cess-pool, the point of final discharge from the house, should be of the same diameter and material as the soil-pipe. The joints should be made with equal care, and the pipe should be exposed to view throughout while within the house-walls. * Am. Architect, p. 124, Sept. 15,1883. HOUSE-DRAINAGE. 177 If sunk below the floor of the cellar it should be laid in a covered trench, so that it may be readily inspected. The junc- tion between the vertical and horizontal pipe should not be at a right angle, but the angle should be rounded. The drain-pipe should not be trapped. This is contrary to the advice of sanitary authorities generally, but the author thinks it unadvisable to trap the drain-pipe. There should be no obstruction to the outflow of sewage from the house, and a trap in the drain-pipe is of no avail against the passage of sewer-air from the sewer or cess- pool into the soil-pipe, if the pressure of the air in the former is increased. Furthermore, if the passage of air backward and forward between the sewer and the external air at a sufficient height (above the roofs of houses, for example) is free and unobstructed, the sewers (or the cess-pool, as the case may be) will be better ventilated than if an obstruction to such free circulation, in the form of a trap, be placed in the drain-pipe. Nearly all sanitary authorities direct that an opening for the admission of fresh air-"fresh-air inlet"-should be made in the drain-pipe, before its connection with the sewer or cess- pool. This is done with the view of having a constant current of fresh air entering near the base of the soil-pipe and passing upward through it. Theoretically the current ought always to pass in this direction. Practically, however, the current is found, at times, to pass the other way, and the foul air from the soil-pipe may be discharged into the air near the ground, where it would be much more likely to do harm than when discharged high up in the air beyond the possibility of being breathed. OFFICIAL SUPERVISION OF THE SANITARY ARRANGEMENTS OF DWELLINGS. In most cities and towns the municipal authorities have provided for an official inspection of buildings, to prevent neglect of precautions against fire and other manifest dangers to life. It is only very recently, however, that the authorities of some of the larger cities in this country have enacted laws to prevent 178 TEXT-BOOK OF HYGIENE. improper construction of house-drainage works. Although none of these laws or ordinances cover the subject completely, yet their proper enforcement must result in great advantage. Within the past few years, following the example of Edin- burgh, volunteer associations have been organized in various cities of this country, with the object of securing constant expert inspection and supervision of the drainage arrangements of dwellings and other necessary sanitary improvements. The good results accomplished by the Newport Sanitary Protection Society, the New Orleans Auxiliary Sanitary Associa- tion, and other similar bodies attest the usefulness of such organizations. [The following works are recommended to the student who desires a fuller knowledge on the subjects treated in this chapter:- W. II. Corfield, Dwelling-Houses, Their Sanitary Construction and Arrangements, N. Y., 1880.-Wm. Paul Gerhard, House-Drainage and Sanitary Plumbing, Fourth Report State Board of Health of R. I., 1881.-Eliot C. Clarke, Common Defects in House-Drains, Tenth Annual Report Mass. State Board of Health, 1879.J CHAPTER VII. Construction of Hospitals. SITE. If the choice of a site for the habitations of healthy per- sons is a matter of vital importance, as was pointed out in the last chapter, it needs no argument to impress upon the reader the actual necessity of choosing a site with wholesome surround- ings for a habitation for the sick. In selecting a site for a hos- pital, therefore, it is of prime importance to avoid a location where unsanitary influences prevail. While a hospital should always be easily accessible, it is not desirable that it should be in a noisy or crowded part of a city. Where a hospital is primarily designed for the reception of accident or " emergency " cases, it is, of course, necessary to have it near to where accidents are likely to occur. In a city this will probably be in the most crowded and noisy part. The direction of the prevailing winds from the city should be avoided in selecting a site for a hospital. Free admission of sunlight and air must be secured to all parts of the hospital. An elevated location is therefore desir- able, although exposure to violent winds must, if possible, be avoided. The soil upon which a hospital is built should be clean, easily drained, with a deep-ground water-level, not liable to sudden oscillations. The neighborhood of a marshy or known malarious region should be avoided. THE BUILDINGS. The building area must be large enough to permit the construction of buildings in accordance with the modern recog- nized principles of hospital construction. Overcrowding is not 179 180 TEXT-BOOK OF HYGIENE. permissible, either of the grounds by buildings or of the build- ings by patients. Having determined the number of patients for whom pro- vision is to be made and the character of the diseases to be treated, an estimate must be made of the area necessary for a hospital. Taking into account all the buildings needed, the area required will be-for two or more storied buildings-not less than 30 square metres per bed. If one-story buildings are to be erected more space will be required, and if infectious diseases are to be treated in the hospital the above space-allowance must be doubled or trebled. In the new Johns Hopkins Hos- pital, in Baltimore, the area occupied by the buildings is 56,000 square metres, and provision is to be made for 300 patients. This, covering, of course, the area occupied by the administra- tion building, nurses' home, kitchen, dispensary, operating and autopsy theatre, laundry, etc., gives an area of 187 square metres per bed. The actual allowance of floor space per bed is 11J square metres; for patients with infectious diseases the space- hllowance is nearly treble, being 29 square metres. Within recent years the principles of hospital construction have undergone considerable modification. While formerly a large hospital consisted usually of one large, two or more storied building, in which all the various departments were comprised under one roof, the aim has recently been to scatter the wards as much as practicable consistent with reasonable ease of supervision and administration. Under the former plan, with large wards connected by common corridors and stairways, ease of administration was primarily secured; in the latter, the most important object of a hospital, "a place for the sick to get well in," is more nearly attained. While many hospitals are still being constructed on the old plan, of a single block of several stories in height, nearly all sanitary authorities are agreed that the plan of separate pavilions of one or, at most, two stories, in which the buildings are entirely disconnected, or connected only by means of an open corridor for convenience of THE HOSPITAL BUILDINGS. 181 administration, is best for the patients, and, leaving out of account the cost of the ground, is also the most economical. The recent development of the pavilion system of hospitals may be attributed largely to the success obtained in treating the sick and wounded in the simple barrack hospitals during the late war between the States. The army barrack hospital is the original type of the pavilion hospital of the present day. Each pavilion consists of one or two wards, containing from ten to thirty beds altogether. In each pavilion or ward is also a bath- and wash- room, water-closet, dining-room, scullery, attendants' room, and sometimes a day-room for patients able to be out of bed. The two-story pavilion is built on the same plan, and is generally adopted in cities, or where economy of space is desir- able for financial reasons, and where no infectious diseases are treated. Where practicable, one-story pavilions should always be adopted, as they are more easily heated, ventilated, and served than two-storied buildings. When a number of pavilions or wards are connected by a corridor with each other, and with a central or administration building and other service buildings, the aggregation constitutes a modern pavilion block-hospital. The Johns Hopkins Hos- pital, already referred to, is a model hospital of this class, and its plans should be studied in detail by all who are more par- ticularly interested in hospital construction. The general wards are in one- and two- story buildings, connected by a corridor with each other and with the administration and service buildings. In addition to two buildings containing private rooms and small wards for patients able to pay for the extra accommodations, there is a line of pavilions running from east to west. The corridor cuts all the pavilions near the north ends of the build- ings, separating the ward almost entirely from the service part of the building. This arrangement leaves the south, east, and west fronts of the wards entirely exposed to the sun's rays,- a very important advantage. The kitchen and laundry are at 182 TEXT-BOOK OF HYGIENE. opposite angles of the grounds, while the autopsy building is placed in the extreme northeast corner of the grounds, as far from all the wards as practicable. The free space between the separate pavilions should be at A. Administration Building. B. Female Pay-Ward. C. Male Pay-Ward. D. Male Surgical Ward. E. Female Surgical Ward. F. Male Medical Ward. G. Female Medical Ward. H. Gynaecological Ward. I. Isolating Ward. K. Kitchen. L. Laundry. N. Nurses' Home. O. Dispensary. R. Patho- logical Building. 8. Stable. U. Amphitheatre. X. Apothecary's Building. Y. Bath-House. Fig. 18.-Plan of Johns Hopkins Hospital. least twice the height of the building. In the Johns Hopkins Hospital, the space is 18 metres between the one-story common wards, which are 11 metres in height from the surface of the ground to the ridge of the roof. VENTILATION AND HEATING. 183 VENTILATION AND HEATING. The cubic space (initial air-space) per bed in the wards should not be less than 1500 to 2000 cubic feet (42 to 56 cubic metres), and for surgical or lying-in cases and contagious dis- eases, 70 cubic metres should be allowed. The ventilating arrangements should secure an entire change of the air two to three times in an hour. In most sections of the United States, natural ventilation can be relied on to keep the air in hospital wards pure (assum- ing, of course, the proper construction of the buildings). The windows, doors, and walls are important factors in securing this ventilation. Hence, especial care is to be paid to their con- struction and arrangement. Many German, French, and English authorities on hospital building urge the importance of making the walls impervious by cement, glass, or paint. The peculiar odor known as " hos- pital odor," it is asserted, cannot be prevented in any hospital in which the floors, walls, and ceilings are not absolutely imper- vious. The American practice is generally in favor of walls which permit transpiration of air. In the experience of the author the imperviousness of the walls is not necessary to secure freedom from hospital odor. It remains a question for serious consideration whether the diminution of natural ventilation would not counterbalance any good resulting from non-absorp- tive walls. The interior of the walls should be perfectly smooth and plain; no projections, cornices, or offsets of any kind are per- missible. The desirability of this restriction was clearly ex- pressed nearly a hundred years ago by John Howard: "From a regard to the health of the patients, I wish to see plain, white walls in hospitals, and no article of ornamental furniture intro- duced."1 Windows should run quite to the coiling, and should not be arched, but finished square at the top. There should be one * An Account of the Principal Lazarettos of Europe, etc., p. 57. London, 179L 184 TEXT-BOOK OF HYGIENE. window for every two beds. The window-sash should be double to retain heat, and the lights heavy, clear glass. Ventilation can be promoted by raising the outer sash from below and lowering the inner one from above. The insertion of a Sher- ringham ventilator at the top of the inner sash will aid in giving the incoming air-current an upward direction. Heating is best accomplished by introducing hot air from without, or by stoves or fire-places in the centre of the wards. Where hot air is introduced from without, it should be heated by passing it over steam- or hot- water coils, and not by passing it through a furnace, which may produce super-heating and excessive dryness of the air. In a series of experiments by Dr. Edward Cowles at the Boston City Hospital,1 the air was heated to 32° by passing it over steam-coils. It was admitted to the wards by numerous inlets 30 centimetres square. The best velocity for ventilating and warming purposes was found to be 54 metres per minute. Exit openings were in the ceiling, and it was found best to make them large, as by this means the rapidity of exit currents is reduced. Where the warming of the ward must be accomplished by stoves or fire-places in the ward, the best plan, for square and octagon wards, is to have a large central chimney with arrange- ments on the four sides for fire-places or stoves. This chimney can also be used as a very efficient ventilating shaft throughout the year by a device put in practice by Mr. John R. Neimsee, architect of the Johns Hopkins Hospital.2 In oblong wards, two or more large stoves, placed at equal distances along the centre of the wards, will heat the wards effectually. Floors should be made of tiles, slate, or oak or yellow-pine lumber. If wood is used, it should be well seasoned, perfectly smooth, and all joints accurately made. The floor should be kept constantly wraxed to render it impervious to fluids. 1 Report of the Massachusetts State Board of Health for 1879, pp. 231-248. 4 Hospital Construction and Organization: Plans for Johns Hopkins Hospital, p. 335 ei seq. New York, 1875. VENTILATION AND HEATING. 185 The space between the floor and ceiling below should be filled with some fire-proof non-conducting material, such as cement or hollow bricks, in order to isolate each floor or ward as much as possible from others, both to prevent transmission of noise and extension of fire. All corners and angles on the inside of the building should be rounded to facilitate the removal of dust. In cleaning up, care should be taken not to stir up the layers of dust too much by active sweeping or dusting. The floors, furniture, door- and window- casings should be wiped off with damp cloths. Soiled bedding, clothing, dressings, and bandages must be promptly removed from the ward. Mat- tresses and other bed-clothing should not be shaken in the ward.1 Water-closets or (where the dry method of removal of ex- creta is in use) earth- or pail- closets should be placed where they can be easily reached by the patients, but the apartment in which they are placed must not open directly into the ward. The entrance to this apartment should be from the corridor or, better still, from the open air. The ventilation of water- closets should be independent of and entirely distinct from that of the ward or other part of the hospital building. It is, of course, unnecessary to more than call attention to the vital importance of the prompt removal of all excreta, both solid and liquid, from the ward or hospital building. To at- tempt disinfection of excreta and allow them to remain in the ward after being voided is a pernicious practice, which should under no circumstances be permitted. All utensils for the re- ception of excreta, bed-pans, etc., should be immediately emptied and thoroughly cleansed. Urinals are not advisable; the simple hopper-closet with hinged, hard-wood seat, as described in Chapter VI, is sufficient. A bath-room and lavatory should be attached to every ward. It should be placed in the service building, and be *A Wernich : Ueber Verdorbene Luft in Krankenrseumen. Volkmann's Sammi. Klin. Vortr., No. 179, p. 24. 186 TEXT-BOOK OF HYGIENE. easily accessible to the patients. There should also be portable bath-tubs in order that baths may be given in the wards when necessary. Every large general hospital should also have a special apartment or building where baths of various kinds, such as medicated, vapor, Turkish, and Russian baths, could be given. In lying-in hospitals, special arrangements for giving vaginal and uterine douches must also be furnished. A daily water-supply of at least 450 litres per bed should be provided. The water should be easily accessible from the wards and various parts of the service building. All water-closets, soil- and waste- pipes must be properly trapped; all joints must be properly made and all sewer con- nections made on the most improved plans. All work of this sort should be properly tested before being accepted, and frequently inspected afterward. No sewer or house-drain should be laid under a ward. A disinfecting chest for disinfecting soiled clothing, bed- ding, dressings, etc., should be placed in the basement of the ward, and connected with the latter by an iron chute, closing perfectly by an iron top. The best and most convenient disin- fectant is steam. This is also the best means to destroy vermin in clothing and bedding. It is questionable whether a nurse's room should be attached to a hospital ward. The nurse's place, when on duty, is in the ward itself, not in a room separate from it. Where there is a nurse's room, it should not be furnished with sleeping arrangements, for this is a strong temptation to neglect of duty on the part of the nurse. A nurse not on duty should not be permitted to remain about the ward. A ward-kitchen should be in the service building, where articles of food can be kept hot or cold when necessary, and where special dressings, cataplasms, hot water, etc., can be pre- pared. A small gas-stove only should be allowed in the ward- kitchen, as the regular meals of the patients are prepared in the ADMINISTRATION AND MANAGEMENT OF A GENERAL HOSPITAL. 187 central kitchen, which should be totally detached from the hospital. The ward-kitchen can be easily utilized as a nurse's room, and in a small hospital can also be used as a store-room for the patients' body- and bed- linen and clothing. The dining-room for patients able to be out of bed should be in the service building. A room with a good light and well ventilated and heated should be selected for this purpose. In the intervals between meals this room could be used as a day- room for such patients as should be out of bed, but who are not able to be in the open air. A dead-house, containing a dead-room, autopsy-room, and a room fitted up for rough microscopic and possibly photo- graphic work, is a necessity to every well-appointed general hospital. The dead-house should be entirely separate from the ward buildings. The kitchen should be separate from the other buildings, and in large hospitals should also be the central station for the heating arrangements, if hot water or steam are to be used. The laundry may be connected with it. The kitchen should be con- nected with the wards by means of a covered corridor to avoid exposure in carrying the food to the wards. The administration building should contain office-rooms for the superintendent and resident physician, pharmacy, library, reception-rooms for visitors, living-rooms for one or more assist- ants, and dwellings for the superintendent and resident physician. THE ADMINISTRATION AND MANAGEMENT OF A GENERAL HOSPITAL. The general management of a hospital should be under the direction of a superintendent, wrho, besides being a medical man, should be especially qualified by study and experience for the work. The superintendent of a large hospital should not be expected to perform any of the routine professional work in the wards, but he should be responsible for the service, both profes- sional and lay, in the hospital. He should be the financial officer, and in all other things concerning the hospital his 188 TEXT-BOOK OF HYGIENE. judgment should decide. lie should have sufficient assistance to permit all necessary duties to be promptly performed. For this purpose he should have a secretary, or clerk, who should not be a medical man; otherwise the attention of the latter misdit be withdrawn from his clerical duties to the more inter- o esting professional work in the hospital. The plan advocated by some authorities, to have two superintendents for large hos- pitals,-one of whom shall be a medical man and direct only the professional work of the hospital, while the other shall have charge of the administrative functions,-does not commend itself to the author. It involves a division of responsibility which will, in nearly all cases, eventually lead to differences of opinion likely to prove unfavorable to the best interests of the hospital. It is customary in this country to appoint as resident physi- cians and surgeons in hospitals, recent graduates, whose functions are usually limited to carrying out the directions of the visiting physicians and surgeons, and sometimes to act on their own responsibility in emergencies. This system has some advantages for the physicians, but is usually detrimental to the best interests of the patients. The resident medical officer in a large hospital should always be a thoroughly qualified, experienced physician, capable of deciding promptly when the occasion arises, and he should be responsible to the superintendent for the proper per- formance of his professional duties. Necessarily, a physician w ith the qualifications indicated, would demand a very much larger salary than is usually paid resident physicians, but it should be understood that no hospital in which the good of the patient is the first consideration can be conducted on a cheap basis. Visiting physicians and surgeons and all resident medical officers should be chosen with reference to their general and special qualifications for the duties expected of them. It would seem to be a good plan to make the selections for subordinate positions, at least, by competitive examination. The sick in a hospital should be properly classified. Male ADMINISTRATION AND MANAGEMENT OF A GENERAL HOSPITAL. 189 and female patients should, of course, be treated in separate wards. A primary classification into medical, surgical, and obstetrical cases or wards is also indicated. Infectious dis- eases, such as typhoid fever, erysipelas, cholera, yellow fever, croupous pneumonia, etc., should not be treated in the same wards with rheumatism, Bright's disease, cardiac and nervous disorders, or simple digestive derangements. It is questionable, however, whether it is advisable to make a very elaborate classi- fication of the various diseases except in very large hospitals. An accurate record, made at the time of observation, and not written from memory afterward, should be kept of the his- tory and progress of every case. The record should show not merely the symptoms and diagnosis, but the medical and hy- gienic treatment. In most hospitals where such records are kept the entries are made either in a simple memorandum-book or in a more or less complicated case-record. A simple form of case-record has been devised by Surgeon Walter Wyman, United States Marine Hospital Service, which seems to possess advantages that render its general adoption desirable. The following convenient form of record for obstetric cases is used in the Maryland Maternite under direction of the author:- Table XIX. Name Date of Admission Registered No Confinement No Labor began, Date Hour Minute Date of Delivery Hour Minute Previous Confinements Obstetric Case-Record of Maryland Maternite. EXTERNAL MEASUREMENTS OF PELVIS. Between Anterior S. S. Processes Between Widest Part of Iliac Crests External Conjugate Diameter DURATION OF LABOR AND CHARACTER OF PAINS. 1st Stage Hours Minutes 2d Stage Hours Minutes 3d Stage Hours Minutes 190 TEXT-BOOK OF HYGIENE. Rupture of Membranes Hour Minute Maternal Pulse During Pains Between Pains Drugs Used Quantity When Operations Performed Pelvis Cervix Perinaeum Date of Beginning Milk Flow Pulse and Temperature for Same Date For Previous Day Method of Delivery of Placenta Position when Delivered Weight ( Length Breadth Thickness Shape Time of Tying Cord Length Spiral Point of Insertion Knots Varicosities Urine Before Labor. 1st Day After Labor. 8th Day After Labor. Specific Gravity Reaction Albumen, percent Sugar Chlorides • 9 A.M. 7 P.M. 1st day 2d " 3d " 4th " 5th " 6th " 7th " 8th " 9th " 10th " PULSE AND TEMPERATURE. CHILD. Presentation and Position Sex Foetal Heart Between Pains During Pains Caput Succedaneum Respiration Circulation Temperature Weight at Birth 3d Day 6th Day Method of Feeding MEASUREMENTS. Length at Birth Length 4th Day ADMINISTRATION AND MANAGEMENT OF A GENERAL HOSPITAL. 191 DIAMETERS. At Birth. 4th Day. Occipito-Frontal Occipito-Mental Suboccipito-Bregmatic Biparietal At Birth. 4th Day. Occipito-Frontal Suboccipito-Bregmatic Shoulders Hips Discharged Name of Nurse CIRCUMFERENCES. In hospitals where cases of surgical diseases and injuries are received, a special apartment should be fitted up as an operating room. Operations should not be performed in a ward in the presence of other patients. [The following works are recommended for additional study upon this subject:- Hospital Construction and Organization; New York, 1875 (espe- cially the essays of Drs. Billings, Folsom, and Stephen Smith).-Kran- kenanstalten,by L. Degen, in V. Pettenkofer und Ziemssen's Handbuch der Hygiene.-Spital, by C. Bohm, in Realencyclopadie d. ges. Heil- kunde, Bd. XII.-General Principles of Hospital Construction, by F. H. Brown, in Buck's Hygiene and Public Health, vol. i.] CHAPTER VIII. Schools. The hygiene of schools comprises the consideration of the sanitary principles underlying the construction of school-houses and school-furniture; the proper amount of time to be devoted to study at different ages ; the special diseases of school-children, their causes, and means for their prevention. CONSTRUCTION OF SCHOOL-HOUSES. In the construction of school-houses the same hygienic principles are applicable as in dwelling-house construction. The selection of a site for the school-building should command the same careful consideration that is necessary in determining upon a site for a dwelling. Proximity to marshes and other unsan- itary surroundings should be avoided. If the soil is damp it should be properly drained, and all sources of insalubrity in the neighborhood avoided or, if possible, removed. School-houses should not be over three stories high; cor- ridors and stairways should be wide, straight, and well lighted. All stairs should be securely built, and be guarded with ample, strong railing. All doors should open outward to permit ready egress and reduce the danger of accident in panics from any cause. In addition to the study- or recitation- rooms, provision should be made for play and calisthenic-exercise rooms. Well- lighted and ventilated side-rooms should be provided for the reception of outside clothing, umbrellas, overshoes, etc. These articles should not be kept in the recitation- or study- rooms. Floors should be made of accurately-joined flooring, and rendered impervious by oil or paraffine coating. 193 194 TEXT-BOOK OF HYGIENE. Appropriate measures must be employed to prevent the permeation of the building by ground-air. The inside walls of school-rooms may be tinted a neutral gray, or light blue or green. Ceilings should be white. Walls and ceilings should not be painted, but lime-coated to permit free transpiration of air. Schools should be so constructed as to permit of ready heating and ventilation, cleaning, and keeping clean. In large schools the method of heating will usually be by furnace-heated air, although a better method would probably be by steam- er hot-water pipes. The ventilation of school-rooms must be carried out on the principles indicated in Chapter I. With careful and intelligent teachers, natural ventilation will give better satisfaction than a complicated artificial system. Where windows and doors must be largely depended upon for ventilation, the Bury window ven- tilator, illustrated on a previous page, will give satisfactory results unless the school-room is overcrowded. Opening the doors and windows when the pupils are out of doors-flushing the rooms with fresh air-is an excellent aid, and is even useful in cases where the most elaborate artificial system of ventilation is in use. A model study-room, according to modem views, should be about 9 to 10 metres long, not over 7 metres wide, and 4 to 4| metres high. Such a room could be easily lighted by win- dows on one side only, and readily heated and ventilated. It would also enable the teacher to exercise a close supervision over his pupils. In a room of this size forty pupils would be a proper number, although fifty could be accommodated. The initial air-space for each pupil would be 5.60 cubic metres if there were fifty pupils in the room, and 7 cubic metres if there were only forty. This would be slightly reduced by the allowance for the teacher. It is believed that study-rooms should face toward the north. The IijHit entering from the north side of a building would be equable during a whole day. While a larger window CONSTRUCTION OF SCHOOL-HOUSES. 195 surface would be necessary than with an easterly or southerly exposure, it is held that the light, being devoid of all glare, would be more effective. Where the light is admitted on the east, south, or west sides of the building, the direct entrance of the sun's rays must be prevented by curtains, by means of which the amount and proper distribution of the light is regulated with difficulty. The windows of the school-room should reach from about the height of the pupil's shoulder (when seated) to nearly or quite to the ceiling. Arches or overhanging cornices over the windows should be avoided, as they cut off much light. For the same reason the near proximity of other high buildings and of trees should be avoided in selecting a site for a school- house. The window area should be not less than one-fifth of the floor area, otherwise the light will be deficient. The light should be admitted only from the left side of the pupil. When admitted from the right side the shadow cast by the pen in writing interferes with good vision; if admitted directly in front of the pupil, the glare of the light will injuri- ously affect the eyes; while, if it enter from behind, the book or paper of the pupil will be so much in shadow as to compel him to lean so far to the front in bringing his eyes nearer to book or paper that nearsightedness is very likely to be devel- oped. Furthermore, if the light is admitted into the room at the backs of the pupils, the eyes of the teacher are liable to suffer from the constant glare. In a school-room of the dimensions above stated, a row of windows on one side, forming an area of glass one-fifth of the floor-space, will thoroughly and satisfactorily illuminate the room, with the least unfavorable influence upon the organs of vision. It is advisable, therefore, to always insist on this arrangement of lighting of school-rooms. Where artificial light is used in a school-room, it should be in the proportion of one burner to every four pupils. All burners should be provided with chimneys and vertical reflectors. 196 TEXT-BOOK OF HYGIENE. Water-closets and privies should not be placed in cellars or basements. This would seem to be self-evident, and yet in many city school-houses these places of retirement are in this unsuitable location. When it is considered that large schools are frequently warmed by hot air taken from the cellar, it furnishes an additional reason to avoid this location for water- closets. On the contrary, the custom, in some country schools, of placing the privy at a considerable distance from the school- room and in an exposed situation, is almost equally reprehen- sible, as the pupils, especially girls, are prone to neglect obeying the calls of nature, from which neglect many disorders arise. In a recently-introduced system of ventilation and excre- ment removal for schools, the closets are in the basement, and the excrement, as voided, is rapidly dried by a current of air, and the odor in this way quickly destroyed. Unfortunately, in thus drying the excrementitious matter, micro-organisms may be taken up in the air-currents and carried into the school-rooms. SCHOOL FURNITURE. Desks should be slightly sloping, the edge nearest the pupil being about 1 inch (2.5 centimetres) higher than his elbows. The front edge of the seat should project a little beyond the near edge of the desk, so that a plumb-line dropped from the latter should strike the seat near its front edge. If the seat is not thus brought slightly under the desk, the pupil is compelled to lean forward in writing, which position prevents proper ex- pansion of the chest and increases the blood-pressure in the eyes,-a condition promotive of near-sightedness. Seats should be only high enough so that the feet rest flat upon the floor. If they are higher, a foot-board must be pro- vided. Children should not be condemned to the cruelty of having their feet dangling " between heaven and earth " while they keep their seats. Seats and desks should be graded according to the sizes of the pupils-not their ages or standing in the class. 197 SCHOOL FURNITURE. An ideal seat and desk would be one made to measure for each pupil, but this is manifestly impracticable, inasmuch as with the constant growth of the child the seats would be rapidly outgrown. The desk shown in Fig. 19 1 is adjustable to children of different sizes, and seems to solve the problem which has so long puzzled the school sanitarian. The desks are made for a single pupil and the seat and desk are independently adjustable. Fig. 19.-Adjustable School-Desk. (Front View.) The frame is of iron and the seat, back, and desk of hard-wood lumber. Blackboards should not be placed at a greater distance than 10 metres from the farthest pupil. The ground of the board should be a dead black, without lustre. In writing exercises upon the board, care should be taken that the letters and figures are made sufficiently large, and with rather heavy strokes of the crayon, in order that they may be easily seen from the most distant part of the room. It has recently been demonstrated that a black letter on a white ground can be seen at a greater distance than 1 Made by the Rushville School Furniture Company, Rushville, Ind., U. S. A. 198 TEXT-BOOK OF HYGIENE. a white letter on a black ground. Hence, it might prove advantageous to the eye-sight of school-children to substitute for the present blackboard and chalk, a white board and black crayon. In some European lecture-rooms this plan has been adopted with satisfaction. AMOUNT OF TIME TO BE DEVOTED TO STUDY. Young children should not be kept at the same study or in the same position for long at a time. The exercises should be frequently varied. It is especially with children in the primary grades that care should be taken not to overburden their minds with too many hours of study, or too long con- tinuance at the same exercise. Children should not be placed in school much, if at all, before the completion of their 7th year. From 7 to 9 years they should be kept at their studies not longer than three hours daily; from 9 to 12 years four hours may be allotted them; and from 12 to 16 years they may be kept at mental work five to six hours daily. This does not mean that pupils are to be kept continuously at their studies during these hours, but that they should be neither compelled nor permitted to study longer than these periods each day. It is believed that these figures repre- sent the capacity for endurance in the majority of children, and they should be adopted in all schools where the largest return in mental acquirements is desired at the least expenditure of health. Excess of time expended in study is almost certainly followed by physical deterioration. " A little less brain: a little more muscle," for our children, is a legitimate demand that we may make of legislators and school-boards. Gymnastic exercises should form part of the daily routine in all schools. These exercises should take place, when practi- cable, in the open air. Playing, romping, laughing, and sing- ing should be encouraged, rather than the natural tendency to boisterous play restrained. It is especially desirable that female children should be encouraged to take part in these DISEASES OF SCHOOL-CHILDREN-. 199 diversions. The desire, on the part of many parents, to see little girls deport themselves as young ladies, before the time even when they write their age in two figures, is very rep- rehensible, and deserves the most unqualified condemnation. Moliere's satirical remark, " Il n'ya plus d'enfants," seems to be literally true at the present day. DISEASES OF SCHOOL-CHILDREN-. The principal diseases incident to school-life are myopia, spinal deformities, nervous and digestive disorders, pulmonary phthisis, and contagious diseases. It is believed that by judi- cious sanitary measures these can all be very much diminished and some entirely prevented. It has been shown by the examination of the eyes of school- children that near-sightedness increases progressively from the lowest to the highest classes. Children who enter school with an hereditary tendency to myopia, or who are, perhaps, already near-sighted to a slight degree, soon become more intensely myopic; while others, who may be even hypermetropic on enter- ing school, will be found to have become near-sighted during school-life. In examinations of over 30,000 pupils of grammar and high schools in Germany, Austria, Russia, and Switzerland, it has been found that the average proportion of near-sightedness is a fraction over 40 per cent., varying, in the different classes, from 22 per cent, for the lowest to 58 per cent, for the highest classes. These figures represent the averages of all the ex- aminations made. In some particular schools, for example in the gymnasium (high school) of Erlangen, the percentage in the higher classes was 88 per cent., in the gymnasium of Coburg 86 per cent., and in the gymnasium of Heidelberg the propor- tion of myopic students in the highest class is said to have reached 100 per cent, in 1877. In the primary schools the per- centage was found to be much lower. Recent investigations in the schools of Stockholm, by Widmark, show that among school-children examined under 7 years of age there was no 200 TEXT-BOOK OF HYGIENE. myopia. In the higher classes the myopia increases not only in degree, but in frequency. The diagrams, Figs. 20 and 21, show graphically the increase in degree and frequency of myopia in the several school-classes. These observations show that the number of myopic individuals bears a constant relation to the intensity of use of the visual organs. The results of the observation of different observers in different countries also Fig. 20.-Myopia According to School-Classes-Boys. uniformly point to the conclusion that not only does the number of near-sighted pupils increase as the higher classes are reached, but the degree of myopia increases likewise. Thus, a pupil who may have only a moderate degree of myopia on entering the school will have myopia in a higher degree as he advances in his classes. Erismann found, on re-examining the same pupils annually, that in six years 13.14 per cent, of those ex- amined had developed myopia from emmetropia, while in 24.57 DISEASES OF SCHOOL-CHILDREN. 201 per cent, of near-sighted pupils the degree of myopia had increased.1 The principal causes of the prevalence of near-sightedness in schools are badly-arranged or insufficient light, bad air, over- heating of the school-rooms, improper construction of desks compelling children to lean forward while reading or writing, and badly-printed text-books. The use of small type, poor paper, and bad press-work in text-books is very reprehensible. The type technically known as Long Primer is the smallest that Fig. 21.-Myopia According to School-Classes-Girds. should be used in text-books. That badly-arranged light and improper seats are causes of myopia has been shown by Flor- schutz in his examinations of the pupils in the public schools of Coburg. He found that in the newer schools, in which the light and seats are better arranged, the percentage of near-sight decreased. The average percentage of those examined in 1874 was 21, while in 1877 it had been reduced to 15,2 showing 1 Erismann, Die Hygiene der Schule, in von Pettenkoffer und Ziemssen's Handbuch der Hygiene, II Th., 2 Abth., p. 30. ' Quoted by Cohn in Realencyclopaedie d. ges. Heilk., Bd. XII, p. 263. 202 TEXT-BOOK OF HYGIENE. the great improvement due to the application of correct sanitary principles in the construction of school-houses. Defective hearing has recently been shown to be especially frequent among school-children. A Berlin aurist found 1392 children out of 5902 (23.6 per cent.) suffering from ear disease of some kind. Dr. Samuel Sexton, of New York, and the late Dr. Chas. F. Percivall, director of music in the public schools of Baltimore, have arrived at similar results after examination of a large number of school-children. Spinal curvature is present in a large proportion of the children attending schools. Statistics are not very full upon this subject, but one author, Guillaume, states tliat he found lateral curvature of the spine in 218 out of 731 school-children, -a proportion of 29.5 per cent. This, of course, includes the slighter degrees of curvature, which cannot properly be termed a disease. Among 30,000 Danish school-children 13 per cent, had some variety or degree of spinal deformity. M. Eulen- burg1 found that among 1000 persons with lateral curvature of the spine, the disease began in 887 between the ages of 6 and 14; that is to say, during the years of school-life. Girls are affected more than ten times as often as boys, the proportion being 93.43 per cent, in the former and only 6.57 per cent, in the latter. The especial causes of spinal curvature occurring during school-life are improperly-constructed seats and desks and an improper position of the body. Many pupils habitually assume a " twisted " position, which is very liable to produce spinal dis- tortion in children of weak muscular development. The manner in which a desk that is too high for the pupil may produce spinal distortion is very well shown in Fig. 22. An improper position is more likely to be unconsciously assumed by girls than by boys. The clothing is responsible for this, for when the girl files into her place behind the desk, her clothing, hanging loosely about her, is swept back and forms a pad, upon which * Realencyclopaedie d. ges. Heilk., Bd. XI, p. 561 DISEASES OF SCHOOL-CHILDREN. 203 she sits with one buttock. The greater elevation of her seat on that side throws the spinal column out of the vertical line, which is compensated by a partial twisting of the trunk. The attention of teachers should be directed to this faulty habit, which can be easily corrected, and its consequences averted by timely interference. Nervous disorders are comparatively frequent among school- children. Headaches are often due to insufficient ventilation, improper food, bad digestion, and excessive mental strain. Defective light may also be the cause of headaches by causing Fig. 22.-Showing Influence of a High Desk in Causing Spinal Curvature. ocular fatigue. Hysterical and imitative affections are not infrequent, and sometimes pass through entire schools, including even the teachers. Girls are, of course, more subject to this class of disorders than boys, but the latter are not entirely exempt. Derangements of the digestive organs are exceedingly frequent among school-children. They can generally be traced to the use of improper food. The eating of cold lunches should be discouraged as much as possible. Nuts, candies, pies, fruit-cakes, and, above all, pickles are 204 TEXT-BOOK OF HYGIENE. most fruitful sources of digestive derangements of children. The absence of proper accommodations to enable children- especially girls-to answer the demands of nature are frequent sources of digestive and nervous disorders. The seeds of pulmonary consumption are frequently im- planted during school-life. A neglected cough ; bad ventilation, under which term may be comprised overheating and cold draughts, as well as polluted air; improper position of the body, excessive mental work, or underfeeding, may, any of them, be the starting-point of this fatal disease. Especial care should be taken to prevent the introduction or dissemination of contagious diseases through schools. The importance of this duty should be at all times impressed upon school-boards and teachers. In the first place, no child should be admitted within the door of the school-room unless it first presents undoubted evidence of protection against small-pox, either by having passed through a previous attack or by a proper vaccination. In case of an actual or threatened epidemic of small-pox the entire school, including teachers, should be vaccinated. Diphtheria has been shown to be frequently spread through the agency of schools.1 This fatal disease demands especial precautions on tlie part of teachers and others involved in the management of schools, to prevent its introduction to these institutions. Children should not be admitted to school coming from a house where there is at the time, or has recently been, a case of contagious disease, such as small-pox, diphtheria, scarlet fever, or measles. At least four weeks should be allowed to elapse after the termination of such disease before a child from the infected house is re-admitted to the school. It goes without saying that no child having itself been sick with a contagious disease should be admitted to school until entirely restored to 1 The Relations of Schools to Diphtheria and to Similar Diseases, H. B. Baker, Public Health, vol. vi, p. 107. DISEASES OF SCHOOL-CHILDREN. 205 health. The aforesaid limit of four weeks is the briefest period allowable before the quarantine of the infected house (so far as the schools are concerned) can be relaxed. When a case of contagious disease has accidentally obtained entrance to the school, the pupils should be dismissed for the day, and the room thoroughly disinfected by means of sulphur, chlorine, or, what is better, scrubbing and spraying with solution of mercuric chloride. Teachers are not infrequently guilty of the grave impru- dence of sending pupils from the school to the house of an absent child to inquire the reason of the latter's non-appearance at school. It frequently happens that the absent child is sick, and the messenger is invited to the sick-room to see his or her class- mate. There can be no room for doubt that scarlet fever, diphtheria, and measles have often been introduced into schools in consequence of such thoughtlessness on the part of teachers. In order to promote the proper hygienic management of schools, all teachers should be required to submit to an exami- nation in the principles and practice of hygiene, at least so far as school hygiene especially is concerned. This is a demand that school-boards could reasonably insist upon, and there can be no question that the improvement in the health of the pupils would amply justify the innovation. [Students may consult with advantage the following special articles:- D. F. Lincoln, School Hygiene, in Buck's Hygiene and Public Health, vol. ii, and Lomb Prize Essay on School Hygiene, Concord, N. H., 1887.-F. Erismann, Die Hygiene der Schule, in Von Pettenkofer und Ziemssen's Handb. d. Hygiene, II, Th. 2 Abth.-Reuss, Schulbank- frage, in Realencyclopsedie d. ges. Heilk., Bd. XII.-H. Cohn, Schul- kinderaugen, ibid.-C. J. Lundy, School Hygiene, Public Health, vol. ix.-Rohe, The Necessity of the Sanitary Supervision of Schools, Journ. Am. Med. Ass'n, Dec. 28, 1889.] CHAPTER IX. Industrial Hygiene. One of the most interesting chapters in the study of hygiene is that which treats of the relations of occupations to health and life. While it is unquestionable that certain occupations are intrinsically dangerous to health, there can be no doubt that in many instances incidental conditions not necessarily connected with the occupation are factors in the production of disease. Such factors are bad ventilation and other insanitary surround- ings, as well as in many cases want of sufficient or proper food. Occupations induce disease by compelling the workmen to inhale irritating, poisonous, or offensive gases, vapors, or dust; or by causing the absorption through the skin or mucous mem- branes of irritating or poisonous substances. Changes of tem- perature, as exposure to great heat or cold, produce diseases which are, in some instances, characteristic. In another class of cases the excessive use of certain organs, as the nervous system, the eyes, the vocal organs, or various groups of muscles, produce characteristic morbid effects. Again, a constrained attitude while at work, a sedentary life, or occupations involving exposure to mechanical violence are recognized sources of dis- ease and death. The following table gives the mortality and average age at death of all decedents over 20 years of age whose occupation was specified, in the State of Massachusetts, for thirty-one years and eight months. The total number of decedents was 144,954; the average age at death, 50.90 years. Subdivided into classes and individual occupations, the results are as follow:- 207 208 TEXT-BOOK OF HYGIENE. Table XX. Occupations of Persons whose Occupations were specified, and whose Deaths were registered in Massachusetts during a period of thirty-one years and eight months, ending with December 31, 1874-1 Occupations. Number of Persons. Average Age at Death. Occupations. Number of Persons. Average Age at Death. Class I. Cultivators of Nail-makers .... 174 41.49 the Earth: Farmers, Pail- and Tub- makers 5 36.60 Gardeners, etc. . . . 31,832 65.29 Painters 1,850 45.07 Paper-makers .... 288 48.29 Class II. Active Me- Piano-forte-makers . 111 43.33 chanics Abroad . . . 10,893 56 19 Plumbers 131 35.53 Brick-makers .... 106 46.85 Potters 40 56.67 Carpenters and Joiners 6,150 53 33 Pump- and Block- Caulkers and Gravers 180 58.59 makers 89 54.79 Masons 1,662 50.33 Reed-makers .... 9 42.78 Millwrights 118 59.14 Rope-makers .... 248 58.05 Riggers 161 52 25 Tallow-chandlers . . 67 54.93 Ship-carpenters . . . 873 58 53 Tinsmiths 375 41.05 Slaters 81 40.99 Trunk-makers . . . 48 39.60 Stone-cutters 1,025 40.90 Upholsterers .... 124 38.82 Tanners 537 50.36 Weavers 480 44.95 Wheelwrights . . . 507 56.98 Class III. Active Me- Wood-turners .... 76 52.07 chanics in Shops . . 16,576 47.57 Mechanics (not speci- Bakers 471 47.04 fled) 2,015 44.84 Blacksmiths 2,402 53.26 Brewers 28 47.11 Class IV. Inactive Cabinet-makers . . . 781 48.84 Mechanics in Shops 17,233 43.87 Calico-printers .... 9 52.11 Barbers 403 39 81 Card-makers 39 48.23 Basket-makers . . . 70 61.63 Carriage - makers and Book-binders .... 150 40.12 Trimmers 276 48.21 Brush-makers . . . 53 43.11 Chair-makers .... 138 41.77 Carvers 90 34.00 Clothiers 84 56.50 Cigar-makers .... 154 38.36 Confectioners .... 85 44 11 Clock - and watch- Cooks 112 40.82 makers 100 52.86 Coopers 927 59.22 Comb-makers .... 134 51.38 Coppersmiths .... 101 45.89 Engravers 124 40.88 Curriers 366 41.50 Glass-cutters .... 76 43.16 Cutlers 131 39.21 Harness-makers . . . 423 48.74 Distillers 27 56.85 Jewelers 468 40.34 Dyers 143 45.17 Operatives 2,138 39.16 Founders 361 42.51 Printers 717 38.62 Furnace-men .... 133 43.42 Sail-makers 217 53.21 Glass-blowers .... 132 37.88 Shoecutters .... 362 42.94 Gunsmiths 250 48.86 Shoe-makers .... 9,772 44.61 Hatters 356 54.67 Silver or Gold smiths 92 46.13 Leather-dressers . . . 179 47.23 Tailors 1,393 47.34 Machinists 2,097 41.67 Tobacconists .... 43 50.35 Millers 278 57.14 Whip-makers .... 99 42.63 Musical-Inst. mkrs. . 33 46.73 Wool-sorters .... 155 48.09 * Thirty-third Registration Report of Massachusetts, p- cvi et seq. 209 INDUSTRIAL HYGIENE. Table XX (continued'). Occupations. Number of Persons. Average Age at Death. Occupations. N umber of Persons. Average Age at Death. Class V. Laborers (no Gentlemen 1,512 68 42 special trades) . . . 28,058 47.41 Grocers 517 47.59 Laborers 27,382 47.49 Innkeepers 467 50.04 Servants 389 40.10 Manufacturers . . . 1,375 51.23 Stevedores 76 52.09 Merchants 3,927 54.17 Watchmen 193 50 06 News-dlrs. and Car'rs 27 41.22 Workmen in Powder- R. R. Agents or Con- 39.85 mills Class VI. Factors 18 39.67 ductors Saloon- and Restau- 318 7,035 36.29 rant- keepers . . . 299 40.90 Laboring Abroad, etc. Stove-dealers .... 12 45.25 Baggage-masters . . . 37 34.08 Telegraphers .... 5 28.80 Brakemen 246 26.44 Traders 2,908 48.08 Butchers 537 50.19 Chimney-sweeps . . . Drivers 4 327 34.50 38 88 Class IX. Profes- sional Men .... 5,175 50.81 Drovers 17 49.29 Architects 29 47.07 Engin'rs and Firemen 567 38.77 Artists 186 44.18 Expressmen Ferrymen ...... Lighthouse-keepers . Peddlers 216 9 10 417 41.30 53.78 60.40 45.18 Civil Engineers . . . Clergymen Comedians Dentists 117 965 32 114 42.32 58.57 37 31 41.61 Sextons 81 59 94 Editors and Reprtrs. 87 46.68 Soldiers 2,885 28 37 Judges and Justices . 18 64.11 Stablers 354 42.54 Lawyers 676 56.45 Teamsters 1,282 40.35 Musicians 266 41.59 Weighers and Gaugers 24 60.67 Photographers . . . 10 36.80 Wharfingers . . . 22 50.00 Physicians Professors 1,166 45 54.99 55.93 Class VII. Employed Public Officers . . . 437 55.37 on the Ocean .... 8,841 46.44 Sheriffs, Constables, Fishermen 433 42.82 and Policemen . . 158 53.76 Marines 4 41.25 Students 288 23.23 Naval Officers .... 58 50.00 Surveyors 86 51.44 Pilots 82 60.38 Teachers 495 41.79 Seamen 8,267 46.45 Class X. Females . 3,343 39.13 Class VIII. Merch'ts, Domestics 1,037 46 64 Financ'rs, Ag'ts, etc. 15,977 48.95 Dress-makers .... 259 43.36 Agents 376 46.76 Milliners 136 39.42 Bankers 49 57.61 Nurses 116 61.06 Bank Officers .... 151 55.14 Operatives 703 27.82 Boarding-House kprs. 75 47.96 Seamstresses .... 289 46.50 Book-sellers 73 53 05 Shoe-binders .... 48 43.12 Brokers 198 49 58 Straw-workers . . . 73 34 83 Clerks and Book-kprs. 3,435 35.93 Tailoresses 233 47.49 Druggists and Apoth- Teachers 442 31.27 ecaries 255 42.37 Telegraphers .... 7 24.43 The above table cannot be absolutely relied upon for several reasons, the principal of which is that the table is incomplete. Many of the occupations are merely temporary, and persons are 210 TEXT-BOOK OF HYGIENE. constantly shifting from the pursuit of one calling to another. Judges and lawyers, for example, should be included under one heading, while the class " students " should be excluded alto- gether. The table shows, however, very clearly, the relations of certain occupations to longevity. It is seen, for example, that agriculturists have the greatest expectation of life. Next to these come mechanics engaged out-of-doors. Professional men come next, and of these clergymen and members of the bar have the first and second places, respectively. The expectation of life of physicians is above the average, being nearly 55 years. Mechanics engaged in active work in-doors may expect to live 3.70 years longer than those whose occupation requires them to retain a more or less constant position. Occupations which are accompanied by the formation of much dust, either inorganic or organic, are especially unfavor- able. They usually produce diseases of the respiratory organs, which may eventuate in phthisis. In the table it is seen that the average age at death of stone-cutters was 40.90; of cotton-factory operatives-male 39.16, female 27.82 ;1 of cigar- makers, 38.36; and of cutlers, 39.21 years. The figures more or less closely approximate the conditions which have been shown to exist in England and on the Continent of Europe. In Sheffield, the workmen who grind and polish the cutlery, called " dry grinders," are said to suffer from a characteristic pulmo- nary affection termed "grinders' asthma" (emphysema) in the proportion of 69 per cent, of the whole number employed. The average duration of life of the needle-grinders of Derbyshire is 30.66 years. Among the cutlery-grinders of Solingen, in Rhenish Prussia, Oldendorff found 29 per cent, suffering from pulmonary affections, while the average age at death of the " dry grinders " was 40.7 years. These figures must be accepted with much reserve. While it is probable that the average age at death among women engaged in different occupations is less than that of men engaged in the same occupations, the figures in Table XX, Class X, cannot be used as a basis of comparison. So many women are annually withdrawn from the various occupations by mar- riage, which places them under different conditions, that the statistics of the occupations of women in the table are untrustworthy. OCCUPATIONS PREJUDICIAL TO HEALTH. 211 OCCUPATIONS PREJUDICIAL TO HEALTH. The diseases of occupations may conveniently be divided into the following classes:- 1. Diseases due to the inhalation of irritating or poisonous gases and vapors. 2. Diseases due to the inhalation of irritating or poisonous dust. 3. Diseases due to the absorption or local action of irritating or poisonous substances. 4. Diseases due to exposure to elevated or variable temper- ature or atmospheric pressure. 5. Diseases due to excessive use of certain organs. 6. Diseases due to a constrained attitude and sedentary life. 7. Diseases from exposure to mechanical violence. I.-DISEASES DUE TO THE INHALATION OF IRRITATING OR POISONOUS GASES OR VAPORS. Sulphurous-acid gas is used in various trades as a bleach- ing agent. In the manufacture of straw hats and in the drying or " processing " of hops this agent is extensively employed, and the people engaged in these industries frequently suffer from respiratory and digestive disorders. These are, however, rarely serious. If free access of air is allowed, the dangers to health in the above employments are very slight. Nitric-acid fumes may be dangerous to health when in- haled in a concentrated form, but very few cases are on record where any positively deleterious influence can be traced to this agent. Hgdrochloric-acid fumes may prove deleterious to the work- men in soda manufactories, where the fumes are disengaged during the so-called " sulphate process." But the danger is probably slight. On the other hand, attention has recently been called to a peculiar effect of hydrochloric-acid fumes upon the workmen in fruit-canning establishments. The men who seal or " cap " the cans after being filled are the ones affected. The dust. 212 TEXT-BOOK OF HYGIENE. lesion lias been described by Dr. W. Stump Forwood, who says concerning it: " The constant inhalation of the fumes of muri- atic acid, associated as they are with the lead solder, which the busy " capper " neglects to protect himself against, soon pro- duces inflammation of the mucous membrane of the nose, which finally results in ulceration. With some patients, after the removal of the cause and the application of proper treatment, recovery takes place after two or three months; but with those who have a scrofulous taint in their constitutions this ulceration is exceedingly intractable, and, in spite of all treatment, proceeds for months and even years, until the septum is finally perforated. And, strange to say, it is the common experience of those who have suffered that, as soon as perforation takes place, all the soreness and consequent annoyance disappears and the patient recovers, with, of course, a permanent opening in the nasal septum."1 Dr. Forwood adds that anointing the nose, both within and without, several times a day, and avoidance of the acid fumes as much as possible, will prevent the peculiar affection. Ammonia rarely causes disturbances of health in work- men brought into contact with it. When present in the air in large proportion it may give rise to serious symptoms. As it is often used to prevent the poisonous effects of mercury (q. v.), care should be taken that the proportion of the vapor in the air of the work-room should not exceed 5 per cent. Chlorine gas is very deleterious in its effects upon the work- men brought in contact with it in the various industries in which it is employed. Nearly one-half of the workmen engaged in the manufacture of chlorinated lime and in bleaching become affected. The respiratory organs are principally attacked. Pneu- monia is exceptionally frequent. If an affected individual is predisposed to consumption the latter disease is soon lighted up, and quickly proves fatal. The effect of the inhalation of con- centrated chlorine is thus graphically described by Hirt2: " The iPhila. Med. and Surgical Reporter, June 30,1883. •Von Pettenkofer und Ziemssen's Handbuchder Hygiene, etc., II Th., 4 Abth., p. 30. DISEASES DUE TO INHALATION OF GASES OR VAPORS. 213 workman suffers from violent cough and extreme dyspnoea. In spite of the aid of the auxiliary respiratory muscles, the entrance of air to the lungs is insufficient, and the widely-opened eyes, the pale-bluish color, and the cold perspiration plainly show the mortal agony of the patient. With this the pulse is small, the temperature decreased. Soon after removal from the impreg- nated atmosphere these phenomena disappear, and a few hours later the workman is found enveloped in chlorine and hydro- chloric-acid vapors in his accustomed place in the factory. The attacks seem to be but rarely fatal." The constant inhalation of an atmosphere strongly impreg- nated with chlorine produces a cachectic appearance, bronchial catarrh, loss of the sense of smell, and a prematurely aged appear- ance. When this stage of chronic chlorine poisoning has been reached complete health can rarely be re-established, even if the patients be entirely removed from the irritating atmosphere. Carbon monoxide is often present in the air of gas-works, iron smelting-works, and coke or charcoal furnaces. The work- men engaged in these industries often suffer with diseases of the respiratory organs, digestive disturbances, and general debility. Acute poisoning from carbon monoxide is relatively frequent, as already pointed out.1 The prominent symptoms are at first vio- lent headache, dizziness, and roaring in the ears. These symp- toms are followed by great depression of muscular power, nausea, and vomiting. The vomited matters sometimes gain entrance into the trachea, and may thus produce strangulation. Uncon- sciousness, convulsions, and asphyxia rapidly succeed. Paral- yses of the sphincters and of groups of other muscles are often present. The pulse is at first somewhat increased, but soon becomes slower. The respiration is slow and stertorous, and the temperature falls from 2.5° to 3° C. (3° to 4° F.). Glycosuria often occurs. If death does not occur in the attack, the patient fre- quently suffers from great depression, both physical and mental; loss of appetite, constipation, and various paretic conditions. 1 See Chapter I, p. 29. 214 TEXT-BOOK OF HYGIENE. The slow or chronic form of poisoning by carbon monoxide is characterized by headache, dizziness, slow pulse and respira- tion, nausea, and sometimes vomiting and purging. Loss of memory and diminution of mental activity are also said to be effects of the continued inhalation of air charged with carbon monoxide. Carbon dioxide is found as one of the constituents of the "choke-damp" in mines. There is reason to believe that this is often the source of ill health and death in miners, even where the symptoms of acute carbon-dioxide poisoning are not present. Hon. Andrew Roy1 says that "it is more insidious than direct in its operations, gradually undermining the constitution and kill- ing the men by inches." Difficulty of respiration and weakness are the only symptoms calling attention to the pernicious effects of the gas. Where, however, the proportion of carbon dioxide is large, acute poisoning occurs. This is manifested by the following symptoms: Loss of consciousness and of the power of voluntary motion. In some cases there are convulsions; in others the above symptoms are preceded by difficult respiration, headache, depression, drowsiness, or psychical excitement. Re- covery usually soon follows after removing the patient into a purer atmosphere. Vintners, distillers, brewers, and yeast-makers are said to suffer from the effects of carbon dioxide occasionally, but serious results from this cause are probably very infrequent. It may not be amiss to call attention here to another dan- gerous mixture of gases sometimes found in mines, and which is occasionally the source of appalling accidents. This is the so-called "fire-damp" or light carburetted hydrogen (CH4). When this gas is mixed with atmospheric air in the proportion of 6 to 10 volumes per cent., the mixture becomes violently explosive if ignited. The danger does not cease with the explo^ sion, however, for in this act the free oxygen present is consumed 1 Third Annual Report State Mine Inspector of Ohio. Quoted in Buck's Hygiene and Public Health, vol. ii, p. 243. DISEASES DUE TO INHALATION OF GASES OR VAPORS. 215 in the formation of carbon dioxide, and the workmen then die asphyxiated, or from the effects of " choke-damp." The dangers from " fire-damp " can be largely averted by thorough ventilation and by the use of the safety-lamp of Sir Humphry Davy, which gives warning of the presence of the gas and permits the work- men to escape before the explosion takes place. Sulphuretted hydrogen, when present in the air in large proportion,-as, for example, in privy-vaults, cess-pools, and sewers,-may produce serious or fatal poisoning. Formerly, when vaults were cleaned in the primitive way, these accidents were frequent; but at the present day, owing to improved methods of removing excreta, they are comparatively rare. The precautions advised in a preceding chapter1 should be borne in mind when it is necessary for workmen to enter such places. The gases resulting from the putrid decomposition of organic substances, such as are found in tanneries, glue- and soap- works, and similar industries, are popularly believed to give rise to various diseases. There are no observations on record, however, to show that such is the case. As a matter of fact, the workmen engaged in the industries mentioned, seem to be exceptionally healthy, and to resist to a considerable degree the ravages of phthisis and epidemic diseases. Bisidphide of carbon is used in the arts principally in the process of vulcanizing India rubber, and for extracting oils from seeds and fatty bodies. The constant inhalation of the vapor of bisulphide of carbon produces a train of symptoms to which attention was first attracted by Delpech in 1856. The symp- toms have been observed frequently since that time. The follow- ing account is from Hirt2:- " Some days, or even weeks or months, after beginning this occupation, the workmen complain of a dull headache, becoming more severe toward evening. This symptom is soon followed by joint-pains, formication, and itching on various parts of the body. A more or less troublesome cough is present, but is not accom- 1 Chapter I, p. 37. a Op. cit., p. 66. 216 TEXT-BOOK OF HYGIENE. panied by any characteristic sputa. The respiration is regular, the pulse somewhat increased in frequency. During this time certain individuals exhibit a marked exaltation of their intel- lectual powers; they talk more than formerly, and show an interest in matters in which they at other times show no concern. There is, however, very rarely distinct mental disease. The sexual desires are increased in both sexes, menstruation becomes irregular, and the urine possesses a faint odor of bisulphide of carbon. In this manner several weeks or months pass away. Very gradually the psychical exaltation disappears, and a pro- found depression, melancholy, and discouragement succeeds, coupled with which is often loss of memory. Vision and hear- ing become less acute, and the sexual activity is completely destroyed. Anaesthetic spots appear on various parts of the body, and numbness of the fingers prevents the workman from perform- ing any fine work." The disease never proves fatal, but the normal condition of the individual is rarely re-established when the disorder has advanced to the extreme stages mentioned. Iodine and bromine vapors, when inhaled by workmen en- gaged in their preparation, produce symptoms of poisoning which are sometimes very serious. Acute iodic intoxication consists in severe laryngeal irritation, headache, conjunctivitis, and nasal catarrh. Occasionally there is temporary loss of con- sciousness. Chronic iodic cachexia is often found among the workmen. In certain cases atrophy of the testicles and gradual disappearance of sexual power has been observed. In the manu- facture of bromine, a form of bronchial asthma has been observed among those engaged in the establishment. No symptoms corresponding to those of chronic iodism have been observed among the workmen in bromine. The inhalation of the vapors of turpentine produces, in a considerable number of those constantly exposed to them, dis- eases of the respiratory organs, beginning with cough and, at times, resulting in consumption. In other cases derangement DISEASES DUE TO INHALATION OF GASES OR VAPORS. 217 of the digestive organs, strangury, and, in a few cases, bloody urine have been observed. Nervous disturbances are rare after the inhalation of turpentine, and are limited to headache, roar- ing in the ears, or flashes of light before the eyes. Petroleum vapor, when inhaled in a concentrated state, pro- duces symptoms similar to those of anaesthetics. When exposed for a long time to diluted petroleum vapor, workmen sometimes suffer from chronic pulmonary catarrhs or from nervous de- rangements. Among the latter are disturbances of mental activity, loss of memory, giddiness, and headache. These symp- toms are, however, rare. More frequent are pustular or furuncu- lar affections of the skin, which are due probably to the direct irritant effect of the vapor. Lead poisoning is one of the most characteristic diseases of artisans. It attacks workmen engaged in the roasting and smelt- ing of lead ores; in the manufacture of white and red lead and of lead acetate and chromate; in type-making, in painting, and, in short, in all occupations in which the workman is compelled to inhale the vapor or dust of lead, or in which it is conveyed in some manner to the digestive organs. It is believed also that it can be absorbed by the skin and produce its poisonous effects upon the economy. The average duration of life in the roast- ing and smelting furnaces is 41 years; of painters, as shown by Table XX, 4.5.07 years. Of the latter 75 per cent, are attacked by one of the forms of lead poisoning, colic being most frequent. In the manufacture of white lead more than half of the work- men suffer from lead poisoning during the first year, lead colic being present in 60 per cent, of all the cases. In most sugar-of-lead manufactories 60 per cent, of all the operatives constantly suffer from some form of lead poisoning. Poisoning has also been observed in workmen engaged in the manufacture of various pigments of which the acetate of lead is the base (e.g., lead chromates). Among type-founders the symptoms of lead poisoning are not very rare, and even 218 TEXT-BOOK OF HYGIENE. compositors sometimes suffer from lead poisoning. In the latter case the lead must be absorbed through the skin in order to produce its effects. The various forms in which lead poisoning affects the indi- vidual are the lead cachexia, manifested by loss of weight, dis- coloration of the skin, the characteristic blue line along the gums, diminution of the salivary secretion, a sweetish taste, and offensive odor of the breath; then lead colic, the features of which are well known ; lead paralysis, the characteristic " wrist- drop," which requires prompt and intelligent treatment, other- wise permanent atrophy of the affected muscles often takes place. Among other nervous manifestations of the poison is a painful affection of the lower extremities, attacking joints and flexor muscles, and remittent in character. At times anaesthesia of the skin of the head and neck is present. In rare cases serious mental derangement occurs. Other grave nervous lesions, such as the so-called saturnine hemiplegia and tabes, are happily extremely rare among the workmen in the metal at the present day. Mercurial poisoning is frequent among the artisans who work in the metal. The smelters of the ore suffer severely and in a large proportion of the entire number employed. Their average age at death is 45 years. Mirror-makers suffer most severely of all the artisans who come in contact with the vapors of the metal. It is beyond question that the confinement in badly-ventilated work-rooms is largely responsible for the poi- sonous effects of the metal upon this class. The special forms in which the poisonous effects are manifested in mirror-makers are salivation, mercurial tremor, and nervous erethism, but, in addition, a very large proportion suffer from pulmonary con- sumption. It is stated that 71 per cent, of the total deaths among mirror-makers (those who coat the glass with the mer- curial alloy) are from phthisis. Among women the symptoms are aggravated, and abortion frequently occurs. Of the children of women suffering from DISEASES DUE TO INHALATION OF GASES OR VAPORS. 219 mercurial poisoning born living at term, 65 per cent, die within the first year. In the Almaden quicksilver mines in Spain a considerable proportion of the workmen suffer from the milder symptoms of mercurial intoxication (gingivitis, salivation, or dryness of the mouth). The more severe manifestations (tremor, convulsions, contractures, violent muscular pains, paralysis, cachexia) are much less frequent, and latterly not so severe as they were formerly. Fire-gilders, fulminate-makers, and physical instrument- makers not infrequently suffer from the deleterious effects of inhaling the vapor of mercury. Hatters are also liable, to a considerable extent, to the poisonous effects of the metal.1 It has been found that upon sprinkling the floor of the work-room of mirror-makers with aqua ammonia, so as to im- pregnate the atmosphere with ammonia, the bad effects of mer- cury on the system are markedly diminished. Care must be taken, however, not to use the ammonia to excess, otherwise the diseases caused by this agent may attack the workmen. Zinc or copper vapors, or possibly a combination of the two, given off from the brass, which is an alloy of these metals, produces a peculiar train of symptoms known as " brass- founders' ague." The symptoms are described by Hirt, who has suffered from two attacks of the affection himself, as fol- lows 2: "A few hours after attending the process of brass- casting, one notices a peculiar, uncomfortable sensation over the whole body. More or less severe pains in the back and gen- eral lassitude cause a discontinuance of the ordinary occupa- tion. While the pains appear now here, now there, and are extremely annoying, no changes in the pulse or respiration are noticeable. In a short time, however, usually after the patient has taken to the bed, chilliness comes on, which soon increases to a decided rigor, lasting fifteen minutes or longer. In the o 7 o o i Hatting as Affecting the Health of Operatives, L. Dennis, Report New Jersey State Board of Health, 1879 ; Connecticut State Board of Health, 1883. a Op. cit., p. 122. 220 TEXT-BOOK OF HYGIENE. course of an hour or less the pulse now reaches a rapidity of 100 to 120 beats per minute. A tormenting cough, combined with a feeling of soreness in the chest, comes on. In conse- quence of the repeated acts of coughing, the increasing frontal headache produces exceeding discomfort. Soon, however, usu- ally after a few hours, the height of the attack is reached; free perspiration indicates the stage of defervescence, and during the gradual diminution of the symptoms the patient falls into a deep sleep, lasting several hours. On awakening, a slight headache and lassitude only remain as reminders of the attack." It is said that about 75 per cent, of the workmen in brass- foundries are attacked by this affection; the attack is liable to be repeated at every exposure. A chronic form of poisoning is said to occur among zinc- smelters after following their occupation for ten to twelve years. It consists of hypermsthesia, formication, and burning of the skin of the lower extremities, soon followed by alteration in the temperature and tactile sensation, and diminution of the mus- cular sense. Paresis of the lower extremities sometimes comes on. The disease has not yet been sufficiently investigated. Aniline vapor is exceedingly poisonous when inhaled in a concentrated state. Hirt describes an acute form which usually results fatally: "The workman falls suddenly to the ground; the skin is cold, pale; the face is cyanotic, the breath has the odor of aniline, the respiration is slowed, and the pulse increased. The sensation, diminished from the beginning of the attack, gradually entirely disappears, and death follows in a state of deep coma."1 There is a milder form which comes on after several days of exposure. It is characterized by laryngeal irritation, diminution of appetite, headache, giddiness, great weakness, and depression. The pulse is rapid, small, and irregular. Respiration is little altered. There is decrease of sensibility of the skin. Convulsions may occur, but are usually of short duration. 1 Op. cit., p. 127. DISEASES DUE TO INHALATION OF DUST. 221 The chronic form of aniline poisoning is characterized by three sets of symptoms: those affecting the central nervous system, the digestive tract, and the skin. Among the first are lassitude, headache, roaring in the ears, and disturbances of sensation and motion of greater or less degree. The digestive derangements consist in eructations, nausea, and vomiting. The cutaneous lesions are eczematous or pustular eruptions, and sometimes round, sharply-circumscribed ulcers with callous borders. There is no trustworthy evidence that in the manufacture of aniline colors poisonous symptoms are produced in the workmen. II.-DISEASES DUE TO THE INHALATION OF IRRITATING OR POISONOUS DUST. The inhalation of air containing particles of organic or inorganic matter has long been accepted as a cause of certain special diseases of artisans. The diseases so caused are usually limited to the pulmonary organs, and consist of acute and chronic catarrh, emphysema of the lungs, pneumonia, interstitial inflammation of the lungs,-the so-called fibroid phthisis or pul- monary cirrhosis. Coal-dust is inhaled by coal-miners, charcoal-burners, coal- handlers, firemen, chimney-sweeps, foundry-men, lead-pencil makers, etc. Chronic bronchial catarrhs are most frequent, while phthisis and emphysema are almost absent from the list of diseases affecting these workmen. Dr. W. B. Canfield has reported an interesting case of pneumonoconiosis in which there was coincident bacillary phthisis.1 The table on page 208 shows that the expectation of life of foundry-men, fumace-men, fire- men, and chimney-sweeps is much below the average. Metallic dust is inhaled by blacksmiths, nailers, cutlers, lock- smiths, file-cutters, cutlery- and needle- polishers, etc. While 1 Trans. Med. and Chir. Fac., Md., 1889. 222 TEXT-BOOK OF HYGIENE. in this class of workmen cases of bronchitis and pneumonia are relatively frequent, much the largest proportion suffer from phthisis. A table compiled by Hirt shows that out of the total number of sick in the different classes of workmen the cases of phthisis were:- 62.2 per cent, for file-cutters, 69.6 " " needle-polishers, 40.4 " " grinders, 12.2 " " nailers. The Massachusetts table gives the average duration of life for blacksmiths at 53.26 years, of nail-makers at 41.49 years, and of cutlers at 39.21 years. The needle-polishers at Sheffield, as already stated (page 210), have only an average duration of life of 30.66 years. In this work and that of grinding knives, scissors, and similar articles, the metallic dust is mixed with mineral dust (particles of silica from the grindstone). This mixture seems to be much more deleterious than metallic dust alone, as shown by the shorter average duration of life and the enormous percentage of cases of consumption. Mineral dust is inhaled by the workmen in a large number of different industries. The grinders in the ground-glass factories suffer most severely. Hirt found the average duration of life in grinders who began this occupation after their 25th year to be 42.50 years, while in those who began at the age of 15 the average duration was 30 years. Millstone cutting is also a very dangerous occupation. Pea- cock1 gives the average age of these workmen at 24.1 years. Stone-cutters generally suffer frequently from phthisis, probably largely in consequence of the constant inhalation of the mineral dust produced during their work. The Massachusetts table gives the average age at death of these workmen at 40.90 years, while Hirt's table gives a much lower age, namely 36.3 years. Potters and porcelain-makers are exposed to similar dangers from their occupation, but to a much less degree. The table on 1 Quoted by Merkel, in von Pettenkofer und Ziemssen's Handbuch der Hygiene, II Th., 4 Abth., p. 197. DISEASES DUE TO INHALATION OF DUST. 223 page 208 gives the average age at death at 56.67 years,-rather a high average. Slaters and workmen in slate-qnarries suffer in a large pro- portion of cases from chronic pneumonia, and die at a compara- tively early'age. Masons and carpenters have an average duration of life of 50.33 and 53.33 years, respectively. One-third of all the diseases from which they suffer affect the respiratory organs. Gussenbauer has reported a very interesting series of cases of a peculiar inflammatory affection of the diaphyses of the long bones in the artisans who are engaged in the manufacture of pearl buttons. Gem-finishers are exposed not only to the inhalation of dust, but to poisonous gases (carbon monoxide) and vapors (lead). The proportion of sickness among them is very high. Vegetable Dust.-The workmen compelled to inhale vege- table dust are those who work in tobacco, cotton-operatives, flax-dressers, paper-makers, weavers, wood-turners, millers, and laborers in grain-elevators. Workmen in tobacco usually suffer, within a few weeks after beginning work, from a nasal, conjunctival, and bronchial catarrh, which soon passes off, as the mucous membranes seem to become accustomed to the irritation. Nausea is also frequent at first, due probably to the absorption of small quantities of nicotine. Females exposed to tobacco-dust usually suffer from digestive and nervous troubles. They are also said to abort frequently. Dr. R. S. Tracy,1 as a result of his observations among cigar-makers in New York, states that the fecundity of these people is much less than the average. Three hundred and twenty-five families visited had only 465 children, an average of 1.43 to each family. Dr. Tracy is inclined to attribute this to the frequent abortions that occur among the females exposed to the inhalation of tobacco-dust. According to the Massachusetts 1 Buck's Hygiene and Public Health, vol. ii, p. 62. 224 TEXT-BOOK OF HYGIENE. table, cigar-making is an unfavorable occupation, the average age at death being 38.36 years. Cotton-operatives, flax-dressers, weavers, and workmen in paper-mills are subject to various diseases of the respiratory organs. Coetsem, as long ago as 1836, described a peculiar pulmonary affection among cotton-operatives, which he termed pneumonic cotonneuse. The observation does not seem to have been verified by others; at all events, the author is unable to find any other record of a similar affection in the literature of the subject. Among weavers the mortality from phthisis is comparatively high. Among paper-makers Hirt found an average duration of life of 37.6 years. The people who sort rags are liable to a fatal infectious disease, "rag-sorters' disease" (Hademkrankheit *), which resembles in all respects, and is prol> ably nothing less than, anthrax. No cases have been reported in this country, but, as the importation of rags from abroad is carried on to a considerable extent, no apology is believed to be necessary for calling attention to it. The " wool-sorters' disease," to which attention has recently been called in England, is doubt- less similar in its nature. Millers suffer in a large proportion of cases from pulmonary affections, especially bronchial catarrh and pneumonia. Accord- ing to Hirt, 20.3 per cent, of all the diseases of these workmen are pneumonias, 9.3 per cent, bronchial catarrhs, 10.9 per cent, phthisis, and 1.9 per cent, emphysema. The average duration of life is 45.1 years. The Massachusetts table gives 57.14 years, -a very much more favorable exhibit. The laborers in grain-elevators are compelled to inhale a very irritating dust, which causes acute and chronic catarrhs of the respiratory organs. Dr. T. B. Evans, of Baltimore, has reported a series of cases of catarrhal pneumonia in these work- men, which were characterized by some very peculiar features. Brush-making, according to the statistics of Hirt, is a very dan- gerous occupation. Nearly one-half of the deaths among brush- 1 See article by Soyka, Realencyclopaedle d. ges. Heilk, Bd. VI, p. 165. DISEASES DUE TO POISONOUS SUBSTANCES. 225 makers are from phthisis, due, in great measure, to the inhalation of the sharp fragments of bristles produced in trimming the brushes. In the Massachusetts table the average duration of life is given at 43.11 years. III. DISEASES DUE TO THE ABSORPTION OR LOCAL ACTION OF IRRITATING OR POISONOUS SUBSTANCES. Arsenic is used in the manufacture of green pigments and for various other purposes in the arts. In the preservation of furs and in taxidermy it finds extensive use. In the prepara- tion of the pigment known as Paris green the workmen are frequently entirely covered by a layer of the poisonous salt. The poisonous symptoms occur in consequence of the absorption of the poison through the skin or from its local action, and but rarely on account of inhalation of vapors or dust in which it is contained. The most marked symptoms are chronic gastric catarrh, superficial erosions in the mouth, dry tongue, thirst, and a burning sensation in the throat. These symptoms may con- tinue for months, or even years, and gradually produce a com- plete breaking down of nutrition and the vital powers. Violent itching skin eruptions of an eczematous character are not infre- quent complications of the internal symptoms. Lewin has described a localized pigmentation of the skin in workmen (engravers) in silver. The left hand is especially affected. The occurrence of the affection is explained by the numerous slight injuries of the hands by the graver's tools and the local absorption and decomposition of the silver. Phosphorus produces two classes of effects in persons sub- jected to its influence. The milder effects are produced by the inhalation of the fumes of the substance, and are limited to digestive disturbances and diseases of the pulmonary organs. The severer symptoms are only observed among the employes in match-factories, and are due to the local action of the phos- phorus upon the tissues affected. The characteristic disease produced by phosphorus is a 226 TEXT-BOOK OF HYGIENE. painful periostitis of the lower or upper jaw. The limitation of the affection to this locality is believed to be due to the action of the phosphorus dissolved in the saliva. The fact that the lower jaw, with which the saliva comes more thoroughly in contact, is most frequently affected seems to indicate that this view is the correct one. The disease begins, on an average, five years after the beginning of the employment. Hirt estimates the proportion of employes in match-factories attacked at 11 to 12 per cent. The first symptom of the disease is toothache, soon extending to the jaw. The cervical glands swell up; the gums become reddened and spongy; abscesses form about the diseased teeth, from which large quantities of thin, offensive pus are discharged. Examination with a sound reveals carious, nodulated bone. The cheeks become swollen, erysipelatous, and may suppurate and discharge pus externally. Hutchinson has reported a case in which the long-continued internal administration of phosphorus as a medicine produced maxillary necrosis. The destruction of the soft tissues continues until resection of the jaw is finally undertaken and the disease checked by surgical interference, and removal of the patient from the influ- ence of the pernicious substance. Dr. J. Ewing Mears reports1 16 cases of phosphorus ne- crosis. He concludes " that the antidotal powers of turpentine have been established, both in neutralizing the effects of the poison upon operatives during their work and also in the treat- ment of the early stage of the disease. The disease is to be prevented by the adoption of thorough methods of ventilation, stringent rules with regard to cleanliness, and the free disen- gagement of the vapors of turpentine in all the apartments of factories in which the fumes of phosphorus escape." In the manufacture of quinine a troublesome eczema is caused in about 90 per cent, of the employes. It seems to be due to emanations given off from the boiling solutions. It 1 Trans. Am. Surg. Association, 1887. DISEASES DUE TO ELEVATED OR VARIABLE TEMPERATURE. 227 begins with intense itching, followed by swelling and the forma- tion of vesicles, which soon burst and form crusts. There is considerable fever when the swelling is great. It is said that blondes are more frequently affected than those of dark com- plexion. The disease soon disappears if the work is given up. The workmen engaged in the manufacture of bichromate of potassium are said to suffer from an ulceration of the nasal mucous membrane very similar to that already described as due to the vapors of hydrochloric acid (p. 212). Rapidly spreading, deep ulcers are also said to form if the bichromate comes in contact with abraded surfaces of the skin. The strong alkali handled by tanners frequently produces fissured eczemas of the hands, which are painful and often diffi- cult to cure. The workmen in petroleum refineries frequently suffer from acneiform or furuncular eruptions. Among glass-blowers, syphilis is frequently communicated by an infected mouth-piece which is used by the men in turn. IV.-DISEASES DUE TO EXPOSURE TO ELEVATED OR VARIABLE TEMPERATURE OR ATMOSPHERIC PRESSURE. Cooks and bakers are exposed almost constantly to a high temperature, which produces an unfavorable influence upon health and predisposes them to diseases of various kinds. The Massachusetts table shows that cooks have a much shorter duration of life than bakers, although the statistics of both trades are unfavorable. The prevailing diseases among cooks and bakers are rheu- matism and eczematous eruptions, generally confined to the hands, forearms, and face. Blacksmiths, founders, and firemen suffer from the intense heat to which they are exposed, in addition to the inhalation of coal-dust, as has already been pointed out. The stokers in the engine-rooms of steam-ships suffer especially from the excessively high temperature to which they are subjected by their occupation. 228 TEXT-BOOK OF HYGIENE. A form of heart-weakness, described by Levick as " fireman's heart," is prevalent among them. Sailors, farmers, coachmen, car-drivers, and teamsters are subjected to stress of weather, changes of temperature, and storms. They suffer frequently from rheumatism, acute bron- chitis, pneumonia, and Bright's disease. Car-drivers are said also to suffer from painful swelling of the feet, varicose veins and ulcers, and mild spinal troubles.1 Sun-stroke is not confined to any class of artisans, but persons who perform very hard labor, especially in a confined atmosphere, suffer most frequently. The effects of compressed air on workmen in tunnels and deep mines has already been referred to.2 The most serious symptoms occur not when the individual is subjected to the increased pressure, but when the pressure is too rapidly dimin- ished. V. DISEASES DUE TO THE EXCESSIVE USE OF CERTAIN ORGANS. The prevalent belief that the overuse of the intellectual faculties is a frequent cause of mental disease is not borne out by facts. Men and women who perform an amount of mental work regarded by most persons as excessive have, in spite of this, a long duration of life. There are no exact statistics upon this subject, but Caspar, half a century ago, made the following estimate of the average duration of life among professional men : Clergymen live 65; merchants, 62.4; officials, 61.7 ; lawyers, 58.9; teachers, 56.9, and physicians, 56.8 years. In the table on page 209 the figures are somewhat less favorable, although corresponding in general with those of Caspar. Hence, it is seen that, of professional men, those whose occupation compels the exercise of high mental powers have a higher duration of life than any other class, except farmers and mechanics engaged actively out of doors. Those professional occupations only which necessitate a more or less irregular mode of life and 1 A. McL. Hamilton in Report New York Board of Health, p. 444,1873. 2 Chapter I, p. 12. DISEASES DUE TO A SEDENTARY LIFE. 229 frequent subjection to physical exhaustion and dangers from contagious disease, such as the work of physicians and journal- ists, make an unfavorable showing in the statistics. The prop- osition may be laid down that it is not mental activity, however great, but mental worry that tends to the abbreviation of life. The occupation of a tea-taster is said to produce a peculiar nervous condition, manifested in muscular tremblings, etc., which compels the individual to give up the work in a few years. Persons who test the quality of tobacco, an occupation corre- sponding to that of tea-taster, are said to suffer from nervous symp- toms, which may include amaurosis and other grave affections. Those persons who are compelled to use their eyes con- stantly upon minute objects frequently suffer from defective vision. So engravers, watch-makers, and seamstresses are liable to near-sightedness, amaurosis, and irritation of the conjunctiva. Public speakers and singers frequently suffer from catarrhal or even paretic conditions of the throat, which usually disappear on relinquishing the occupation for a time. Telegraph operators and copyists suffer from a peculiar convulsive affection of the fingers, called " writers' cramp." Cigar-makers are also said to suffer from a similar cramp of the fingers used in rolling cigars. Performers on wind instru- ments are liable to pulmonary emphysema, on account of the pressure to which the lungs are frequently subjected. Boiler- makers often suffer from deafness, in consequence of their constant existence in an atmosphere in a state of continual violent vibration. The affection is generally recognized as " boiler- makers' deafness." Dr. C. S. Turnbull has reported several cases of " mill-operatives' deafness." Its characteristic is an inability to hear distinctly except during a noise. VI.-DISEASES DUE TO A CONSTRAINED ATTITUDE AND SEDENTARY LIFE. It is probable that the large mortality and morbility rate of persons whose occupations keep them confined within doors 230 TEXT-BOOK OF HYGIENE. are due, next to the defective ventilation, to the constrained attitude which most of them necessarily assume. Thus, carvers, book-binders, engravers, jewelers, printers, shoe-makers, book- keepers, and cigar-makers all have a low average duration of life. It is found, likewise, that many of these artisans suffer most from pulmonary and digestive troubles, among the former being phthisis, and among the latter constipation, dyspepsia, and haemorrhoids. VII.-DISEASES FROM EXPOSURE TO MECHANICAL VIOLENCE. It will be seen, by reference to the table on page 209, that all persons whose occupations involve an intimate contact with machinery, and in the pursuit of which accidents frequently happen, have a short duration of life. Persons liable to these dangers are machinists, operatives in factories, workmen in powder-mills, baggage-masters, brakemen, drivers, engineers, firemen, and other workmen on railroads. Aside from the diseases to which some of these classes are liable in consequence of exposure to variable atmospheric conditions, the grave acci- dents to which they are so frequently exposed render their occupations extremely dangerous. Brakemen on freight rail- roads, for example, are classed by insurance companies as the most hazardous " risks," and some companies refuse to take them at all. The table on page 209 tends to confirm the conclusion of the insurance companies, for, excluding the class of " students," which, for manifest reasons, cannot be used as a comparison, brakemen have the shortest average duration of life of all the occupations noted in the table. [The student is referred, for more complete information on the subjects considered in the foregoing chapter, to the following works:- L. Hirt, Die Krankheiten der Arbeiter.-Eulenburg, Handbuch der Gewerbehygiene.-Layet, Hygiene des Professions et des Industries.] CHAPTER X. Military and Camp Hygiene. The subjects embraced in this chapter can be most con- veniently arranged under the following heads:- I. The Soldier and his Training. IV. The Dwelling of the Soldier. II. The Food of the Soldier. V. Camp Diseases. III. The Clothing of the Soldier. VI. Civilian Camps. I. THE SOLDIER AND HIS TRAINING. The relations existing among different nations at the present time require that a standing army of greater or less number be maintained by each for the common safety. This being the case, it needs no argument to prove that such an army should be composed of the best material available in order that it may be depended upon for defense or offense when necessity demands that it should be called into active service. Hammond says with truth1 that " a weak, malformed, or sickly soldier is not only useless but a positive incumbrance " to an army. It is of the first importance, therefore, to exclude from the military service, by a rigorous physical examination, all individuals whose physical condition is defective, who are either suffering from or predisposed to disease. The foremost authorities on military hygiene are agreed that no recruit should be enlisted for actual service before the 20th year. In the English army the lowest age at present is 19 years; in Germany, 20 years; in France, 20 years for actual service {recrues), 18 years for enlistment {engages); and in the United States, 21 years. The limit of age upward in the latter army is 45 years, except in cases of re-enlistments. The height of recruits must be at least 165 centimetres; minimum chest 1 Hygiene, p. 19. Philadelphia, 1863. 231 232 TEXT-BOOK OF HYGIENE. measurement 75 centimetres, with at least 5 centimetres' expan- sion ; and weight from 54 to 81 kilogrammes. In the cavalry service the maximum weight is 75 kilogrammes. Every recruit must be vaccinated before enlistment. The physical examination of recruits before enlistment must be made by a medical officer, whose decision, in the United States army, is definitive. In the German army the decision of the medical officer is not final, but subject to revision by the recruiting officer, who may, if he sees fit, overrule the medical officer's opinion and enlist a man who has been decided to be unqualified for the military service. In this and various other respects, such as pay, rank, and effective power, the Medical Staff of the United States Army has many advantages over that of most foreign armies. II.-THE FOOD OF THE SOLDIER. The army ration of the United States, which is given below, was fixed by regulations before the more-recent researches of Professor Voit on nutrition were completed. The ultimate com- position, which yields 142 grammes proteids, 116 grammes fats, and 435 grammes carbohydrates, shows an excess of fats and deficiency of carbohydrates. Table XXI shows the daily allow- ance for each soldier:- Table XXI. 342 grammes pork or bacon, or 567 " fresh beef. 454 " hard bread, or 566 " flour. 68 " beans or peas, or 45 " rice or hominy. 45 " green coffee. 17 " salt. 68 " sugar. To this is also added vinegar, pepper, and tea in place of coffee. Although the regular food-allowance in the United States army is liberal, and is largely in excess of the needs of the soldier THE CLOTHING OF THE SOLDIER. 233 in garrison, medical officers generally agree that in active service it is insufficient in quantity and not sufficiently varied. The money value of each of the above articles in the ration is fixed by the government, and may be drawn instead of certain of the articles, and other articles of food purchased and thus the dietary varied. The money so drawn constitutes what is known as the " company fund." In the hands of a judicious commanding officer, the company fund can be made a source of great benefit and comfort to the men, but that it is at times mismanaged or misapplied is well known to army sur- geons. Aside from the insufficient quantity and variety of food furnished to soldiers, the cooking, especially in temporary camps, is often defective and causes digestive derangements and con- sequent innutrition. A good cook should be attached to every company. III. THE CLOTHING OF THE SOLDIER. The clothing of the United States soldier is tolerably well adapted to its uses. It is generally well made, and of good, serviceable material. The only exception that can be made with reason is that the foot-gear is not made to individual measure, and hence peculiarities of shape of the feet cannot be taken account of. For this reason painful affections of the feet, due to ill-fitting boots or shoes, are of frequent occurrence. When on a march, the soldier carries his extra clothing packed in a knapsack and strapped upon the back. His blankets and great-coats are rolled into a cylinder and strapped upon the knapsack. The weight each soldier has thus to carry, in addition to his arms and ammunition, amounts to considerable. There is reason to believe that the pressure produced by the straps of a heavy knapsack may cause not only discomfort but actual disease. It is believed by many officers that the knapsack could be abolished with advantage, and the extra clothing rolled up in the blanket, or a water-proof sheet, and slung over the left shoulder. 234 TEXT-BOOK OF HYGIENE. Soldiers are generally housed either in barracks, huts, or tents. The former are usually the habitation of the soldiers in garrisons or permanent camps, while huts or tents are used for the purpose of sheltering the occupants of temporary camps. Barracks.-A military barrack is a one-storied building constructed of stone, wood, or iron, or a combination of these materials. The general plan of the barrack comprises a large room for the beds of the soldiers, one or more smaller rooms for the non-commissioned officers of the company or squad, and a wash-room. The sleeping-room of the soldier is also his living- or day- room. It is evident, therefore, that sufficient air-space and good ventilation must be provided if the soldier's health is to be maintained. In England, 17 cubic metres are recommended for the initial air-space. In the new barracks constructed in France according to the plans of M. Toilet, 22 cubic metres are allowed to each occupant. The special points of distinction of the system of Toilet, of which Schuster says that " to it belongs the future of barrack construction," are : The frame of the building is of light-iron ribs; the interspaces are walled up with bricks or stone; the roof is slate; the ceiling is arched, and all corners are rounded to prevent lodgment of dust. Ventilation is provided by openings in the walls at the edge of the roof for the entrance of fresh air, and by ridge ventilators. In France, barracks have been built according to Toilet's system at Bourges, Cosne, Macon, and Antun. Although occu- pied but a short time, it appears that the health of the soldiers remains better in them than in the barracks constructed on the old style. The system would seem also especially to lend itself to the construction of hospitals. The wash- and bath- rooms of the barracks should be so arranged as to encourage the soldier to cleanliness. Where the only lavatory in a barrack is, as the author has seen it, an open porch, men are not likely to IV.-THE DWELLING OF THE SOLDIER. THE DWELLING OF THE SOLDIER. 235 spend much time in cold weather in washing their faces and hands, to say nothing of the rest of their bodies. The kitchen and dining-room should be detached from the building serving as quarters; otherwise the odors of the cooking will pervade the building. The sinks or latrines should be placed at some distance from the quarters and kitchen, and out of the line of prevailing winds. The writer has personal knowledge of a permanent military post within a few miles of the city of Washington, where, only a few years ago (and, for aught known to the contrary, at the present day), " the rear," or place of depositing excrement, was about 70 metres distant from the kitchen and men's quarters, and directly in line (to leeward) with the prevailing winds! Before erecting any buildings it is, of course, necessary to endeavor to secure a clean and dry subsoil. Attention is called to the principles underlying the construction of dwellings, Chap. VI. Tents and Huts.-The tents used in the army are the hos- pital-tent, the officers' wall-tent, the A-tent, and the shelter- tent, which is a modification of the last. The conical, or Sibley tent, which was frequently seen in camps in the early part of the war between the States, has gone out of use. Soldiers give the preference to the shelter tent, which is light, each man's piece weighing only 1.18 kilogrammes. Two pieces being joined together by buttons and button-holes, and thrown over a ridge-pole supported upon uprights, and the four corners fast- ened to pegs driven into the ground, form a tent 1.20 metres high, 1.65 metres long, and having a spread at the base of between 1.8 and 2.1 metres. Such a tent will form a comfort- able shelter for two men, unless there should be strong winds or driving rains, when the ends could be closed by blankets, brush, or an extra piece of shelter-tent. The uprights and ridge are steadied by short guy-ropes, one of which is furnished with each piece of the tent. In winter, especially when camps of more or less perma- nence are formed, the soldiers usually build log huts. The 236 TEXT-BOOK OF HYGIENE. interstices between the logs are plastered up with mud or clay, and the roof is formed of canvas, generally several pieces of shelter tent joined together. The ground around the tent or hut should be trenched in order to carry off the rain-fall. Cleanliness within and around tents or huts is of the first importance, and should be enforced in all camps by the proper au- thority. Military authorities have long since learned that in the matter of cleanliness of body, clothing, or surroundings voluntary action on the part of the soldier cannot be relied upon. Frequent and thorough inspections will alone secure proper cleanliness. V.-CAMP DISEASES. • The soldier's profession has been aptly characterized by Ruskin as " the trade of being slain." In the late war between the States, the total deaths of the Federal army numbered 359,496, -over 15 per cent, of the entire number of enlistments. Of this number, however, 224,586 (nearly two-thirds) died from disease, while the remaining 134,910 (a small fraction over one-third) were killed in battle or died from the effects of wounds. The colored troops especially suffered greatly from the effects of disease. Diarrhoea and Dysentery.-The most fatal diseases of camp life, especially in time of war, are diarrhoea and dysentery. The statistics of the Federal army during the late war are given in the following table1: - Table XXII. Total Deaths from Diarrhoea and Dysentery in the U. S. Army, from May 1, 1861, to June 30, 1866. White Troops, from May 1, 1861, to June 30, 1866. Colored Troops, from July 1, 1863, to June 30, 1866. Total. Acute Diarrhoea .... Chronic Diarrhoea . . . Acute Dysentery .... Chronic Dysentery . . . Cases. 1,155,226 170,488 233,812 25,670 Deaths. 2,923 27,558 4,084 3,229 Cases. 113,801 12,098 25,259 2,781 Deaths 1,368 3.278 1,492 626 Cases. 1,269,027 182,586 259,071 28,451 Deaths 4,291 30,836 5,576 3.855 Total 1,585,196 37,794 153,939 6,764 1,739,135 44,558 1 Medical and Surgical History of the War, second medical volume, p. 2. CAMP DISEASES. 237 Owing to the fact that a considerable number of deaths were reported without assigning any cause, Dr. Woodward esti- mates the total number of deaths from the above diseases at 57,265, or, in the proportion of one death from diarrhoea and dysentery to three and one-half deaths from all diseases. Among the prisoners of war held by the Confederate States in Anderson- ville prison, where tolerably complete records were kept, more than half the total deaths were from diarrhoea and dysentery, while the ratio of deaths to cases of the above two diseases was a fraction over 76 per cent. This frightful mortality from these two diseases, both in the prisons and among the armies in the field, is principally due to the insanitary conditions surrounding the soldiers. Where the demands of hygiene were especially ignored; where the food was bad in quality, or badly cooked; the water impure; the soil polluted by excreta and other filth; where the men were exposed to stress of weather or to a paludal atmosphere;-under these conditions, the above diseases of the intestines prevailed in their greatest extent and most fatal degree. Malarial Fevers.-The diseases due to the paludal poison are exceedingly frequent among soldiers encamped in malarial sections. During the Civil War a very pernicious form of malarial fever received the designation of the locality in which it prevailed, and passed into the literature under the name of " Chickahominy fever." While malarial diseases were largely represented in the morbility reports during the war, the most serious results of the influence of the malarial poison were manifested in its effects upon patients sick with other diseases. Thus, typhoid fever, dysentery, or pneumonia, in a patient saturated with malaria, wras very much more serious than where this complication was absent. In the malarial regions in the interior of the country, the Mississippi Valley, and the southern portion of the Western Territories, malarial fevers are among the most prevalent camp diseases. Greater attention in locating camps, and care devoted to draining the subsoil and maintaining a low level of the ground- 238 TEXT-BOOK OF HYGIENE. water, would doubtless result in improvement in the sickness- rate from this cause in the army. Typhoid Fever.-Typhoid fever is prevalent in camps and garrisons. As it may be propagated through the medium of infected discharges of typhoid patients, it will readily be perceived that neglect of the precaution of promptly disinfecting such dis- charges will almost inevitably result in spreading the disease, either by direct inhalation of effluvia from the patient or excreta, of pollution of the drinking-water, or by contamination of the soil, and subsequently of the atmosphere, by the intestinal dis- charges of the patient. Phthisis.-Especially among troops in barracks phthisis is a very fatal disease. Formerly the mortality from it was very heavy. Recent improvements in the hygiene of military posts and greater care in selecting recruits have very greatly diminished the death-rate from phthisis among soldiers. Acute pulmonary affections, such as bronchitis, pleurisy, and pneumonia, are com- paratively frequent in camps, being due to exposure. Typhus Fever and Scurvy.-These two diseases are at the present day comparatively rare as camp diseases. They break out, however, on every occasion when the laws of hygiene are violated by permitting overcrowding, overwork, and underfeeding. This is almost certain to occur during war, and hence either fully-developed scurvy or a scorbutic taint are almost constant accompaniments of an army in the field. Among the allied armies in the Crimea, and in the Federal army during the war, scurvy and typhus fever claimed a considerable share in the mortality. Purulent Conjunctivitis.-This affection of the eyes is fre- quent among soldiers. It has even been supposed to be peculiar to soldier life, and has hence been termed " military ophthalmia." It is contagious, and is probably most often spread by the use of basins and towels in common. It is not merely annoying, but is a very grave affection, often causing perforation of the cornea and destruction of vision. The military surgeon should be on the lookout for it, and promptly isolate those infected. 239 CAMP DISEASES. Venereal Diseases.-The contagious diseases of the sexual organs are a veritable scourge of the soldier's life. The history of these diseases is intimately interwoven with the history of armies, camps, and wars. The first wide-spread appearance of syphilis in the fifteenth century is coincident with the siege of Naples by the French army under Charles VIII.1 It has since that time been a constant companion of the soldier in peace or war, and in all seasons and countries. Some progress toward its restriction has, however, been made in recent years in certain localities, but there is still wide room for improvement. In 1867 the venereal diseases reported in the Prussian army were 53.9 per 1000 of mean strength. In 1882 this number had been reduced to 41 per 1000, in 1863 to 36.4, and in 1884 to 32.8 per 1000. In the Austrian army there were 81 per 1000 in 1870, diminishing to 73.5 per 1000 in 1884. In the British army the ravages of the venereal diseases were so terrible that legal measures for their restriction by subjecting prostitutes to inspection were taken. In 1859 the proportion of venereal disease among the home troops was 400 per 1000. In 1864 and 1866 the passage and enforcement of the "Contagious Dis- eases Act " caused a marked diminution of these diseases. This reduction is particularly noticeable in syphilis. The following table gives a comparative view of the number of cases of syphilis per 1000 in the naval service at ports under the acts, and at ports where the acts were not enforced:- Table XXIII. Ports Under the Acts. Ports Not Under the Acts. 1860-1863 (no restriction), 75.02 per 1000 70.50 per 1000 1864-1865 (acts enforced), 79.12 a " 100.00 a « 1866-1870 (acts extended), 47.19 a " 84.74 a « 1871-1880,.... 40.64 a " 99.35 a In the French army the proportion of venereal diseases was 53 per 1000 from 1862 to 1866. In 1867 the proportion in- creased to 106 per 1000. This increase was attributed to the 1 See article on Syphilis, Chapter XIX. 240 TEXT-BOOK OF HYGIENE. infection during tlie Mexican campaign. In 1879 the propor- tion had again diminished to 65.9 per 1000. In the United States Army the venereal diseases numbered 63 per 1000 among the white and 81 per 1000 among the colored troops in 1884. A chart drawn by Major Charles Smart, surgeon United States army,1 shows in an interesting manner how opportunity for infection influences the increase of venereal disease. At the breaking out of the war, when large numbers of men enlisted, the record shows a rapid increase of venereal. When the armies were in the field, and opportunities for the pursuit of Venus were few, the proportion of venereal decreased. At the expiration of the first triennial period of enlistment, the soldier with his final pay and thirty days' fur- lough crowded the cities, and entered on a period of dissipation which usually sent him back to the recruiting officer with empty pockets and an attack of gonorrhoea or syphilis. At this time the records show a large number of cases, which gradually diminished until the end of the war, when the opportunities for infection preliminary to the final muster-out crowded the hospitals once more with venereal cases. The experience with the Contagious Diseases Act in Eng- land points out the true way to limit or entirely extirpate this disease among the military and naval forces. An inspection at regular intervals not only of public prostitutes, but also of the soldiers themselves, and segregation of the infected in hospitals until the infective period is past, will do more to limit the spread of venereal disease than all other preventive measures, public or private, put together. VI.-CIVILIAN CAMPS. The camps of civil life, whether established for the purpose of furnishing a refuge to the inhabitants of cities invaded by epidemic diseases, as yellow fever or cholera, or whether for religious purposes (camp-meetings), or for recreation (hunting * Medical and Surgical History of the War, third medical volume. CIVILIAN CAMPS. 241 and fishing camps, etc.), should be organized and managed on the same principles as the military camp. The site should be selected with judgment-a clean, dry soil, and abundance of wood and water being requisite for a healthy camp. A superintendent or officer of the day should be appointed, whose duty it is to carefully inspect the camp daily, and compel the prompt removal of all filth and offal from the immediate vicinity. Cleanliness of person, clothing, and household is as important while " roughing it " in camp as at home. Singularly, this is very often forgotten by very intelligent people. The advantage of a well-administered refugee camp in case of yellow-fever epidemics has been clearly shown by the brilliant success of the depopulation of Memphis during the epidemic of 1879 and of various Florida cities and towns in 1888. These experiments deserve imitation. [The following works on Military and Camp Hygiene should be studied in connection with this chapter:- Smart, The Hygiene of Camps, in Buck's Hygiene and Public Health, vol. ii.-Wolzendorff, Armee Krankheiten, in Realencyclopsedie d. ges. Heilk., Bd. I, p. 489.-Schuster, Kasernen, in von Pettenkofer mid Ziemssen's Handbuch der Hygiene, II Th., 2 Abth.-Cameron: Camps, Depopulation of Memphis, Epidemics of 1878 and 1879. Public Health, vol. v, p. 152.-Frolich, Militarmedicin.-Medical and Surgical History of the War, especially the second and third medical volumes. -Annual Reports of the Supervising Surgeon-General of the United States Marine Hospital Service, 1888-9.] CHAPTER XI. Marine Hygiene. The melancholy accounts of the mortality from scurvy, dysentery, and typhus fever, which were formerly a part of the history of so many naval and passenger vessels, are happily now only records of the past. Occasionally, however, careless- ness of the authorities, or of those responsible for the safety of people who " go down to the sea in ships," results in an out- break of one or other of these diseases even at the present day. Thus, for the fiscal year ending June 30, 1882, 71 cases of scurvy and purpura were reported by the medical officers of the Marine Hospital Service. It appears that only in one instance (where 6 cases of scurvy had occurred on one vessel) was any investigation ordered. A most superficial investigation showed that the law relating to the issue of lime-juice had been violated by the master of the vessel. No prosecution resulted. Such facts indicate that laxness in the enforcement of the regu- lations expressly made to prevent this fatal disease may be again followed by outbreaks of greater or less gravity. I. THE SAILOR AND HIS HABITS. Although the sailor of the present day, especially in the naval service, is morally and intellectually far in advance of the " Jack Tar " of former days, his life, both afloat and on shore, leaves much to be desired on the score of temperance, chastity, and purity of thought and speech. The life of a sailor in the United States navy, only thirty years ago, is thus graphically described by Medical Director Albert L. Gihon1: " She was manned by a motley crew, of whom Americans were a minority, 1 Thirty Years of Sanitary Progress in the Navy: Annual address by the President to the Naval Medical Society, Washington, 1884. 243 244 TEXT-BOOK OF HYGIENE. and Englishmen, Irishmen, Northmen, and ' Dagos ' constituted the far greater part. Some had just returned from another cruise, having squandered or been robbed of their three years' pay by the landsharks, who cajoled them, only half sober, to the rendez- vous, to be reshipped, and thence to be herded, uncared for, on the receiving-ship, still popularly termed the 'guardo,' until drafted on board the first sea-going vessel. All of them were in debt, most of them insufficiently clad, and unable to properly outfit themselves. The wretched herd, who were thus gathered from the purlieus of Water Street, and North Street, and South Street, who at night were kenneled worse than dogs, by day fed like them-crouching on their haunches around greasy mess-cloths, cutting with jack-knives or pulling to pieces with grimy fingers the chunks of ' salt horse ' and ' duff ' which made their daily fare, and which later in the cruise were both spoiled and scanty, did not constitute an elevating subject for contemplation. " Stint of good food," continues Dr. Gihon, " was, how- ever, not the chief of the old-time shell-back's ocean trials. Fed like a brute, housed worse than one, however faithfully his labors were performed, there was for him only a long, dreary season of imprisonment. For him there was no glad holiday on shore, when the land broke the monotony of the waste of waters. The officers might rush pell-mell out of the ship, but Jack could only strain his longing eyes upon the green fields or busy sea- ports. Notwithstanding the hardships of the voyage, the wretched food, and the outbreaks of disease, the crew were con- fined eight months on board ship, before ' general liberty ' was given, and then men and boys were sent on shore for forty-eight hours to indulge in a mad revel, and to return crazed by rum, battered, and bruised. The poor wretch, first made ravenously hungry for dissipation by his enforced confinement, was then expected to be temperate in the feast of indulgence offered him, and punished with vindictiveness if he sought to gorge himself with the poor semblance of pleasure. The ' cat ' had been THE SAILOR AND HIS HABITS. 245 abolished, but half a dozen boys strung upon the poop 'bucked and gagged '; half a dozen men triced up by their thumbs in the rigging; each of the upright coffin-like ' sweat-boxes' with its semi-asphyxiated inmate; the ' brig ' with its bruised and bloated crew in irons; the main-hold with its contingent under hatches; the sick-list swollen out of all proportions by in- ebriates, injured men, and venereal cases;-these were the fruits of the general liberty, which, within my professional life, repre- sented the sum of sanitary interest in the man before the mast." Under such circumstances little could be hoped for in the way of personal advancement of the crew. The labors, how- ever, of the writer just quoted, and others, among whom may be mentioned Wilson and Turner, of the navy, and Woodworth, Hebersmith, and Wyman, of the Marine Hospital Service, have drawn prominent attention to the unsanitary conditions of the sailor's life, and legal enactments have done much to elevate him to his proper rank as a human being, entitled to be treated with humanity, at least. The seaman in the navy is now well clad, and receives an abundance of food, of good quality, usually well cooked and decently served. " Latrines and bath- and wash- rooms under the top-gallant forecastle; mess-tables and benches; mess- lockers and clothes-lockers; a place where, and opportunities when, men can read and write; and frequent daily liberty to go on shore, if not already common to every vessel, are yet now so generally the concomitants of the well-officered and well-dis- ciplined and efficient ship, that ere long their absence will be accounted a fault."1 A medical corps, selected after the most rigorous examination known to the profession, and provided with every aid and appliance of medical science, cares for the enlisted sailor and marine when ill or injured, as tenderly as for the commissioned officer. The sailor in the merchant service, however, is still at the * Thirty Years of Sanitary Progress in the Navy, Gihon. 246 TEXT-BOOK OF HYGIENE. mercy of inhuman masters, who exact excessive service in return for insufficient food, scanty clothing, miserable lodging, abuse, ill-treatment, and neglect when sick or disabled. II.-THE PASSENGER. During the ten years from 1870 to 1879, inclusive, passen- ger vessels carried 1,561,126 passengers from foreign ports en route to New York City. The mean duration of each voyage was 13.5 days. Out of the above number of passengers 2518 died on the voyage,-a death-rate of 1.61 per 1000 for the voyage and 43.5 per 1000 per annum. These figures accentuate the importance of sanitary improvement in passenger vessels. The causes of this excessive mortality among emigrants-for it is almost exclusively among the passengers in the steerage, or " between decks," that the deaths occur-are overcrowding, im- proper feeding, defective ventilation, filthy personal habits, and inefficient medical attention when sick. Although overcrowd- ing is prohibited by statute, yet in every emigrant vessel that arrived in New York during the first nine months of 1880 the number of passengers was in excess of the number allowed by law.1 The shorter voyages and better sanitary conditions ob- tainable since steamships, especially those built of iron, have come into general use for the carriage of passengers, have very much reduced the mortality on ocean voyages; but, as just shown, the death-rate is still excessively high, and many more im- provements in the hygiene of emigrant vessels and of passengers are desirable. III.-THE SHIP AS A HABITATION. As a habitation for the sailor and passenger the ship de- mands the attention of the sanitarian. The principal points in which he is interested are the construction and ventilation of sleeping-apartments, and the means of keeping the entire ship clean and free of water and impure air. The keel is the foundation of the ship. Branching out * Hygiene in Emigrant Ships, Turner, Public Health, vol. vi, p. 24. THE SHIP AS A HABITATION-. 247 transversely from it are curved timbers, the ribs, which, with the keel, constitute the ship's frame. The ribs are covered exter- nally and internally with planking, and the spaces between the two coverings are the frame-spaces, which are usually partly filled with filthy water, decomposing organic matter, and foul air. The water collects in the bottom of the vessel, the bilge,1 whence it is pumped out of the vessel. If the pumping is neglected the bilge-water becomes very offensive, and may cause disease in persons exposed to exhalations from it. The frame- spaces are rarely ventilated, and hence are frequent sources of pollution of air on board vessels. The sleeping-apartments of the crew of a merchant vessel are in the forecastle, usually a small, dark, damp, filthy, unven- tilated space in the bow of the vessel, where they are kenneled like brutes. On naval vessels the crews sleep on the berth- deck, which, in the rarest instances, is properly lighted and ventilated. The berth-deck is usually below the water-line. In nearly all and even the best class of vessels in the United States naw the air-allowance for each man is less than 3 cubic metres, rarely reaches 4, is oftener from 2 to 2J, and is some- times as low as 1 cubic metre. The men swing by night in hammocks suspended from the beams overhead, and removed when not in use, carried on deck, and stored in lockers, called "hammock-nettings," on the ship's sides. That a ship should, above all, be seaworthy would seem to require no argument. It is self-evident that a leaky or rotten ship is at all times a highly dangerous habitation, yet crews and passengers are almost daily exposed to the perils of shipwreck in unseaworthy vessels, especially in the mercantile marine.2 " Dampness, dirt, foul air, and darkness," according to Gihon, " are the direst enemies with which the sailor has to battle when afloat."3 The first requisite for a healthy ship is 1 Hence called "bilge-water." 2 The Safety of Ships and Those who Travel in Them, Woodworth, Public Health, vol. iii, p. 79 et seq. * Naval Hygiene, 3d ed., p. 28. 248 TEXT-BOOK OF HYGIENE. dryness. "A damp ship is an unhealthy ship," says Fonssa- grives, the greatest authority on naval hygiene. From official reports it appears that the relative humidity of the berth-deck of vessels in the United States navy is nearly always above 80 per cent., very often rising to 90 and 95 per cent.1 From the same source it is learned that the class of respiratory diseases furnished, with one exception, the largest amount of sickness in the navy during the year 1880. It is the concurrent testimony of all authorities in marine hygiene that the vicious custom of daily drenching the decks with water, under the plea of cleanli- ness, is mainly responsible for this excessive moisture and its results. The battle of naval hygiene was long fought on this contested field of wet decks, until the fact became so patent that wet ships were always unhealthy ones. It is, therefore, one of the most important aims of marine hygiene to curtail this practice. Gihon recommends that the decks be painted and then coated with shellac, occasionally renewed, to make them non- absorbent, and to wet them as rarely as possible, consistent with cleanliness, the smooth surface of the shellacked deck beinjj quickly swabbed over with hot water and thoroughly dried. The ship should be clean and well ventilated. Efforts to keep a ship clean should not be expended upon the decks only ; the occupied apartments below the hatches, the bilges and frame- spaces should all receive especial attention from the sanitary inspector. It is quite frequently necessary to remove the flooring of the vessels in order to expose the accumulations of filth, which often make an infected ship synonymous with a dirty ship. An unobstructed passage, to which ready access can be had through removable covers, should extend under the flooring from one end of the vessel to the other. To disinfect a dirty ship, steam forced into the hold under pressure, before and after the filth has been cleaned out, gives the most satisfactory results. 1 Report of Surgeon-General of the Navy, Washington, 1880. THE SHIP AS A HABITATION. 249 Fumes of sulphur burned in the presence of watery vapor, and chlorine are next in efficiency.1 Solutions of sulphate of iron or chloride of zinc may be poured into the bilges to prevent decomposition. It has been estimated2 that a minimum of 15 cubic metres of air-space, with facilities for thorough ventilation, should be allowed to each person on board ship. It is safe to say that no vessel that floats gives to her passengers or crew the advantages of such conditions. Ventilation of the holds and bilges, and of the spaces between the timbers or ribs, "intercostal ventilation," as Turner calls it, is especially necessary. Any system of ven- tilation that does not contemplate the removal of the foul bilge- air is unworthy of consideration by the sanitarian. The venti- lating apparatus which has been introduced on board vessels of the United States navy consists essentially of two longitudinal mains extending through the holds and under the engines, boil- ers and coal-bunkers the entire length of the ship, beginning in contracted extremities at bow and stern and terminating in a chamber or " blower-room " on the berth-deck just forward of the mainmast. In this room a Sturtevant fan or blower, 2 metres in diameter, is driven by an engine at from 150 to 300 revolu- tions a minute, expelling the air through a 70-centimetre funnel, opening high above the spar-deck. Small metal pipes connect these longitudinal mains with every state-room, store-room, pantry, and other inclosed apartment on the berth-deck, orlop, and holds, from which the foul air is aspirated by the revolution of the fan. Fresh air finds its way below through the wind-sails, ventilating-shafts, hatchways, and air-ports, entering the apart- ments by way of doors, crevices, and other natural apertures. Similar small metal pipes also connect the bilges with the longi- tudinal mains, and air is thus drawn through the frame-spaces between the timbers, which terminate below at the floor of the 1 Report of Committee on Disinfectants, American Public Health Association. 4 Hygiene of Emigrant Ships, Public Health, vol. vi, p. 26. 250 TEXT-BOOK OF HYGIENE. ship and open above on the spar-deck, and a circulation of fresh air is thus established in the frame or " skin " of the ship, con- tributing greatly to its dryness and to the preservation of the material of the vessel. The absolutely essential condition of this system of ventilation is that the blower shall revolve, but, unfortunately, sanitary interests are too often sacrificed on the pretext that economy of fuel will not permit the operation of the fan.1 All parts of the vessel used as habitations or sleeping- apartments should receive sufficient sunlight. At present, very few vessels have the quarters of the crew so disposed as to admit any sunshine at all. In the fire-rooms of steamships, especially on that class of naval vessels termed monitors, the temperature often rises so high as would seem to render continued existence in it impossi- ble. Gihon states that the average temperature in the fire-room of the monitor Dictator was 145° F. (63° C.), while Turner states that in another vessel the average fire-room temperature was 167° F. (75° C.).2 The firemen and coal-heavers (stokers) frequently suffer from heat-stroke, and, in a very large proportion of cases, from heart disease. Lavatories and bathing facilities should be furnished on vessels for passengers and crew, and both should be compelled to keep their bodies and clothing clean. A more liberal supply of water for drinking, a more frequent issue of fresh meat and vegetables, and better cooking are the sanitary considerations to-day in the subsistence of the sailor. The American naval ration is superior in variety and palatableness to that of any foreign service, but skilled cooks are still a desideratum on board men-of-war, and medical officers have long been insisting that schools for their instruction should be established at recruit- ing stations. The composition and distribution of the rations are given in the following table:- 1 Hygiene (Naval), Hand-book of the Medical Sciences, Gihon. * Buck's Hygiene and Public Health, vol. ii, p. 190. THE SHIP AS A HABITATION. 251 Table XXIV. ALLOWANCE FOR GENERAL DAILY USE. (Either one of the following.) Rations Established by Law. Specified by Law. Substitutes Authorized by Law. Ration No. 1 . ■ 1 lb. salt pork f pint beans or peas . . $ If lb. fresh meat; or, f lb. preserved meat. Vegetables of equal value ; or, | lb. rice. Ration No. 2 . ■ 1 lb. salt beef ( 4 lb. flour £ 2 ozs. dried fruit .... If lb. fresh meat; or, f lb. preserved meat. Vegetables of equal value. Ration No. 3 . - f lb. preserved meat . . 1 lb. rice 2 ozs. butter X1 oz. desiccated mixed vegetables No substitute, f pint beans or peas. No substitute. 6 ozs. canned vegetables. Ration No. 4 . . J lb. preserved meat . . 2 ozs. butter 16 ozs.desiccated tomatoes No substitute. No substitute. 6 ozs. canned tomatoes. DAILY ALLOWANCE. Rations Established by Law. Specified by Law. Substitutes Authorized by Law. Ration No. 1 . . 14 oz. biscuit 1 lb. soft bread. 1 lb. flour. j lb. rice. Ration No. 2 . . | oz. tea 2 ozs. coffee. 2 ozs. cocoa. Ration No. 3 . . 4 ozs. sugar I For coffee and sugar, extract of coffee combined with milk and sugar may be substituted by the Secretary of the Navy, if not more expensive. WEEKLY ALLOWANCE. Rations Established by Law. Specified by Law. Substitutes Authorized by Law. Ration No. 1 . . Ration No. 2 . . Ration No. 3 . . 2| pint pickles | pint molasses .... | pint vinegar None. None. None. * These articles being out of the market, and not procurable, the nearest possible sub- stitutes are given. 'One-half pint of pickles is considered equal to % lb., and is issued as such. 252 TEXT-BOOK OF HYGIENE. IV. DISEASES ON SHIPBOARD. The diseases most liable to attack persons on shipboard are: Diseases of the respiratory organs, rheumatism, malarial diseases, digestive disorders, scurvy, typhus fever, and skin diseases; and, where the infection has been conveyed to the vessel by other persons or by fomites: yellow fever, cholera, small-pox, and venereal diseases. It is interesting to note in the last-published report of the Surgeon-General of the Navy that, among a total of 8550 admissions of sick and disabled officers and men of the Navy and Marine Service, nearly 90 per centum were included in the following classes, to wit:- Casualties, . . 1917 Affections of the respiratory tract, . . .1149 Venereal diseases, 1071 Malarial and other fevers, 888 Diseases of the integument, .... 888 Rheumatism, 521 Affections of the nervous system, . . . 489 Diarrhoeal maladies, ...... 483 The remaining 1144 were distributed over a wide range of titles, of which many, as adynamia, cephalalgia, constipation, odontalgia, etc., have no special pathological significance. It is probable that only about one-fourth of the cases of disease occurring at sea are attributable to any of the circumstances of oceanic life, and these are almost entirely inflammatory affections of the air-passages and intestinal tract, neuroses, including nausea marina, and rheumatism.1 Most of these affections can be prevented by proper meas- ures of hygiene, as demanded by the conditions described in this chapter or by the enforcement of the following regulations:- Inspection of crews and passengers should be made com- pulsory before shipment. Persons suffering from contagious or infectious diseases should not be taken on board.2 In order to 1 The Therapy of Ocean Climate, Gihon, Transactions of American Climatological Asso- ciation, 1889. 3 Gihon relates an instance where a man suffering from parotitis was transferred from the hospital of a receiving-ship to a vessel going to sea. The disease was communicated to more than seventy of the crew of the latter vessel. DISEASES ON SHIPBOARD. 253 make this provision effective, the history of the individual for two weeks prior to his application for shipment should be known to the inspecting officer. Passengers should possess bills of health from the local authorities at their homes, in order that the presence or absence of such diseases as small-pox, yellow fever, cholera, or plague may be established by the inspector. Cholera has always been introduced into this country by immi- grants. Everybody admitted to the ship should be vaccinated. During several years past a number of epidemics of small-pox have been traced to foreign immigrants who had not been properly vaccinated. Sailors in the merchant service should, like those in the navy, be submitted to a close personal inspection, and those suffering from venereal diseases should be rejected. The usual history of the cases is that they soon go on the sick-list, and thus become an incumbrance instead of an aid on the vessel. Statistics show that 1 man in every 7 or 8 in the naval service and 1 in every 4 of the crews of merchant vessels are affected writh some form of venereal malady.1 These inspections should not be restricted to examinations for venereal diseases, but indi- viduals incapacitated for the performance of a seaman's duties by any cause should be rejected. This precaution would un- questionably reduce the number of marine disasters directly traceable to deficiency in the working force on board vessels. In this country the services of the medical officers of the Marine Hospital Service might be made available to carry out these inspections. All sailors are liable to be placed in positions where the prompt and accurate distinction of colors becomes necessary, hence all color-blind individuals should be rejected as seamen. The inability to distinguish colors has often been the cause of grave accidents at sea. Pilots can no longer obtain a license unless they satisfactorily pass an examination with reference to their ability to distinguish colors. * The Prevention o£ Venereal Diseases, Gihon, Public Health, 1882. 254 TEXT-BOOK OF HYGIENE. [The following works contain more detailed information upon the subject treated in the foregoing chapter:- A. L. Gihon, Practical Suggestions in Naval Hygiene, 3d ed., Washington, 1873.-T. J. Turner, Hygiene of the Naval and Merchant Marine.-Buck's Hygiene and Public Health, vol. ii.-Walter Wyman, Hygiene of Steamboats on the Western Rivers.-Report of Supervising Surgeon-General M.H. Service for 1882.-Annual Reports of the Surgeon- General of the Navy for 1879, 1880, and 1881.-Various papers by J. M. Woodworth, A. L. Gihon, T. J. Turner, Hebersmith, and A. N. Bell in Public Health, vols. i, iii, and vi.-Hygiene, Naval, by Albert L. Gihon, M.D., in Reference Hand-book of Med. Sciences.] CHAPTER XII. Prison Hygiene. Although the frightful mortality which formerly seemed a necessary accompaniment of the life of the convict has in the past half-century markedly diminished, the death-rate among prisoners is still very greatly in excess of that of persons of the same age in a state of liberty. The observations and labors of John Howard, the self- sacrificing philanthropist, in the latter half of the last century, and of Elizabeth Fry, in the first half of the present, directed the attention of legislators to the necessity of reform in the con- duct of prisons and the treatment of prisoners. As a conse- quence of the labors of these reformers, the principles of prison discipline have been more fully developed during the past forty years by students of social science everywhere, and certain propositions have been formulated, which govern, to a greater or less degree, legislation upon this subject. These propositions are, briefly, as follow :- Prisoners must be properly classified according to the nature of their crime and the duration of imprisonment. The two sexes must be strictly separated, and no oppor- tunity given for intermingling while in the prison. Female prisoners should have female attendants exclusively. Male watchmen or other attendants should not be allowed in the female department of a prison. All prisoners must be kept employed at some manual labor, not necessarily for profit, but as an agency in the moral reforma- tion of the convict. Punishments for infractions of discipline must not be excessive. 255 256 TEXT-BOOK OF HYGIENE. Efforts should be constantly made tending to the reclama- tion of criminals from their life of sin and crime. Due care must be taken by the State to preserve the health and life of the prisoner whom the State has deprived of liberty and the opportunity of taking care of himself. A proper classification of prisoners, according to the degree of their criminality, the nature of the crime of which they have been convicted, or the length of time for which they have been sentenced, is now insisted upon by all students of prison dis- cipline. As this subject more nearly concerns the social or legal relations of prisoners rather than their sanitary interests, it is here passed over with a mere mention. The separation of the sexes, necessity of female attendants on prisoners of the same sex, employment of prisoners, and moral reformation of criminals likewise belong especially to the social aspects of the question, and can find no discussion in this place. Regarding the remaining proposition, however, that which demands that the State shall exercise due care over the prisoner's health, it comprises a question that demands consideration in a text-book on hygiene. There is now a general concurrence of opinion that the State, in depriving any person of liberty, has no right to subject the individual suffering such deprivation to any danger of disease or death. In other words, the State has no right to abbreviate the life of the convict sentenced to prison. This proposition requires that the State see to it that the prisoner is well fed, well clothed, and well housed; that he shall be well cared for when sick, and that when his term of imprisonment expires he shall be set at liberty, with only such effect upon his normal expectation of life as would result from the ordinary wear and tear of life upon his health. It must be confessed, however, that the State is very far short of attaining this object. The mortality of convicts, even in the best-regulated prisons, where especial attention is paid to the sanitary requirements of such buildings, is three times as PRISON HYGIENE. 257 great as among workmen in mines, confessedly one of the most dangerous occupations. If insurance companies desired to insure the lives of prisoners, the companies would be obliged, in order to secure themselves against loss, to make the premium equivalent to an advance in age of twenty years. This means that a free person has as long an expectation of life at 40 years as a prisoner has at 20. Attention is again called to the fact that the conditions in the most favorably situated and liberally managed prisons only are here considered. What the results are in other institutions, less favorably constructed and managed, will be apparent from the following brief statement: Mr. George W. Cable has shown1 that in some of the prisons in the Southern States, under the vicious lease system, the mortality is eight to ten times greater than in properly con- structed and managed prisons elsewhere. In Louisiana, for example, 14 per cent, of all the prisoners died in 1881; and in the convict wood-cutting camps of the State of Texas one-half of the average number so employed during 1879 and 1880 died. The mortality of prisoners is greatest in the second, third, and fourth years of their confinement. In Millbank Prison, in England, the death-rate per 1000 was 3.05 in the first year, 35.64 in the second, 52.26 in the third, 57.13 in the fourth, and 44.17 in the fifth years of imprisonment. The diseases most frequent among prisoners are pulmonary phthisis and diseases of inanition, manifested by general dropsy. Consumption furnishes from 40 to 80 per cent, of all deaths. When prisoners are attacked by acute febrile or epidemic diseases (small-pox, cholera, dysentery), the mortality is much higher than among persons in a state of liberty. This fatality is due to an ansemic or cachectic condition, which has been called " the prison cachexia,"-a depravement of constitution which yields readily to the invasion of acute diseases. Prisons should be built upon a healthy site, be properly heated and ventilated, have an abundant water-supply, and 1 Century Magazine, February, 1884. 258 TEXT-BOOK OF HYGIENE. be supplied with facilities for a prompt and thorough removal of sewage. Baths and lavatories should be conveniently ar- ranged in order that thorough cleanliness can be enforced. The problem of feeding prisoners requires careful study. The food should not only be sufficient in quantity and of good quality, but it should be well cooked, and the bill of fare varied often in order to avoid creating a disgust by an everlasting sameness. Prisoners often suffer from nausea and other digestive derangements, brought on solely by the monotonous character of the daily food. In workshops and sleeping-rooms, dormitories or cells, the cubic air-space allowed to each inmate should not be less than 17 cubic metres, with proper provision for ventilation. The use of dark or damp cells as places of confinement is a relic of the barbarism in the treatment of convicts against which John Howard raised his voice so effectively in the last century. An abundance of sunlight should be admitted into every room in which a human being is confined. An important hygienic measure is daily exercise in the open air. It should be regularly enforced, and its modes frequently varied in order that it may not degenerate into a mere perfunctory performance. Punishment for infractions of the prison discipline should be inflicted without manifestation of passion, and only under the immediate direction of some official responsible to the State. It is questionable whether physical punishments, such as whipping, tricing up by the thumbs with the toes just touching the floor, bucking and gagging, and similar barbarities should be permitted under any condition. The permission to exercise such power is extremely liable to be abused by officials. The system of leasing out prisoners to private parties, which prevails in some of the southern United States is vicious in the extreme, because it places the convict under the control of persons not responsible to the State, and, in the majority of instances, morally unfitted to wield the power of inflicting punishment.^ PRISON HYGIENE. 259 [The following works on prison hygiene and prison reform are recommended to the student:- A. Baer, Gefangniss-Hygiene, in von Pettenkofer und Ziemssen's Handbuch der Hygiene, II Th., 2 Abth.-Trans. International Peniten- tiary Congress, London, 1882.-Trans. National Prison Association, Baltimore, 1872.-G. W. Cable, The Convict-Lease System in the South- ern States, Century Magazine. February 1884.] CHAPTER XIII. Exercise and Training. The healthy functions of the bodily organs can only be maintained by more or less constant use. A muscle or other organ that is unused soon wastes away, or becomes valueless to its possessor. On the other hand, trained use of the various organs makes them more effective for the performance of their functions. Thus, by practice, the eye can be trained to sharper vision, the ear to distinguish slight shades of sound, the voice to express varying emotions, the tactile sense to accurately appre- ciate the most minute variations of surface and temperature, and the hand to greater steadiness or the performance of difficult and complex feats. The effectiveness of other organs, muscles, or groups of muscles can also be increased by systematic train- ing, as is seen in the athlete and gymnast. PHYSIOLOGICAL EFFECTS OF EXERCISE. When a muscle contracts, the flow of blood through it is increased. Hence, contraction of a muscle, which consumes or converts stored-up energy, at the same time draws upon the cir- culation for a new supply of food-material to replace that con- sumed. The activity of the circulation through a muscle in action results in increased nutrition and growth of the muscle. During muscular action the activity of the respiratory process is increased. A larger quantity of air is taken into the lungs, more oxygen is absorbed by the blood, and an increased elimination of carbon dioxide takes place. The experiments of Pettenkofer and Voit show that, while in a state of rest the average absorption of oxygen in twelve hours amounted to 708.9 grammes, during work the amount reached 954.5 grammes. 261 262 TEXT-BOOK OF HYGIENE. For the same period the elimination of carbonic dioxide was: during rest, 911.5 grammes; during work, 1284.2 grammes. Upon the circulation muscular exercise likewise exerts a manifest influence. The action of the heart is increased both in force and frequency, the arteries dilate, and the blood is sent coursing through the system more rapidly than when the body is at rest. Cutaneous transpiration is also promoted by muscular exer- cise. It is probable that in this way some of the effete matters in the system are removed, being held in solution and carried through the skin in the perspiration. PHYSICAL TRAINING. There can be no question that systematic training of the muscles has a favorable influence upon health and longevity. Persons who are actively engaged in physical labor, other things being equal, are healthier, happier, and live longer than those whose occupation makes slight demands upon their muscular sys- tem. In default of an active occupation the latter class is forced, if good health is desired, to adopt some form of exercise which will call the muscles into activity. • The principal methods of physical training are walking or running, rowing, swimming, and the various in-door gymnastic exercises. Rapid walking or running is one of the best methods of physical exercise, for, not only are the muscles of the legs and thighs developed, but the capacity of the chest is increased-one of the principal objects of physical training. By combining walking with some form of in-door gymnastics, such as practice with dumb-bells, Indian clubs, rowing-machines, or pulley- weights, nearly all the good effects of the most elaborate system of training can be obtained. For the gymnastic exercises various forms of useful labor may be substituted with advantage, such as wood-chopping or sawing, or moderate work at any physical labor. The scheme of studies in our public-school system should PHYSICAL TRAINING. 263 include physical training for both sexes. This is a question not merely of individual, but of national importance. Weak and unhealthy children are not likely to grow up into strong and healthy men and women; and the latter are necessary for the perpetuity of the nation. The time seems to have arrived when physical education should no longer be looked upon as a whim of unpractical enthusiasts and hobby-riders, but as an indispen- sable element in every school curriculum. There is a tendency among instructors in physical training to make their systems too complicated, or dependent upon expen- sive or cumbersome apparatus. This is to be deprecated. All the muscles of the body can be called into action by very simple exercises, easily learned and readily carried out. An important preliminary to all methods of training is a thorough physical examination of the pupil by a competent physician, in order to determine whether certain exercises are allowable. For example, in all organic heart affections exer- cises of a violent character must be interdicted. A boy or man with valvular disease of the heart cannot run, row, or swim with safety. The organ is easily overtasked in this condition and liable to fail in its function. One of the simplest and best methods to cause the pupil to assume a correct position of the body, and to acquire ease and grace in his movements, is to teach him the "setting-up," as practiced in the United States army.1 In walking, a free, swinging step should be acquired, with the head erect, shoulders thrown back, and chest well to the front, the whole body from the hips upward inclining slightly forward. The clothing should be loose around the upper part of the body, in order not to interfere with the freest expansion of the chest, and to give the lungs and heart ample room for movement. Even in-door gymnastic exercises alone, when prac- ticed under intelligent provision, will accomplish very favorable results, as shown by the following table:- * Upton's Infantry Tactics. School of the Soldier, Lesson I. 264 TEXT-BOOK OF HYGIENE. Table XXV. Showing Average State of Development on Admission to Gymnasium ; Average State of Growth and Development after Six Months' Practicing Two Hours a Week, and Average Increase During that Time. (Bowdoin College Gymnasium, under Dr. D. A. Sargent. Two Hundred Students from the Classes of 1873 to 1877, inclusive. Average Age, 18.3 Years.f On Admission. After Six Months' Practice. Average Increase. Height 170. cm. 170 6 cm. .6 cm. Weight 60.7 kg. 61 6 kg. 900 gms. Chest (inflated) 87 5 cm. 91.8 cm. 4 3 cm. Chest (contracted) 80.6 " 82.4 " 1.8 " Forearm 25. " 26.8 " 1.8 " Upper arm (flexed) 27.5 " 29 " 15" Shoulders (width) 38 7 " 40.5 " 1 8 " Hips 78 7 " 84 4 " 5.7 " Thigh 48.7 " 52 6 " 3.9 " Calf 31.2 " 33. " 1.8 " OVEREXERTION. However necessary for the preservation of health physical exercise may be, overexertion should be carefully avoided. Overstrain and hypertrophy of the heart are often the results of excessive exertion. Dr. Da Costa has described a form of " irri- table " and weak heart occurring especially among soldiers, which he has clearly traced to overexertion. Severe labor and violent athletic exercises have been followed by like serious results. Long-distance pedestrianism has furnished within recent years quite a number of individuals who were broken down in health by the excessive strain on the physical organization involved. Cardiac strain is not infrequent among this class. Spasm, paralysis, or atrophy of muscles sometimes results, when these are exhausted by uninterrupted or excessive exer- cise. This effect is shown by writers' and telegraphers' cramp, and similar affections. For these reasons it is important that both exercise for health and actual work should be so regulated as to conduce to the individual's benefit, and not to his detri- ment. 1 Apparatus used: Weights, 4500 to 6750 grammes; Dumb-bells, 1125 grammes; Indian clubs, 1575 grammes ; Pulleys. OVEREXERTIOX. 265 [On the subjects embraced in this chapter the following works may be studied with advantage:- A Braynton Ball, Physical Exercise, in Buck's Hygiene and Public Health, vol. i.-Wm. Blaikie, How to Get Strong and How to Stay So.- A. Maclaren, Training in Theory and Practice.] CHAPTER XIV. Baths and Bathing. The most important sanitary object of bathing is cleanli- ness. A secondary object of the bath is to stimulate the func- tions of the skin, and to produce a general feeling of exhilaration of the body. Baths are used of various temperatures. A cold bath has a temperature of from 4° to 24° C. (40° to 75° F.); a tepid bath from 24° to 30° C. (75° to 85° F.), a warm bath from 30° to 38° C. (85° to 100° F.), and a hot bath from 38° to 43° C. (100° to 110° F.). Tepid, warm, or hot baths are used principally as cleansing agents or as therapeutic measures. They cause dilatation of the cutaneous capillaries, diminish blood-pressure, and reduce nervous excitability. The hot bath is also a method for restor- ing warmth to the body in certain cases of shock, or to remove the immediate effects of injurious exposure to low temperature. The so-called Russian and Turkish baths, so popular in the larger cities of this country, are modifications of vapor- and hot- air baths, or rather combinations of these with cold baths. The Turkish bath is especially to be recommended for its depurative and invigorating effects. Cold baths are used not merely for their cleansing effects, but principally for their stimulating effects upon the system. When first plunging into a cold bath there is usually a moment- ary shock; the respiration is gasping, and the pulse is increased in frequency. These symptoms disappear in a few moments, however, and reaction follows. To a healthy person a cold bath is a delightful general stimulant, removing the sense of fatigue after physical exertion and causing an extremely refreshing sensation throughout the body. 267 268 TEXT-BOOK OF HYGIENE. As a therapeutic measure, the cold bath has a wide field of usefulness. For the reduction of the bodily temperature in fevers and inflammatory diseases, and especially in heat-stroke, it is more prompt and effective than any other agent at the com- mand of the physician. Sea-Bathing.-The most stimulating form of the cold bath is doubtless the salt-water bath as taken at the sea-shore. The revulsive effect of the impact of the waves and breakers upon the skin and the stimulation due to the saline constituents of the sea-water heighten the invigorating effects of the simple cold bath. The beneficial results of sea-bathing are, however, not entirely due to the bath, but are to a great degree dependent upon the bracing air of the sea-shore, absence of the care and anxieties of business, and the temporary change in food and habits that a residence at the sea-side involves. Nevertheless, salt-water baths are more stimulant to the skin than those of simple water, and part of the good effects of sea-bathing can often be obtained from a salt-water bath taken at home. The following mixture of salts dissolved in about 125 litres of water for one bath makes a fairly good substitute for a sea-bath:- Take of Chloride of sodium (common salt), . . .4 kilogrammes. Sulphate of sodium (Glauber's salt), ... 2 " Chloride of calcium | kilogramme. Chloride of magnesium, . . . . 1 j kilogrammes. There is a prevalent popular belief that it is extremely dan- gerous to enter a cold bath when heated or perspiring. The author is of the opinion that this belief is erroneous. The stim- ulant and bracing effects of the cold bath are most manifest if it be taken while the individual is very warm or bathed in perspira- tion. Several years ago the author made a series of observations upon himself to determine the effects of the cold bath when the body was very warm. Every afternoon a free perspiration was provoked by a brisk walk of about 2 kilometres in the sun. As soon as the clothing could be cast off, and while the body was still freely perspiring, a plunge was taken into a fresh-water bath of about 15.5° C. (60° F.). No ill results followed; on RULES FOR BATHING. 269 the contrary, the sensation immediately following the bath, and for six or eight hours afterward, was exceedingly pleasant. The health remained perfect, and the weight decidedly increased during the two months the practice was continued. There is probably no danger to a healthy person in this practice, but it is considered advisable to immerse the head first (" take a header "), to avoid increasing the blood-pressure in the brain too greatly, which might result if the body were gradually immersed from the feet upward. RULES FOR BATHING. The following series of rules have been issued by the English Royal Humane Society, and are all worth observing by bathers: "Avoid bathing within two hours after a meal. Avoid bathing when exhausted by fatigue or from any other cause. Avoid bathing when the body is cooling after perspiration. Avoid bathing altogether in the open air, if, after having been a short time in the water, there is a sense of chilliness, with numbness of the hands and feet; but bathe when the body is warm, provided no time is lost in getting into the water. Avoid chilling the body by sitting or standing undressed on the banks or in boats, after having been in the water. Avoid remaining too long in the water, but leave the water immediately if there is the slightest feeling of chilliness. The vigorous and strong may bathe early in the morning on an empty stomach. The vonner, and those who are weak, had better bathe two or three hours after a meal; the best time for such is from two to three hours after breakfast. Those who are subject to giddiness or faintness, or suffer from palpitation or other sense of discomfort at the heart, should not bathe without first consulting their medical adviser." To these instructions may properly be added that a warm or hot bath should be avoided, if the person is liable to ex- posure to cold within a few hours after the bath; that women should, as a rule, not take a cold bath while menstruating, or during the last two months of pregnancy; and that persons 270 TEXT-BOOK OF HYGIENE. suffering from organic heart disease should especially avoid surf- bathing. After bathing the body should be thoroughly dried with soft towels, otherwise eczematous eruptions are liable to follow in the parts subject to friction from opposing surfaces of the skin, as in the groins, the perinaeum and inner surface of the thighs, the armpits, or the under surface of the breasts in women in whom these organs are large and pendant. Friction of the skin with a coarse towel, or so-called " flesh-brush," is a popular practice, but is not to be universally commended. The hyperaemia of the surface thus produced may sometimes induce cutaneous diseases (erythema, eczema, psoriasis) in those predisposed. DANGERS OF COLD BATHING. One of the most serious dangers of cold bathing, but which is not sufficiently appreciated, is the tendency to nausea and vomiting if the stomach contains much food. There can be no doubt that many of the cases that are called " cramp," and which frequently result in drowning, are due to this cause.1 Cramps of the various muscles sometimes occur, rendering the bather helpless, and if in deep water he is liable to drown before assistance can reach him. HOW TO RESTORE THE APPARENTLY DROWNED. In drowning death takes place by asphyxia. The respira- tion is arrested by the submersion of the head, the carbonized blood gradually poisons the system, and the heart ceases to beat. So long as the heart will react to its appropriate stimulus the person may be restored to life. The first thing to do, therefore, after a recently-drowned person is taken out of the water, is to attempt to re-establish the arrested respiration. Several methods are in use for this purpose. Sylvester's is one of the simplest. It is as follows:- 1 So far as the author is aware, Dr. John Morris, of Baltimore, first called especial atten- tion to this source of danger. HOW TO RESTORE THE APPARENTLY DROWNED. 271 The body being placed on the back (either on a flat sur- face or, better, on a plane inclined a little from the feet upward), a firm cushion or similar support (a coat rolled up will answer) should be placed under the shoulders, the head being kept in a line with the trunk. The tongue should be drawn forward to raise the epiglottis and uncover the windpipe. The arms should be grasped just above the elbows and drawn upward until they nearly meet above the head, and then at once lowered and re- placed at the side. This should be immediately followed by pressure with both hands upon the belly, just below the breast- bone. The process is to be repeated fifteen to eighteen times a minute. Several years since the Michigan State Board of Health published a method which is comprehensive, effective, easily understood, and readily carried out. This method has also been adopted by the United States Life-Saving Service. The follow- ing are the details of the Michigan method:- Rule 1.-Remove all the obstructions to breathing. In- stantly loosen or cut apart all neck- and waist- bands; turn the patient on his face, with the head down hill; stand astride the hips with your face toward his head, and, locking your fingers together under his belly, raise the body as high as you can with- out lifting the forehead off the ground, and give the body a smart jerk to remove mucus from the throat and water from the windpipe, hold the body suspended long enough to slowly count one-two-three-four-five, repeating the jerk more gently two or three times. Rule 2.-Place the patient on the ground face downward, and, maintaining all the while your position astride the body, grasp the points of the shoulders by the clothing; or, if the body is naked, thrust your fingers into the armpits, clasping your thumbs over the points of the shoulders, and raise the chest as high as you can without lifting the head quite off the ground, and hold it long enough to slowly count one-two-three. Replace him on the ground with his forehead on his flexed arm, the neck 272 TEXT-BOOK OF HYGIENE. straightened out, and the mouth and nose free; place your elbows against [the inner surface of] your knees and your hands upon the sides of his chest over the lower ribs, and press down- ward and inward with increasing force long enough to slowly count one-two. Then suddenly let go, grasp the shoulders as before, and raise the chest; then press upon the ribs, etc. These alternate movements should be repeated ten or fifteen times a minute for an hour, at least, unless breathing is restored sooner. Use the same regularity as in natural breathing. Ride 3.- After breathing has commenced restore the animal heat. Wrap him in warm blankets, apply bottles of hot water, hot bricks, or anything to restore heat. Warm the head nearly as fast as the body lest convulsions come on. Rub- bing the body with warm cloths or the hands and slapping the fleshy parts may assist to restore warmth and the breathing also. If the patient can surely swallow, give hot coffee, tea, milk, or a little hot sling. Give spirits sparingly, lest they produce depression. Place the patient in a warm bed, and give him plenty of fresh air. Keep him quiet. Beware! Avoid delay. A moment may turn the scale for life or death. Dry ground, shelter, warmth, stimulants, etc., at this moment are nothing-artificial breathing is everything-is the one remedy-all others are secondary. Do not stop to re- move wet clothing. Precious time is wasted, and the patient may be fatally chilled by exposure of the naked body, even in summer. Give all your attention and efforts to restore breath-, ing by forcing air into, and out of, the lungs. If the breathing has just ceased, a smart slap on the face or a vigorous twist of the hair will sometimes start it again, and may be tried inci- dentally. Before natural breathing is fully restored, do not let the patient lie on his back unless some person holds the tongue forward. The tongue by falling back may close the windpipe and cause fatal choking. Do not give up too soon; yon are working for life. Any PUBLIC BATHS. 273 time within two hours you may be on the very threshold of success without there being any sign of it.1 PUBLIC BATHS. In all large cities and towns provision should be made for free public baths, conducted under official supervision, and for the especial use and benefit of the poorer classes. General cleanliness is not merely a factor in the preservation of the public health, but there is good reason to believe that the cause of good order and decency would likewise be promoted by furnishing the public the means of easily and cheaply keeping clean. Several of the larger cities in the country have estab- lished public baths upon a limited scale, and these have been very popular and have doubtless been of great benefit. The author has shown2 that about five-sixths of the inhabitants of the large cities in the United States have no facilities for bathing except such as are afforded by a pail of water and sponge, or in summer the proximity of some body of water easily accessible. 1 Report of Michigan State Board of Health, 1874, pp. 91-99. 3 Address in State Medicine, Journal American Medical Association, July 2,1887. CHAPTER XV. Clothing. The primary object of clothing is the protection of the body against the injurious influences of heat, cold, and moist- ure. Secondarily, the moral sense of civilized communities demands that the nude human body shall not be exposed in public. Hence, there are moral as well as sanitary reasons for the wearing of clothing; only the latter can be considered in this place. Bodies radiate or absorb heat accordingly as they are sur- rounded by a medium having a lower or higher temperature than themselves. In order, therefore, to avoid cliilling of the human body, if exposed to a temperature below 37° C. (98° F.), clothing must be worn to prevent or retard radiation of the body-heat. Exposure of the unprotected body to a low tem- perature would not merely cause chilling of the surface, owing to the rapid loss of heat, but would incidentally produce con- gestion of internal organs by causing constriction of the super- ficial capillaries. Clothing is also worn as a protection against great heat. The head, especially, needs protection from the sun's rays. CLOTHING MATERIALS. The materials from which clothing is made are, princi- pally, cotton, linen, wool, silk, and the skins of animals. Of these, probably the most universally used is cotton. It is cheap, durable, does not shrink when wet, absorbs little water, and conducts heat readily. It is therefore especially valuable for summer garments, allowing rapid dissipation of the body-heat and evaporation of the perspiration. Linen conducts heat even better than cotton, and is for 275 276 TEXT-BOOK OF HYGIENE. this reason largely used for summer clothing. Its principal advantage over cotton is that it is more durable and less harsh to the skin. Wool absorbs water readily and is a bad conductor of heat. It is therefore valuable as a winter garment, retarding radiation from the body. Woolen undergarments should be worn at all seasons, in order to prevent too rapid changes of the surface, and so invoking diseases depending upon chilling of the body. Clothing of pure wool (flannels) is liable to irritate the skin of some persons. A mixture of wool and cotton, known as " Saxony wool," is softer and less irritating, and makes a serv- iceable substitute for pure wool. Silk is often used for undergarments. It is light, soft, and a bad conductor of heat. The skins of animals, with the fur on, are often used for outside clothing. They furnish great protection against severe cold. The skin is impermeable to wind and rain, while the thick, pilous covering of fur retards to a very great degree the radiation of heat. In British America, the Northwestern States and Territories, and in the Arctic regions, the use of skin clothing is necessary for comfort. As a protection against moisture (rain and snow) rubber cloth is used for overcoats, etc. While it serves effectually in keeping out the rain, it prevents evaporation of the perspiration, increasing the liability to chill, and rendering the person wear- ing it very uncomfortable, except in cold weather. Leather is used almost exclusively in the manufacture of foot-wear. It is sometimes used, however, for other articles of clothing, such as coats, trowsers, etc. It furnishes most effective protection against cold. The color of the clothing is of great importance. Ex- posed to the sun, white wool or silk absorb very little more heat than linen or cotton, but the same material, of different colors, when exposed to the sun's rays, exhibits marked differ- ences in absorptive capacity. The following table shows the CLOTHING. 277 results of some experiments of Pettenkofer. The material used was cotton shirting of the colors named:- White absorbed 100 heat units. Light Sulphur Yellow absorbed . . 102 " " Dark Yellow absorbed . . . . 140 " " Light Green absorbed .... 155 " " Turkey Red absorbed . . . 165 " " Dark Green absorbed . . . . 168 " " Light Blue absorbed . . . . . 198 " " Black absorbed ...... 208 " " When protected from the sun's rays, however, the material becomes important and the color is of little consequence. Wool, being a bad conductor of heat, retards radiation from the body, and is hence the best material for winter clothing. Gases and vapors, probably also disease-germs, are ab- sorbed by clothing, and may be thus conveyed from place to place. It has been found that woolen clothing possesses this power of absorption to a much greater degree than linen or cotton. The bad odor of a crowded room or of tobacco-smoke frequently clings to woolen garments for days, although they may be exposed constantly to the air during the interval. It would be advisable, therefore, that physicians attending infec- tious diseases, hospital attendants and nurses, should wear linen or cotton clothing instead of woolen. Clothing should be made to fit properly. It should not restrain muscular movements, obstruct the circulation, or com- press organs. Hence, corsets, belts, and garters are to be con- demned. It is a fact of common observation that moderately loose clothing is warmer than close-fitting. Especial attention should be given to the shape and fitting of foot-wear. Boots and shoes are usually made with little regard to the physiological anatomy of the foot, and as a result the feet of most Americans are deformed, beauty and usefulness being in a great degree sacrificed to the Moloch of fashion.1 1 See a practical paper by Dr. Benj. Lee, A Shoe That Will Not Pinch, in Sanitarian for June, 1884, p. 493. 278 TEXT-BOOK OF HYGIENE. Dyes used for coloring fabrics are sometimes poisonous. The author has repeatedly seen troublesome eruptions, and even ulcerations of the legs, from wearing stockings dyed with aniline compounds. By appropriate treatment clothing can be made non- inflammable. Tungstate and phosphate of soda are used to reduce the inflammability of fabrics. The addition of 20 per cent, of tungstate of soda and 3 per cent, of phosphate of soda to the starch-sizing used for stiffening linen is effective. The material is not injured by it, and a smooth surface and polish can be obtained under the hot iron. Prof. Kedzie has recom- mended borax for the same purpose. lie says : " The simplest and easiest way to make your cotton and linen fabrics safe from taking fire is to dissolve a heaped teaspoonful of powdered borax in pint of starch solution. It does not injure the fabric, imparts no disagreeable odor, and interferes in no way with the subsequent washing of the goods. It does not prevent the formation of a smooth and polished surface in the process of ironing. Borax can be found in every village, and is within the reach of all. It is a cheap salt, and its use for this purpose is very simple."1 [The following works may also be studied to advantage:- Hammond, Hygiene, p. 579.-L. Meyer, Kleidung, in Realencyclo- paedie d. ges. Heilk., Bd. VII, p. 446.-Van Harlingen, Care of the Person, in Buck's Hygiene and Public Health, vol. i.] 1 Michigan State Board of Health, p. 181. 1880. CHAPTER XVI. Disposal of the Dead. When life is extinct in the animal body decomposition begins. This may be either putrefactive or non-putrefactive. The difference between the two processes has been explained by Liebig. In putrefaction of organic matters only the elements of water take part in the formation of the new compounds which result, while in non-putrefactive decomposition or decay the oxygen of the air plays an important part. Putrefaction can go on under water, while decay can only take place when the supply of free oxygen is abundant. The prompt removal of the bodies of the dead from the immediate vicinity of the living is a matter of prime sanitary importance. If death results from a contagious or an infectious disease, the necessity for the removal of the corpse is evident. But, even where there is no danger of propagation of infectious disease, the products of putrefaction and decay may give rise to serious derangements of health if allowed to pollute the air. The chief methods of disposal of the dead are burial in the earth, entombment in vaults, and cremation. INTERMENT. The most common method of sepulture is burial in the earth. The corpse is usually inclosed in a case (coffin) of wood or metal, and buried from 1 to 2 metres deep. Here decom- position sets in, which is at first putrefactive and later on non- putrefactive. In the course of several years, from five to ten, the entire body, with the exception of the bones, has usually disappeared and become converted into a dry mold. The soil of a burial-ground should be dry and porous, so 279 280 TEXT-BOOK OF HYGIENE. as to be easily permeated by the air. In a sandy or gravelly soil the decay of a corpse is much more rapid than in a moist, clayey soil. In the latter the bodies more readily undergo putrefaction, or become converted into a substance termed adi- pocere. It has been calculated that in a gravelly soil the decay of a corpse advances as much in one year as it would in sand in one and two-thirds, and in clay in two to two and one-third years. The decay of the dead bodies is principally (if not entirely) dependent upon the presence of living vegetable organ- isms. If the access of free oxygen is prevented, the bacteria of putrefaction will thrive and cause putridity. If, however, the soil is loose, porous, and easily permeable by the air, the bacteria of decay will be present and produce their charac- teristic effects. The barometric pressure seems to affect the decomposition of dead bodies. For example, at the refuge of St. Bernard, in the high Alps, the bodies of those dying are not buried, but exposed to the air, where they undergo a drying, shrinking, and mummification instead of putrefaction or decay. Alternate saturation and drying of the soil promotes the rapidity of decay. Certain occupations are said to produce changes in the tissues which resist decay. Thus, tanners are supposed to resist the final changes of the tissues longer than persons of other occupations. Shakespeare makes the grave-digger in Hamlet say: "A tanner will last you nine years." The corpses of those poisoned by phosphorus, arsenic, sulphuric acid, or corrosive sublimate also decay more slowly than those of cases of infectious diseases. All the tissues may be converted into adipocere, but in the large majority of cases only the fat and connective tissue undergo this change. SUPPOSED DANGERS OF BURIAL-GROUNDS. Popular sanitary literature teems with supposed instances of the injurious influences of cemeteries upon the health of SUPPOSED DANGERS OF BURIAL-GROUNDS. 281 persons living in their vicinity. An unprejudiced consideration of the subject shows, however, that there is no trustworthy evi- dence that any of the gases exhaled by decaying or putrefying bodies are injurious to health. The air of closed burial-vaults may be dangerous from the large proportion of carbon dioxide contained in it, but the other gaseous products of decomposition have no deleterious effects. The dangers to health from the proximity of cemeteries are doubtless very much exaggerated. Pettenkofer and Erismann have shown that a single large privy- vault, containing about 17 cubic metres of excrement, gives off nearly as large an amount of putrefactive gases in the course of one year as is exhaled by a burial-ground containing 556 decomposing corpses in ten years. Where bodies are properly buried, and the ground is not overcharged by corpses, it is not probable that infectious diseases are propagated from interred bodies. There are no facts on record which show that such an event has occurred. The dangers of pollution of water by cemeteries have also been much overestimated. The purifying power of soil-strata, through which the water is compelled to percolate before reach- ing the well after becoming charged with the products of decom- position, is in most cases sufficient to remove all deleterious matters. Cemeteries should not be located within a city, but must be easily accessible. The soil should be dry gravel or sand, with a low ground-water level. The graves need not be deeper than 1J metres to the top of the coffin. ENTOMBMENT IN VAULTS. Burial-vaults in churches or in the open air should be discountenanced. The gases of decomposition are given off directly to the air without the modifying power of the soil, and often constitute a nuisance, even if not deleterious to health. Entombment in vaults or crypts has not a single favorable circumstance to recommend it. 282 TEXT-BOOK OF HYGIENE. CREMATION. Within recent years the rapid incineration of the dead in properly-constructed furnaces has been frequently recommended. In the United States a cremation furnace was built several years ago at Washington, Pa., by the late Dr. J. C. LeMoine. Among the remains of those cremated were those of the late Dr. Samuel D. Gross, the distinguished surgeon. The practice has not gained very many adherents, however, although cremation societies have been organized and furnaces built in several of the cities throughout the country. Aside from the objections urged by the more conservative classes, who desire to adhere to the time-honored custom of interment, serious legal objections have been brought forward. In cases where poisoning is suspected some time after death, the cremation furnace would have destroyed every evidence of crime, and conviction of a criminal poisoner could not be obtained. The real advantages of cremation, such as rapid destruction of a corpse, economy of space in keeping the remains, and avoidance of pollution of the soil by decaying bodies, and pos- sible pollution of air and water, are more than counterbalanced by the expense and the medico-legal objection mentioned. From a sanitary point of view, cremation is not necessary in this country. A proper regulation of cemeteries will prevent any possible dangers to the living from pollution of the air, soil, or water by the decaying remains of human beings. INTERMENT ON THE BATTLE-FIELD. After battles, the disposal of the bodies of the slain is often a serious problem. Naegeli proposes the following method of interment: After selecting the place of burial, the sod and layer of humus are removed from a sufficiently large surface and thrown to one side. The corpses are then laid upon the denuded place, and the layers of corpses separated by sand, gravel, or fine brush-wood. A trench is then dug around the pile of dead and the soil gained is thrown over the corpses until they are 283 INTERMENT ON THE BATTLE-FIELD. covered to a depth of 1 metre, when the humus and sod are placed over the whole. This furnishes a dry grave in which decay rapidly takes the place of putrefaction, and the corpses soon molder away. The same procedure may be followed in cases of epidemics where the number of deaths is too great to properly bury them in single graves. CHAPTER XVII. The Germ Theory of Disease. The ruling doctrine in the pathology of the present day is the germ theory of disease. Based upon the doctrine of omne vivum ex vivo, and supported by strong experimental and clinical evidence, it is accepted by the great majority of physicians. Its advocates claim that the large class of diseases known as con- tagious or infectious are all due to the presence in the blood or tissues of minute organisms, either animal or vegetable. Many other diseases, not at present included in the above class by general pathologists, are also believed, by the adherents of the germ theory, to be caused in the same way. The following con- stitutes a brief review of the most prominent facts in the history of the doctrine :- The doctrine of the vital nature of the contagium of dis- ease-the contagium animatum of the older writers-was held in a vague way by many of the physicians of the past, but it was not until the latter part of the last century that the theory took definite shape. In the works of Hufeland, Kircher, and Linne the idea is expressed with more or less directness that the propa- gation of infectious diseases depends upon the implantation of minute independent organisms into or upon the affected indi- vidual. This hypothesis was, however, first clearly enunciated and defended with great force by Henle in 1840. Three years earlier, Cagniard de la Tour and Schwann had established a rational basis for the theory by their observations upon the yeast- plant and its relation to fermentation. In 1835 Bassi had dis- covered in the bodies of silk-worms affected by muscardine, a disease of these insects which proved very destructive, a para- site which was soon shown to be the cause of the disease. Within the next few years, Tulasne, DeBary, and Kuehn 285 286 TEXT-BOOK OF HYGIENE. proved that certain fungi were the causes of the potato-rot and other diseases of plants. Schoenlein, Malmsten, and Gruby, between 1840 and 1845, demonstrated that those skin diseases of man classed as the tineae were due entirely to the action of vegetable parasitic organisms. Up to this time the germ theory, as now accepted, had received no support from experiments. All the diseases claimed as parasitic were purely local; so far as the parasitic nature of the general diseases was concerned, all was hypothetical. In 1849, Guerin Meneville discovered a corpuscular organism in the blood of silk-worms affected by the pebrine, which was later proven by Pasteur to be the true cause of this destructive dis- ease. Pollender, in 1855, and Brauell, in 1857, found numer- ous minute rod-like organisms (bacteria) in the blood of animals dead from splenic fever. In 1863 Davaine investigated the subject more fully, and showed beyond doubt that the little organisms discovered by Pollender were the true cause of splenic fever, or anthrax. The more recent researches of Robert Koch upon the history of these bacteria or bacilli of splenic fever have removed all doubt of their etiological significance. In 1883 the last-named observer startled the medical world by the assertion that consumption or tuberculosis was a disease of microbic origin, and dependent upon the presence, in the affected tissues, of an organism which he named bacillus tuber- culosis. Much controversy arose upon this point, but Koch fortified his position so strongly with proofs, both experimental and clinical, that it may now be regarded as fully demonstrated. Koch has likewise shown (1885) that Asiatic cholera is due to a bacterial organism, termed by him the " comma bacillus," from its shape. It is generally regarded by bacteriologists, how- ever, to belong to the class of organisms known as spirilla, and not to the bacilli. Eberth discovered the bacillus which is now generally accepted as the cause of typhoid in 1880; Fehleisen, the micrococcus of erysipelas in 1883; Obermeier, the spirillum of relapsing fever in 1868; Schutz and Loftier discovered the THE GERM THEORY OF DISEASE. 287 bacillus of glanders in 1882; Neisser announced the discovery of the micrococcus of gonorrhoea in 1879. The bacillus of leprosy was discovered by Hansen in 1879. The micro-organ- isms of malaria (oscillaria malariae), which are believed to be animal organisms, were discovered by Laveran in 1881. This organism is different from the bacillus malarice of Klebs and Tommasi-Crudeli, which most pathologists do not regard as pos- sessing any pathological significance. Pneumonia may also be regarded as a microbic disease, since the demonstrations of Sternberg, Weichselbaum, and Frankel of the constant presence of the micrococcus Pasteurii in the sputa in that disease. The careful observations and researches of the investigators mentioned, as well as of many others who have worked earn- estly in this field, have established the germ theory of disease upon a secure foundation. For the diseases mentioned the parasitic origin may be accepted as fully proven. For a number of others, among which may be mentioned small-pox, yellow fever, diphtheria, scarlet fever, typhus fever, measles, hydrophobia, etc., the etiological connection between the disease and certain hypo- thetical organisms not yet discovered appears probable. In connection with the germ theory there has arisen of late a very important question in its bearing upon preventive medi- cine. This is the value of the so-called protective inoculations against infectious diseases. The protective influence of vacci- nation against small-pox is firmly established by indubitable evidence. Within the last three or four years a procedure in- troduced by Pasteur to protect animals against certain fatal in- fectious diseases, such as splenic fever, fowl-cholera, and rabies, has claimed much attention. Pasteur's observations were first made upon the disease termed chicken-cholera. He found that the blood of the dead fowls, or of those attacked by the disease, swarmed with bacteria. Inoculation of healthy fowls with this diseased blood, or with the bacteria alone, carefully freed from all animal fluids, produced the same disease. The bacteria were therefore assumed to be the cause of the disease. The 288 TEXT-BOOK OF HYGIENE. investigator then took a quantity of these bacteria and " culti- vated " them through a number of generations, using sterilized chicken-broth as a culture medium. Fowls inoculated with the result of the last cultivation were still attacked by the same symptoms, but in a very mild degree, and almost uniformly recovered from the disease. On subsequent inoculation with infected blood no effect was produced upon the " vaccinated " fowls, while the same blood introduced into fowls not " pro- tected " by the previous inoculation produced its customary fatal effect. Pasteur and others repeated these experiments with the organisms found in the blood in splenic fever and obtained similar results. Inoculations made with cultivations from the spinal cord of animals suffering from rabies have also been claimed as protective against this disease and hydrophobia. These protective inoculations have been made upon large num- bers of sheep and cattle within the past three years, and with very remarkable success. Recently, however, it has been shown that the protection afforded by the inoculation is a very tem- porary one, and that after a variable but brief interval the pro- tected animals are again liable to be fatally attacked by the disease. The opinion seems to be justified that cultivation pro- duces only a temporary degeneration of the bacteria, which rapidly disappears when the organisms are again brought in relation with their proper nutritive fluid. The " protective in- oculations " produce a mild attack of the disease, which is for a time a bar against a second attack; but the effect soon wears off, leaving the animal in its pristine condition of receptivity toward the infective material. [The following works on this subject are recommended to the student:- Sternberg and Magnin, The Bacteria; second edition.-Fluegge, Fermente nnd Mikroparasiten, in von Pettenkoffer und Ziemssen's Handbuch d. Hygiene.] CHAPTER XVIII. Contagion and Infection. The adjectives "contagious" and "infectious" are used to designate certain diseases which are propagated by immediate contact, or through the intervention of some other medium, from the sick to the healthy. The matters in which reside the mor- bific power are now believed by many to be vegetable organisms, but not a few pathologists hold to the view that the real con- tagia, or disease-bearing agents, are modified animal cells or abnormal fluids. The differentiation between contagion and infection is not easy. Many of the diseases commonly called contagious are also infectious; that is, they are propagated not merely by direct contact, but also by air, water, or food which may have become infected with the morbific agents. Syphilis, for example, may be regarded as simply a contagious disease; at the present day, at least, we cannot conceive syphilis to be propagated by breath- ing infected air or drinking water contaminated.with the poison of syphilis. Cholera, typhoid, and yellow fevers, on the other hand, are examples of infectious diseases, neither of them being directly contagious, but conveyed from sick to well through the medium of contaminated air, water, or food. Between these two stand small-pox and typhus fever (and perhaps the other exanthemata), which are not merely contagious, but infectious also. There is still a third class of acute diseases not properly included in either of the classes mentioned. This is the class of miasmatic diseases, of which malarial fevers are the type. Ac- cording to recent observations, pneumonia ought, perhaps, to come in this class. The contagious and infectious diseases are of particular 289 290 TEXT-BOOK OF HYGIENE. interest to sanitarians, because it is believed that by judicious carrying out of sanitary measures they can be prevented. Hence they are sometimes termed preventable diseases. Another pecu- liarity of the infectious diseases is that they usually occur in groups of cases. Thus, small-pox, measles, scarlet fever, typhus fever, diphtheria, and others of the class do not occur sporadi- cally, as it is termed; that is to say, it rarely happens that only one case of small-pox is observed in a locality, unless active measures are at once taken to stamp it out. Usually a number of cases occur successively, and in most instances the succeeding cases can be traced ultimately to the first case. Contagious and infectious diseases frequently appear as epidemics. Authorities differ as to the proper definition of an epidemic; that is, given the population of a place, how many cases of an infectious or contagious disease are necessary before the disease can be considered epidemic at such place. The following formula was given by the New Orleans Medical and Surgical Association in response to the query, " Under what cir- cumstances is it proper to declare such diseases (diphtheria, scarlet fever, measles, small-pox, yellow fever, etc.) epidemic in a place V' The answer given is that the disease should be declared epidemic when the number of cases should reach these proportions1:- For a population of 100 ... 5 per cent. " " " 500 ... 4 " " " " " 2,000 to 5,000 . 22| " thousand. " " " 6,000 to 10,000 . 16 " " " " " 20,000 to 50,000 . 8 " ten thousand. " " " 50,000 to 100,000 . 4 " " " " " " 200,000 1 " " " A disease is said to be pandemic when it spreads rapidly over a great extent of country, and endemic when it is constantly present in a place. Diseases which may be prevalent in certain localities, i.e., endemic, not infrequently spread over larger areas 1 Public Health, vol. vi, pp. 416, 417. CONTAGION AND INFECTION. 291 of country,-overflow their borders, as it were,-and become epi- demic or pandemic. Thus cholera, which is endemic in certain districts of India, frequently spreads over adjacent territory, and at times the epidemic wave, as it has been called, rolls over nearly the whole world. Plague, malarial and yellow fevers make similar epidemic excursions into other countries, or sec- tions of country, at a distance from the places where they are endemic. Contagious and infectious diseases possess another peculi- arity in that a certain time is required after the introduction of the poison into the system before the disease manifests itself by its typical symptoms. This is called the "stage of incubation," and varies for different diseases. The following table shows the stage of incubation of a number of such diseases:- Table XXVI. INCUBATION OF INFECTIOUS DISEASES. Measles, ........ 10 days. Small-pox, ....... 12 " Mumps, ........ 18 " Diphtheria, ....... 3 " Scarlet fever, ....... 3 " Whooping-cough, ...... 14 " Typhoid fever, 14 " Typhus fever, . . . . . . . 1 to 2 " Chicken-pox, ....... 4 " Erysipelas, ....... 4 " The period during which the infectiveness of the patient lasts also varies. In some cases it probably depends upon the measures taken to prevent the spread of the disease, e.g., disin- fection of the patient and his surroundings. CHAPTER XIX. History of Epidemic Diseases. Ax important part of the knowledge of the sanitarian is that which relates to the history of the great epidemic diseases which have at various periods devastated large areas of the in- habited world. In this chapter the history of these diseases will be briefly traced. Although some of these diseases have nearly or quite ceased, a knowledge of their habits and of the causes that finally led to their extinction is of great value, for the reason that the principles and measures of prevention which were effective in times past are the same which must apply at pres- ent and in the future. Hence, time spent in looking back over the fields traversed and noting victories won will not be wasted. The epidemic diseases which will here claim attention are the Oriental plague, the sweating sickness, small-pox, Asiatic cholera; typhus, typhoid, scarlet, relapsing, and yellow fevers; diphtheria, dengue, epidemic influenza, and syphilis. In addi- tion, some information will be given on certain of the diseases of animals transmissible to man. Among these are sheep-pock, actinomycosis, bovine tuberculosis (perlsucht), rabies, anthrax (milzbrand), and glanders. THE ORIENTAL PLAGUE. The Oriental plague, bubonic plague, the black death, or simply the " plague," or great pestilence, overtopping in its fatality all other pestilences, is mentioned by a number of the Greek and Latin medical authors. The first account which clearly refers only to this disease is given by Procopius. Ac- cording to this and other contemporary authors, the disease be- gan to spread in the year 542 from Lower Egypt, passing in one direction along the coast of Northern Africa, and in the other 293 294 TEXT-BOOK OF HYGIENE. invading Europe by way of Syria and Palestine. In the course of the succeeding years this pandemic reached "the limits of the inhabited earth," in the language of the writers of the day. The disease prevailed about half a century, and produced the greatest devastation wherever it appeared. " Cities were devastated, the country converted into a desert, and the wild beasts found an asylum in the abandoned haunts of man."1 The plague is an acute infectious disease, which is char- acterized by an affection of the lymphatic system, i.e., inflam- mation and swelling of the external and internal lymphatic glands. Accessory symptoms are petechial spots upon the skin, and haemorrhages from various organs, as the stomach, nose, kidneys, rectum, and uterus. Those attacked suffer in varied degrees of intensity. In some, a fulminant form occurs which carries off the patient within three days; there is another class of cases in which buboes develop, with accompanying fever and haemorrhages; and, finally, a light form, rarely fatal, in which only the local symptoms are manifested. In the great pan- demic of the plague in the fourteenth century cough and bloody expectorations were very frequent. In the later epidemics haemorrhage from the lungs has been rarely noticed as a symptom. About the middle of the fourteenth century the bubonic plague made a second incursion into Europe from its home in the East. A most graphic description of its ravages is given by Boccaccio in the " Decameron." This author states that in 1359, "between March and July following, according to authentic reckonings, upward of 100,000 souls perished in the city (Florence); whereas, before that calamity it was not supposed to contain so many inhabitants." This terrible epidemic was forcibly characterized by its com- mon name, " the black death." Hecker estimates that during its continuance, from 1347 to 1351, 25,000,000-one-fourth of the probable total population of Europe-died. In various cities the mortality was-in London, 100,000; in Paris, 50,000; in 1 Warnefried, quoted by Hirsch, Hist-Geographische Pathologic, I, p. 350. THE ORIENTAL PLAGUE. 295 Venice, 100.000 ; in Avignon, 60,000 ; in Marseilles, 16,000, in one month. It was said that in all England scarcely a tenth part of the population escaped death from the disease. The moral effects of this great pandemic of the plague were hardly less deplorable than the physical. Religious fanaticism held full sway throughout Europe, finding its vent in all manner of excesses. The so-called Brotherhood of the Cross, otherwise known as the Order of Flagellants, which had arisen in the thirteenth century, but had been suppressed by the ecclesiastical authorities, was revived during the black pestilence, and large numbers of these religious enthusiasts roamed through the various countries on their great pilgrimages. Their power in- creased to such a degree that Church and State were forced to combine for their suppression. One consequence of this fanat- ical frenzy was the persecution of the Jews. These were accused of being the cause of every evil that befell mankind, and many were put to death. In the fifteenth and sixteenth centuries the plague was generally diffused throughout Europe, and in the second third of the seventeenth century its final incursion into the Occident took place. The great epidemic in London, so graphically de- scribed by Defoe,1 occurred in 1665. In the early part of the eighteenth century (1720) the plague visited Marseilles and Toulon; from 1769 to 1772 it was epidemic in Moldavia, Wal- lachia, Poland, and Southern Russia; near the close of the last, and again in the beginning of the present century, in Transyl- vania, Wallachia, Southern Russia, and Greece. Very recently, in 1878 and 1879, and again in 1885, the plague threatened a new irruption into European territory, being epidemic in the district of Astrachan, on the Caspian Sea. Although the bubonic plague has never been observed in America, and has spared Europe almost entirely during the present century, it still persists in certain countries of Asia and Africa, especially in Arabia, Mesopotamia, Persia, and the coast of Tripoli. 1 Journal of the Plague in London. 296 TEXT-BOOK OF HYGIENE. The older authors ascribed the origin of the plague to various real or supposed conditions. Comets, conjunctions of the planets, " God's just punishment for our sins," and similar causes were advanced to account for the outbreaks. Most of the writers of the post-mediaeval and modern epochs ascribed the disease to meteorological conditions. Observing the fact that the plague never advanced into the torrid zone, and that an epidemic generally ended with the advent of hot weather, a high tempera- ture was believed to be incompatible with the existence of an epidemic, and a cold or temperate climate was considered neces- sary to an outbreak of the disease. The exceptions to the rule are so numerous, however, that the theory of the climatic or meteorological origin of the plague failed of support. The theory which ascribed the origin of the epidemics to the influence of certain hot and dry winds or a high humidity is also insufficient. Certain geological formations have been supposed to furnish favorable conditions for the development of the disease. Facts show, however, that the disease has prevailed epidemically and endemically in various parts of the earth, and of the most diverse geological character. A certain elevation above sea-level has been held to confer immunity, but recent observations in India show that this belief is unfounded, even places at an elevation of 10,000 feet above sea-level giving no security against attack. There is, however, one point upon which nearly all writers who mention the fact at all agree. This is that bad hygienic conditions are always present where plague prevails. Nearly all observers who have left their impressions on record mention the accumulation of filth in the houses and streets, deficient removal of excrementitious and other sewage matters, crowding and im- perfect ventilation of dwellings as causes favoring the develop- ment and spread of the pestilence. All point out the necessity of the removal of these evils as the most important prophylactic measure to be adopted, and all of them call attention to the fact that those classes of the population most exposed to these unfa- vorable influences suffer most from the violence of the epidemic. THE ORIENTAL PLAGUE. 297 The later reports of the epidemics in Persia, India, Mesopo- tamia, and Russia agree in asserting that nothing seems to have promoted the epidemic and endemic prevalence of the plague so much as the material wretchedness of the inhabitants of those countries. In a collection of papers on the plague, printed by a British Parliamentary Commission in 1879, occur these state- ments : " The filth is everywhere," says Mr. Rennie, one of the reporters,-" in their villages, their houses, and their persons. Their dwellings are generally low and ill-ventilated, except through their bad construction; and the advantage of the natives in other parts of India, of living in the open air, is lost to the villagers of Ghurwal, from the necessity of their crowding together for mutual warmth and shelter against the inclemency of the weather." Dr. Dickson, reporting on the plague in Irak Arabi in 1876, says: " The most palpable and evident of all the causes which predispose an individual to an attack of plague during an epidemic outbreak is poverty. No other malady shows the influence of this factor in so striking a degree; so much so, indeed, that Dr. Cabiadis styles the plague 'miserice morbis. In his experience (1876-77, in Bagdad) he found that the poor were seldom spared, the wealthy hardly ever attacked." 1 The manner of the transmission of the plague is generally by prolonged inhalation of an infected atmosphere. Hence, it may be termed an infectious disease, although it is not improbable that it may be communicated by direct contact both of persons and of fomites. It is probably due to a micro-organism, although no demonstration of the latter has been furnished up to the present time. These considerations indicate the measures of prevention to be adopted. They consist of a rigid quarantine of persons and fomites, prompt and complete isolation of infected individuals and localities, and destruction (by fire) or thorough disinfection by steam or sulphurous-acid gas of all materials capable of con- veying the virus of the disease. * Hirsch, op. cit., p. 370. 298 TEXT-BOOK OF HYGIENE. THE SWEATING SICKNESS. This name concisely characterizes an epidemic disease which for the first time appeared in the city of London and other parts of England in the autumn of 1485. According to Lord Bacon,1 the disease began about the 21st of September and lasted until near the end of October. It broke out a second time in the summer of 1507; a third time in July, 1518, spread- ing in the course of six months throughout England. In May, 1529, the disease made its appearance again in the latter country, spreading thence over a great part of the continent of Europe. Another very malignant epidemic broke out in the spring of 1541, lasting through the summer, and limited in its ravages to England. With this last outbreak, in 1551, this disease disappeared entirely in England and has not re-appeared there up to the present day. In the beginning of the eighteenth century, how- ever, a disease very similar in its symptoms and course broke out in Picardy and other districts of Northern France, being confined for a number of years to this section of the country. Toward the end of the century it spread to the south of France, and since that time has appeared epidemically at intervals, 195 dis- tinct outbreaks having been observed in the course of 168 years, from 1718 to 1887. The disease has frequently appeared in Italy since 1755, and in various parts of Germany since 1801. In Belgium it has been observed at a few places within the present century. The disease appeared suddenly, often at night-time. The patient was attacked with palpitation of the heart, dyspnoea, great anxiety and oppression, and profuse perspiration. A miliary eruption often appeared on the skin. In favorable cases these symptoms diminished in the course of one or two days, the urinary secretion, which had been suppressed, was restored, and the perspiration became gradually less free. Recovery ensued in from one to two weeks. In grave cases there were, in the * History of Henry VII. SMALL-POX. 299 beginning of the attack, violent headache, delirium, convulsions, followed by a comatose condition, from which the patients rarely recovered. This disease is undoubtedly of a miasmatic, infectious nature, as proved by its rapid spread and limitation to certain localities. It appears most frequently in the spring and summer, and is nearly always observed in marshy or damp localities. Its spread is favored by a high temperature and humidity. There is no apparent connection between the outbreaks of the sweating sickness and overcrowding or other insanitary conditions; in fact, it is stated by numerous observers, both old and recent, that children, the aged, and generally the poorer classes were remark- ably exempt from the disease. The recent epidemic in France, in 1887, was investigated by Dr. Brouardel, Chantemesse, and other epidemiologists, but no trustworthy conclusions as to the nature of the disease have yet been reached. Since the first appearance of Asiatic cholera in France, in 1832, an apparently intimate connection has been observed between the occurrence of that disease and outbreaks of sweating sickness. A disease strongly resembling the sweating sickness has also been observed in India in districts contiguous to places where cholera was at the time epidemic.1 SMALL-POX. The earliest details concerning small-pox are derived from certain Chinese records, according to which it appears that this disease was known in China upward of 2000 years ago. It was also known at a very early period in India. It is believed to have been introduced into Europe in the second century by a Roman army returning from Asia. It is believed that the Em- peror Marcus Aurelius died of small-pox, which prevailed in his army at the time of his death. The first distinct references to small-pox in medical literature occur in the writings of Galen, in the second century. Rhazes, 1 Murray, Madras Quart. Med. Journ., 1840-41. Quoted in Hirsch, loc. cit., p. 83. 300 TEXT-BOOK OF HYGIENE. ill the ninth century, wrote upon the disease, describing it very accurately. The almost universal susceptibility to small-pox caused wide-spread devastation wherever it appeared previous to the introduction of vaccination. The statement is made that in England, in the last century, about one person in every three was badly pock-marked. The mortality from the disease was exceedingly great, being, in the latter half of the eighteenth century, about 3000 per million of inhabitants annually. In India the mortality from small-pox has been exceedingly great within the last twenty years. From 1866 to 1869, 140,000 persons died in the Presidencies of Bombay and Calcutta, having a population of about 40,000,000. Several years later, from 1873 to 1876, 700,000 died from this disease. China, Japan, Cochin China, the islands of the China Sea, and Corea are frequently ravaged by small-pox. In the latter country nearly all the inhabitants are said to bear evidence of an attack of the disease. The Samoyedes, Ostiaks, and other natives of Eastern Siberia have frequently suffered from devastating epidemics. In Kamt- chatka the disease was introduced in 1767, and produced frightful ravages. Many villages were completely depopulated. In Mexico small-pox was introduced by the Spaniards in 1520. In a short time it carried off over 3,500,000 of the natives. In the Marquesas Islands one-fourth of the inhabitants have fallen victims to the disease since 1863. It was first introduced into the Sandwich Islands in 1853, and carried off 8 per cent, of the natives. Australia, Tasmania, New Zealand, and the Fcjee Archi- pelago remain exempt to the present day from small-pox. It has several times been carried to Australia by vessels, but has always been promptly checked by the vigilance of the authorities. On the Western Hemisphere small-pox was unknown before the arrival of the European conquerors. It has been spread by the whites or imported African slaves to nearly all the Indian SMALL-POX. 301 tribes of both continents. When it attacks large communities unprotected by previous outbreaks of the disease, or by inocula- tion or vaccination, its ravages are frightful. The mortality of unmodified small-pox is usually between 30 and 40 per cent. Small-pox is a highly contagious and infectious disease. It is produced by actual contact, by inoculation, and by inhaling an atmosphere charged with the poison. In order to cause an outbreak two factors are necessary: first, a number of individuals susceptible to this disease, and, second, the introduction into the body, in some manner, of the virus upon which it depends. Small-pox is spread from (1) persons sick with the disease; (2) others, not themselves sick or susceptible, but coming in contact with the poison; (3) fomites (cotton, wool, etc.), and (4) the bodies of persons dead with small-pox. It is also probable that the air in the immediate vicinity of a person sick with small- pox becomes charged with the poison and able to convey the disease. It is at present impossible to fix the distance to which this infectiousness of the air extends, but it does not ordinarily reach beyond the room in which the patient is confined. It is a fact of common observation that the darker races are more commonly attacked, and the disease is likewise more fatal among them. The mortality among negroes is much larger than among other races. It is a current belief that small-pox is only contagious after the development of the pustules. This is a serious error. It is probably contagious in all stages of the disease; certainly as early as the first appearance of the eruption, and probably even in the stage of preliminary fever. One attack of small-pox usually confers immunity from the disease for life. This rule has its exceptions, however, which, if not numerous, are yet not infrequent. The author has seen a case in which the patient suffered from a third attack of the disease. The popular belief, that persons suffering from any acute or chronic disease are less liable to be attacked by small-pox 302 TEXT-BOOK OF HYGIENE. than those at the time in good health, is erroneous. On the contrary, the subjects of chronic disease, such as consumption or dyspepsia, are much more liable to succumb to an attack of small-pox than persons previously in good health. It is true, however, that individuals suffering from some other acute infectious disease, like scarlet fever, measles, typhoid fever, etc., are generally, though not absolutely, exempt from an attack of small-pox during the time they are sick with such disease. But if they are exposed, after recovery, to the small- pox infection, their liability to an attack is as great as in those who have not passed through a similar disease. A number of cases have been reported by Curschmann,1 in which infection by small-pox took place on the day in which convalescence from typhoid fever was established. The author has reported a case2 in which the patient passed through an attack of erysipelas during the incubative stage of small-pox. From all the evidence attainable, the incubative stage was not prolonged by the intercurrent erysipelas. Epidemics of small-pox usually begin in the autumn or winter, and lessen in violence as warmer weather approaches. The spread of the disease is slow at first, increasing in rapidity as the foci of infection multiply. When the poison is imported into a community late in the spring or during the summer, the increase in the number of cases is exceedingly gradual until colder weather sets in. If it is introduced during the winter, the disease spreads much more rapidly, but decreases, and sometimes almost disappears, during the summer. On the return of cold weather, however, the epi- demic starts out with a new lease of activity and presents great difficulties to its restriction. A number of observers, among whom are Coze and Feltz, Lugenbiihl, Weigert, Strauss, Garre, and Wolff, claim to have discovered specific organisms in the contents of variolous pustules, in the blood of patients with the disease, and in vaccine lymph. * Ziemssen's Cyclopaedia, vol. ii. ' Medical News, July 7,1883. 303 SMALL-POX. Expert bacteriologists are, however, not willing to accept the evidence hitherto furnished as conclusive. Inoculation.-The prevention or restriction of such a uni- versal and fatal pestilence as small-pox is a matter of the deepest importance. The first attempt to limit its fatality dates from the end of the seventeenth century. It became generally known in Europe, about the year 1700, that the intentional inoculation of variolous matter into healthy individuals induced an attack of the disease, which generally ran through its various stages with less virulence than when the disease was contracted in the usual manner. In 1716 and 1717 two papers were published in the " Transactions of the Royal Society of England" giving an ac- count of the process of inoculation. The attention of the public was especially directed to the matter, however, by the famous letter of Lady Mary Wortley Montagu, dated April 1,1717. This letter is as follows1: "Apropos of distempers, I am going to tell you a thing that will make you wish yourself here. The small- pox, so fatal and so general amongst us, is here entirely harm- less by the invention of ingrafting, which is the term they give it. There is a set of old women who make it their business to perform the operation every autumn, in the month of September, when the great heat is abated. People send to one another to know if any of their family has a mind to have the small-pox; they make parties for this purpose, and when they are met- commonly fifteen or sixteen together-the old woman comes with a nut-shell full of the matter of the best sort of small-pox, and asks what veins you please to have opened. She immediately rips open that you offer to her with a large needle-which gives you no more pain than a common scratch-and puts into the vein as much matter as can lie upon the head of her needle, and after that binds up the little wound with a hollow bit of shell; and in this manner opens four or five veins. The Grecians have commonly the superstition of opening one in the middle of the forehead, one in each arm, and one on the breast, to make 1 The letter is addressed to Mrs. S. C. (Sarah Chiswell). 304 TEXT-BOOK OF HYGIENE. the sign of the cross; but this has a very ill effect, all these wounds leaving little scars, and is not done by those that are not superstitious, who choose to have them in the leg or that part of the arm that is concealed. The children or young pa- tients play together all the rest of the day, and are in perfect health until the eighth. Then the fever begins to seize them, and they keep their beds two days, very seldom three. They have rarely above twenty or thirty in their faces, which never mark; and in eight days' time they are as well as before their illness. Where they are wounded there remain running sores during the distemper, which I don't doubt is a great relief to it. Every year thousands undergo this operation; and the French ambas- sador says pleasantly: ' They take the small-pox here by way of diversion, as they take the waters in other countries.' There is no example of any one that has died in it, and you may believe that I am well satisfied of the safety of the experiment, since I intend to try it on my dear little son. "I am patriot enough to take pains to bring this useful invention into fashion in England; and I should not fail to write to some of our doctors very particularly about it, if I knew any of them that I thought had virtue enough to destroy such a considerable branch of their revenue for the good of mankind. But that distemper is too beneficial to them not to expose to all their resentment the hardy wight that should undertake to put an end to it. Perhaps, if I live to return, I may, however, have courage to war with them." Soon after the date of this letter the writer's son was inoculated in Turkey, and four years later her daughter also, being the first subject inoculated in England. The practice soon became popular, but several fatal cases among prominent families brought it into disrepute, and for about twenty years very few inoculations were made in England. It was revived about the middle of the century by the founding of a small-pox and inoculation hospital in London. This continued in opera- tion until 1822. The records of this institution showed that only SMALL-POX. 305 three in a thousand died of the disease thus communicated. The practice has now fallen into desuetude, being superseded by vac- cination and prohibited by law in England. Inoculation was introduced into this country in 1721 by Dr. Zabdiel Boylston, of Boston, who had his attention directed to the practice by Cotton Mather, the eminent divine.1 During 1721 and 1722, 286 persons were inoculated by Boylston and others in Massachusetts, and 6 died. These fatal results ren- dered the practice unpopular, and at one time the inoculation hospital in Boston was closed by order of the Legislature. Toward the end of the century an inoculating hospital was again opened in that city. Early in the eighteenth century inoculation was extensively practiced by Dr. Adam Thomson, of Maryland, who was instru- mental in spreading a knowledge of the practice throughout the Middle States 2 In China and India, and perhaps other eastern countries, inoculation was practiced at a very early period. The inoculation of variolous matter, although it mitigated to a very great degree the attack of small-pox following, had one very serious objection, aside from the small death-rate which was a direct consequence of it. This was the fact that inocula- tion always produced small-pox, and thus assisted in propagating the disease; for, however mild the induced disease might be, the inoculated individual was liable to communicate small-pox to others in the most virulent form. Hence, nothing short of uni- versal inoculation, which was manifestly impracticable, would succeed in reducing the danger from the disease. Vaccination.-It had been noticed at various times that a pustular disease which sometimes appears on the udders of cows, called cow-pox, had not infrequently been transmitted to the hands of the dairy-maids and others having much to do with * Dr. John R. Quinan (Md. Med. Journ., June 23 and 30, 1883) believes the claim of Dr. Boylston to be the first American inoculator open to question. The evidence presented is, how- ever, insufficient to discredit the claim of the Boston physician. 3 See Quinan, loc. cit., p. 114. 306 TEXT-BOOK OF HYGIENE. cows. In course of time it was also noticed that persons who had been thus attacked never suffered from small-pox. This protective power of cow-pox was known as early as 1713, and in 1774 Benjamin Jesty, a Gloucestershire farmer, performed vaccination for the first time on record, inoculating his wife and two sons with cow-pox matter as a protection against small-pox. It is stated that when it became known that Jesty had vaccinated his wife and sons, "his friends and neighbors, who had hitherto looked upon him with respect, on account of his superior intelligence and honorable character, began to regard him as an inhuman brute, who could dare to practice experi- ments upon his family, the sequel of which would be, as they thought, their metamorphosis into horned beasts. Consequently the worthy farmer was hooted at, reviled, and pelted whenever he attended the markets in his neighborhood."1 In 1791 a school-teacher in Holstein also inoculated three boys with the matter of cow-pox, but nothing is known of the subsequent history of these cases. Although the above facts are clearly established, it is to Edward Jenner, a modest country doctor of Berkeley, in the county of Gloucester, England, that the merit of demonstrat- ing the protective power of cow-pox against small-pox, and of diffusing a knowledge of this fact, is due. Jenner had his atten- tion directed to the asserted protection conferred by cow-pox during the period of his apprenticeship. After a residence in London as a pupil of John Hunter, he returned to the country to practice his profession. About the year 1776 he began studying the question, and gathering evidence of the protection afforded against small-pox by the accidental inoculation of cow- pox virus. For twenty years he studied the subject, patiently awaiting an opportunity to put his belief to the test of experi- ment. On the 14th of May, 1796, he made his first vaccination on a boy named James Phipps. Six weeks later he inoculated this boy with variolous matter, but without success, no small- 1 London Lancet, September 13,1862. SMALL-POX. 307 pox resulting. Two years later lie published his pamphlet, entitled " An Inquiry into the Causes and Effects of the Variola Vaccinae, etc.," in which he detailed his observations and experi- ments. This publication produced a great sensation in the medical world, and, although much opposition was at first manifested toward his views, he soon gained many adherents. Vaccination, as the operation for the inoculation of cow-pox virus is termed, was rapidly introduced into all civilized countries, and soon demonstrated its good effects by greatly restricting the prevalence of small-pox. It is generally believed that the first one to practice vaccination in this country was Dr. Benjamin Waterhouse, of Boston, in the summer of 1800; but Dr. John R. Quinan has recently shown1 that vaccination was introduced into Maryland, by Dr. John Crawford and Dr. James Smith, at least as early as the date generally assigned for its introduction into Massachusetts. It was believed by Dr. Jenner, and was afterward conclu- sively shown by a number of distinguished experimenters, that vaccinia, as the disease produced by cow-pox inoculation was called, was merely a modification of small-pox as it existed in the cow. Small-pox virus, when inoculated upon the cow, produced cow-pox; but the latter, re-inoculated upon man, produced cow-pox (vaccinia), and not small-pox. Sheep-pock and horse-pock, or " grease," are probably merely modifications of the disease produced by inoculating small-pox into those animals. When cow-pox virus is successfully inoculated into the human system-that is, when a person is successfully vaccinated -the following local and general symptoms are observed:- In the case of a primary vaccination, i.e., where the individual has not been previously vaccinated or attacked by small-pox, the point where the vaccination is made shows no particular change for the first two days. If the vaccination is successful, a small, reddish papule appears by the third day, * Quinan, loc. cit., pp. 118, 131. 308 TEXT-BOOK OF HYGIENE. which, by the fifth or sixth day, has become a distinct vesicle of a bluish-white color, with a raised edge and a peculiar, central, cup-like depression called the umbilication. By the eighth day this vesicle has become plump, round, and pearl-colored, the central umbilication being still more marked. At this time a red, inflamed circle, called the areola, appears, surrounding the vesicle and extending usually in a radius of from to 2 inches when fully developed. This inflammatory ring is usually pretty firm, and there is more or less general fever and often enlarge- ment and tenderness of the axillary glands. After the tenth day the areola begins to fade, and the contents of the vesicle dry into a hard, brownish crust or scab, which falls off between the twentieth and twenty-fourth days, leaving a punctated scar, which gradually becomes white. When the vaccinia has passed through all of these stages, especially if the vesicle filled with pearly lymph, and the areola have been well developed, the vaccination may be considered a success, and the individual protected against small-pox for a number of years, if not for life. Recently the doctrine has been strongly advocated that vaccination is not absolutely protective until a subsequent inoculation of vaccine fails to " take." According to this view, vaccination should be repeated until it fails any longer to exhibit any local reaction. When this has been attained the individual may be considered absolutely protected for life. Theoretically, this view has much in its favor, but there is, as yet, not sufficient evidence to establish it as a law. It may be stated as an established fact that vaccination, although carefully performed and successful, does not confer absolute immunity from small-pox for life. The protective power seems to wear out after a time and the individual then again becomes susceptible to small-pox. An attack of small- pox in a vaccinated individual is, however, nearly always much milder than where there had been no vaccination. There is no fact in the entire range of medicine better established than this: 309 SMALL-POX. that small-pox in vaccinated persons is a much less dangerous disease than typhoid fever, while in unvaccinated cases the mortality ranges from 30 to 40 per cent. An approximate guide to the beneficent influence of vaccination upon the mortality from small-pox is furnished by a table in Seaton's report on vaccination. Before the introduction of vaccination the mortality from small-pox, per million of inhabitants of Eng- land, was nearly 3000 per year. After the introduction of vac- cination the mortality was reduced to 310 per million per year. The most remarkable and convincing statistical evidence on the question is given by Drs. Seaton and Buchanan, of England. During the small-pox epidemic in London, in 1863, they examined over 50,000 school-children, and found among every thousand without evidence of vaccination 360 with scars of small-pox, while of every thousand presenting some evidence of vaccination only 1.78 had any such traces of small-pox to exhibit.1 The reliability of general mortality statistics may be called in question-in some cases, with justice; but the signifi- cance of these figures cannot be evaded. The upper and outer surface of the arm is usually chosen as the point where the virus is inserted, although any part of the body which can be protected against friction, or other mechanical irritation, may be selected. The method varies slightly in the hands of different vaccinators. The two methods most frequently in use are scarification and erasion. The former method has the indorsement of Mr. Seaton, the high English authority. The method of erasion-scraping off the epidermis until the papillary layer of the skin is laid bare-is now most frequently used in this country. The best instrument to use is a clean thumb-lancet; in default of this, an ordinary sewing-needle answers well. Where animal vaccine is used, the ivory slip or sharpened quill may also be used with satis- faction to make the scarification or erasion. Whatever instru- ment is used, it should always be kept perfectly clean. 1 Seaton, "Vaccination," in Reynolds's System of Medicine, vol. i, p. 291. Second edition. 310 TEXT-BOOK OF HYGIENE. A point of vital importance is that which relates to the proper age at which children should be vaccinated. Ordinarily, vaccination should be performed within the first six months of life. In time of danger from a threatened, or in the presence of an actual, epidemic, infants may be vaccinated when only 1 day old. In order to secure permanent protection against small-pox, revaccination should be performed after a certain interval. Some place the period at which this second vaccination should be done at five years, while others allow a longer interval- seven, eight, or ten years. The law of Prussia is that every child that has not already had small-pox must be vaccinated within the first year of its life, and every pupil in a public or private institution is to be revaccinated during the year in which his or her twelfth birthday occurs. This law was passed in 1874. Prior to this time the mortality from small-pox was 15 to 20 per 100,000 of the population. Since the law was enacted the small-pox mortality has varied from 0.3 to 3.6 per 100,000. Not a single death from small-pox occurred in the German army between 1874 and 1882.1 A revaccination, even if successful, seldom passes through all the typical stages of a primary vaccination. The vesicle rarely becomes so full and plump, and is more frequently flat and irregular in outline. Swelling of the axillary glands and other complications also seem to be more frequent than in cases where the vaccination is done for the first time. The question whether the lymph direct from the cow or humanized lymph is the more efficient has caused much dis- cussion. The objections urged against the use of humanized virus are: first, that its protective power has become diminished by transmission through many generations; second, that it is liable to transmit other diseases, such as syphilis, tuberculosis, scrofula, etc.; third, that it is frequently difficult to obtain in 1 Frolich, Militar-Medicin, p. 461. SMALL-POX. 311 sufficient quantities in an emergency, such as an actual or threatened epidemic. The first objection is disproved by the testimony of many of the most distinguished medical men in Europe and this country. Humanized vaccine virus, when properly inoculated, seems to be as completely protective against small-pox as that taken direct from the animal. Among its advantages are, that it " takes " more readily and runs through its stages of develop- ment in a shorter time, and that it will retain its active proper- ties for a greater length of time than animal virus. The physician can usually control the source whence he obtains it. He can watch over the subject that furnishes it and reject that which is suspicious. With humanized lymph collected by the physician himself there can be no doubt as to its purity or age; with animal lymph furnished by the cultivators of that article there can be no certainty about either of these important points. That syphilis has been inoculated with humanized virus can no longer be open to doubt. The recent experiment of Dr. Cory, of England, has settled this question definitely. With care, however, this sad accident can easily be avoided, and the fact that syphilis has been so rarely transmitted by vaccination is sufficient evidence that the danger of such infection is not very great. 7 The most serious objection against the exclusive use of humanized lymph is, that in grave emergencies, such as a rapidly-spreading epidemic of small-pox, it is difficult to obtain a sufficient supply of the lymph. Humanized virus is inoculated, either in the fresh state, i.e., tire lymph is taken from the vesicle on the seventh day and inoculated directly into the arms of other individuals, or else the vesicle is allowed to dry into a crust, with which a thin paste is made by moistening with water at the time of vaccination. The readiest way of using the crust is to crush a small fragment between two small squares of glass, then moistening it with a drop of warm (not hot) water, and smearing it on the spot 312 TEXT-BOOK OF HYGIENE. where the vaccination is to be made. With the lancet a number of cross-scarifications are then made, and the virus well rubbed in. Only so much of the crust should be moistened as will be used at the time. Particular care must be taken not to use saliva for moistening the crust. Aside from being unclean, there is danger of producing blood-poisoning by inoculating certain of the oral secretions.1 Animal virus is obtained by inoculating a calf or heifer with virus, either derived from a case of small-pox, from another case of cow-pox, or by re-inoculating humanized vaccine virus into the animal. The vesicles are opened on the seventh day, and ivory points or the ends of quills coated with the lymph and dried with a gentle heat. In vaccinating with animal virus, the quill or ivory point is first moistened with a drop of water to soften the adhering lymph; the scarification or abrasion of the skin is then made with the lancet, and the virus rubbed well into the scarified spot. In using animal virus the successive stages of development are usually one or two days later than when humanized virus is used. In the former case the areola is rarely developed before the ninth day. Certain complications are likely to occur in the course of the vaccinia, of which the student should be aware. When the areola appears there is usually more or less fever. Sometimes the constitutional manifestations are de- cidedly marked, fever of a high grade being not uncommon. In addition to the glandular enlargement and tenderness, an outbreak of roseola sometimes comes on about the ninth or tenth day. This eruption may be mistaken for scarlet fever, but if it is remembered that two infectious diseases rarely co- exist in one individual during their full development this error will be avoided. Erysipelas involving the entire arm is sometimes observed 1 See Sternberg and Magnin, Bacteria, p. 355. Second edition. 313 SMALL-POX. as a complication of vaccination. This, in nearly every case, depends upon some depravement of the patient's constitution, innutrition, bad sanitary surroundings, or, perhaps, more fre- quently, chronic alcoholism. Individuals who are habitually intemperate in the indulgence of alcoholic liquors are espe- cially unfavorable subjects for vaccination. The results are, fortunately, rarely serious to the patient. Another inconvenient complication of vaccination is the formation of a deep, ill-looking, sloughing ulcer at the vacci- nated point. This has been, in the author's experience, a much more frequent concomitant when animal virus has been used than when humanized virus was resorted to. It should be borne in mind that a very sore arm, especially if followed by the formation of an ulcer or gangrenous sore, may not be protective against small-pox. Such a patient should not be considered properly vaccinated, and must be revaccinated as soon as he recovers, or immediately if there is any danger of small-pox infection. Children with eczematous eruptions, however, localized upon any portion of the body, should not be vaccinated until the eruption is first cured, except in times of danger from small-pox. The eczema will be almost certainly rendered worse in consequence of the general hyperaemia accompanying the febrile reaction, and the physician who performs the vaccination will be blamed for causing the skin disease. The author has placed on record1 two cases of general psoriasis following vaccination, and other cases have been since reported. Urticaria and exudative erythema have also been repeatedly observed. As before stated, syphilis may be communicated to the vaccinee by vaccine virus obtained from a syphilitic subject, but this accident is infrequent. There can be little doubt that some of the cases reported as " vaccinal syphilis " are cases of tardy hereditary syphilis, lighted up by the general systemic disturb- ance following vaccination. * Journal Cutaneous and Venous Diseases, vol. i, No. 1, p. 11. 314 TEXT-BOOK OF HYGIENE. Next in importance to vaccination in the prophylaxis of small-pox is prompt isolation of the sick. No one but the medical and other attendants of the sick should be allowed to come in contact with them. All attendants and other persons exposed to the infection should, of course, be promptly vacci- nated, unless this has been successfully done within the previous year or two. Disinfection of all discharges from the patient and of the room and its contents, after the patient has recovered or died, must be practiced. The best disinfectants in small-pox are bichloride of mercury, free chlorine, and sulphurous acid. When it is learned that a person has small-pox, if he is not removed to a special hospital, a room should be prepared for his occupancy. The carpets should be taken up and the floor kept clean. Window-curtains and unnecessary furniture and drapery should be removed from the room. After recovery of the patient the bed-clothing must be thoroughly disinfected with steam or sulphurous acid, or destroyed by fire. The individual himself should not be allowed to mingle with healthy persons until all danger of infection is passed and the surface of his body has been thoroughly disinfected. ASIATIC CHOLERA. A disease which causes the death of three-fourths of a million of human beings in the country where it is endemic, within the space of five years, and which makes periodical ex- cursions, spreading over nearly the entire inhabited globe with destructive violence, must surely command the interested atten- tion of every intelligent person. Asiatic cholera is an endemic disease of India, where it probably originated centuries ago. Some authors claim to have found satisfactory evidence of its existence in the writings of the classical authors of India and Greece at a period as early as the second century of the Christian era. The evidence is, however, not beyond question. In the sixteenth and seventeenth cen- ASIATIC CHOLERA. 315 turies European travelers in the East gave pretty exact accounts of the disease. One of the most definite of these was given by Gaspar Correa, an officer in Vasco da Gama's expedition to Calicut. lie states that Zamorin, the chief of Calicut, lost 20,000 of his troops by the disease. A still more definite and the first trustworthy account is that of Sonnerat, a French trav- eler. He describes a pestilence having all the characters now recognized as belonging to Asiatic cholera, which prevailed in the neighborhood of Pondicherry and the Coromandel coast in 1768 and 1769, and which carried off 60,000 of those attacked by it within a year. Dr. Macpherson, in his " History of Cholera," gives numerous references which indisputably establish the en- demic existence of the disease in India anterior to the present century. Being endemically prevalent over a greater or less area of India for many years, cholera finally, in 1817, crossed the boundaries of that country, and, advancing in a southeasterly direction, invaded Ceylon and the Sunda Islands in 1818. In a westerly direction the disease was carried to the islands of Mauritius and Bennion, and reached the African coast in 1820. During this year it also traveled northeasterly, devastating the Chinese Empire for the two following years, reaching Nagasaki, in Japan, in 1822. In 1821 the disease spread from India in a westerly direc- tion, extending along the east coast of Arabia to the border of Mesopotamia and Persia. In the spring of 1822 it began with renewed violence, following the river Tigris to Kurdistan, and, extending farther in a westerly direction, reached the Mediter- ranean coast of Syria. In the following year, 1823, it extended from Persia into Asiatic Russia, reaching Astrachan on the European border in September, but dying out nearly every- where beyond the borders of India during the ensuing winter. In 1826 cholera again advanced from India, reaching Orenburg in Russia in 1829, and in the following winter appeared in St. Petersburg. Extending to the north and south, 316 TEXT-BOOK OF HYGIENE. it invaded Finland and Poland the same year. From Persia the disease spread to Egypt and Palestine in 1830-31. From Russia the pestilence invaded Germany in 1831, passing thence in 1832 into France, the British Isles, Belgium, the Netherlands, Norway, and Sweden. In the latter year cholera crossed the Atlantic Ocean for the first time, being car- ried to Canada by emigrants from Ireland, and spreading thence to the United States by way of Detroit. In the same year it was imported into New York by emigrants, and rapidly spread along the Atlantic coast. During the winter of 1832 it appeared at New Orleans, and passed thence up the Mississippi Valley. Extending into the Indian country, causing sad havoc among the aborigines, it advanced westward until its further progress was stayed by the shores of the Pacific Ocean. In 1834 it re-appeared on the east coast of the United States, but did not gain much headway, and in the following year New Orleans was again invaded by way of Cuba. It was imported into Mexico in 1833. In 1835 it appeared for the first time in South America, being restricted, however, to a mild epidemic on the Guiana coast. While the pestilence was advancing in the Western Hemi- sphere, it also spread throughout Southern Europe, invading, in turn, Portugal, Spain, and Italy. Extending in an easterly direction from India, the disease reached China and Japan in 1830-31 ; westwardly, Africa was invaded in 1834, and ravaged by the epidemic during the following three years. This second extensive outbreak of cholera ended in 1837, disappearing at all points beyond the borders of India. In 1846 the disease again advanced beyond its natural confines, reaching Europe, by way of Turkey, in 1848. In the autumn of this year it also appeared in Great Britain, Belgium, the Netherlands, Sweden, and the United States, entering by way of New York and New Orleans. In the succeeding two years the entire extent of country east of the Rocky Mountains was in- vaded. During 1851 and 1852 the disease was frequently im- 317 ASIATIC CHOLERA. ported by emigrants, who were annually arriving in great num- bers from the various infected countries of Europe. In 1853 and 1854, cholera again prevailed extensively in this country, being, however, traceable to renewed importation of infected material from abroad. In the following two years it also broke out in numerous South American States, where it prevailed at intervals until 1863. Hardly had this third great pandemic come to an end before the disease again advanced from the Ganges, spreading throughout India, and extending to China, Japan, and the East India Archipelago during the years 1863 to 1865. In the latter year it reached Europe by way of Malta and Marseilles. It rapidly spread over the Continent, and in 1866 was imported into this country by way of Halifax, New York, and New Orleans. This epidemic prevailed extensively in the Western States, but produced only slight ravages on the Atlantic coast, being kept in check by appropriate sanitary measures. In the same year (1866) the disease was also carried to South America, and in- vaded, for the first time, the States bordering on the Rio de la Plata and the Pacific coast of the Continent. While the epidemic was thus advancing westward from its home in India, it was at the same time spreading northwardly over the entire western part of Asia, and in a southeasterly direction over Northern Africa. In the latter continent it pre- vailed from 1865 to 1869. Cholera never entirely disappeared in Russia during the latter half of the sixth decade, and in 1870 it again broke out with violence, carrying off a quarter of a million of the inhabi- tants before dying out in 1873. It spread from Russia into Germany and France, and was imported, in 1873, into this country, entering by way of New Orleans and extending up the Mississippi Valley. None of the Atlantic-coast cities suf- fered from the epidemic in 1873, and since that year the United States have been entirely free from the disease, with the excep- tion of a few imported cases in New York Harbor in 1887. 318 TEXT-BOOK OF HYGIENE. In June, 1883, a new epidemic of cholera broke out in Egypt, where it raged with great violence. The disease first appeared in Damietta, near the outlet of the Suez Canal. It was unquestionably imported from India, probably Bombay, where it prevailed as early as the month of May. At the time of the outbreak in Damietta that city was overcrowded with people who had come to attend a great religious fair and festival. It has been proven that pilgrims from Bombay were among the attendants at this fair. The epidemic came to an end in Egypt in the autumn of 1883. In the same year (1883) a small out- break occurred in Marseilles, but intelligence of it was carefully suppressed by the authorities. The disease does not seem to have spread from this centre, but in June of the following year cholera broke out in Toulon, having probably been imported in a transport ship returning from Tonquin. This outbreak was very violent and rapidly spread throughout Southern France, Italy, and Spain. After apparently dying out during the winter, it re-appeared in the spring of 1885 with renewed violence. The total number of cases in Spain alone in the latter year was over one-third of a million, with nearly 120,000 deaths. In the summer of 1885 cholera also broke out in a viru- lent form in Japan, and, after a cessation during the following winter, recurred with increased fatality in 1886. In the latter year there were over 100,000 deaths from the disease in that country. During 1886 and 1887 cholera continued in Southeastern Italy and in the Austrian dominions at the head of the Adriatic. A few cases occurred in France and Germany, but by stringent sanitary measures an epidemic was averted. In November, 1886, cholera was carried to South America in an Italian ship, the "Perseo," bound from Genoa to Buenos Ayres. The disease rapidly spread in the Argentine Republic, and, crossing the Andean range, invaded the Pacific coast of the South American continent for the second time, reaching Chili and Bolivia and threatening Peru and Brazil. In Chili alone ASIATIC CHOLERA. 319 there were over 10,000 deaths in the first six months of 1887. The further progress of the epidemic was arrested and the entire Western Hemisphere is now free from the disease. From July to December, 1889, cholera prevailed with con- siderable virulence in Mesopotamia. This epidemic seems, at the time of writing (February 1, 1890), to be at an end. This brief historical sketch of all the epidemics of cholera observed beyond the borders of India demonstrates several facts: first, that the home or breeding-place of cholera is in India, especially the delta of the Ganges, whence it spreads at intervals throughout the world; second, that it always advances along the lines of travel of large bodies of human beings; and, third, that it advances, by preference, along water-routes. The latter is particularly noticeable in the behavior of cholera epi- demics in this country. When it has spread from an Atlantic port, it has, generally, been to other places having water com- munication with that port. Exceptions undoubtedly occur, but the ride is a general one. The disease seems to spread with difficulty along the lines of railroad. When the disease has extended from New Orleans it has always been up the Mississippi Valley, expending its violence upon the river cities-Vicksburg, Memphis, St. Louis, and Cincinnati. Several factors must concur before there can be an epidemic of cholera. These are: first, the cholera poison; second, cer- tain local conditions of air, soil, or water; and, third, individual predisposition. Without a concurrence of all these conditions no outbreak can occur. If, by any means, the co-existence of these three conditions can be prevented, cholera can be averted. The following are facts bearing upon this question: Cholera is communicated through the agency of a specific poison. This does not admit of doubt. The poison may be either an organic germ, or of an inorganic, particulate, or gaseous nature. The recent researches of Dr. Robert Koch, of Germany, indicate that a micro-organism found in the intestinal discharges of cholera patients and in the bodies of those dead with the disease is the 320 TEXT-BOOK OF HYGIENE. active agent in propagating the malady. This organism, named by Koch the "comma bacillus," from its general resemblance to a comma, was first discovered by this eminent pathologist in the intestinal contents of cholera corpses in Egypt in 1883, and in the following year more thoroughly studied in Calcutta, whither he had been sent by the German government to pursue his investigations. It has been demonstrated that this germ is always present in the discharges of cholera patients, and up to this time it has not been found in any other disease. Experi- ments upon animals have also shown that cholera can be pro- duced in the latter by introducing the germ into their bodies in various ways. The demonstration of the bacterial nature of cholera seems to be complete. While cholera cannot be regarded as personally contagious in the same sense or in the same degree as small-pox, there can be no doubt that it is spread only by the poison from other cases of the disease. The regularity of its march along routes by which the intercourse of human beings takes place, and always in connection with other cases of cholera, proves this. There is no undoubted case on record where genuine cholera has been spontaneously developed outside of India. That certain local geological and perhaps meteorological conditions are necessary for the propagation or virulence of the poison of cholera is beyond dispute. Outbreaks usually take place during the summer or autumn, and nearly always partly or entirely die out during cold weather. Further, in nearly all epidemics, certain cities or towns, or portions of a town, into which persons sick with cholera are brought, and where the poison of the disease is thus imported, remain exempt from the effects of the epidemic. The inference to be drawn from this fact is that in such localities the local conditions are unfavorable to the development of the poisonous germ, and it becomes inert. In India all the local conditions favorable to the propagation of the cholera-germ are found. The filthy personal habits of the people, the overcrowding, the intense heat, the lack of suf- ASIATIC CHOLERA. 321 ficient, appropriate, or properly-prepared food, and the exten- sive pollution of the water-supply, all combine to produce the necessary conditions of development of the cause of cholera. These conditions, doubtless, to a considerable extent, give rise to that depression of the system which seems necessary to con- stitute the individual predisposition to become infected. Given, then, at any place, a number of persons of a lowered degree of vitality,-that is to say, persons not capable of resisting unfavorable influences upon their health under unfavoring con- ditions ; given conditions of climate, water, and soil more or less similar to those existing in India: only the introduction of the third factor, the cholera poison, is needed to cause an outbreak. In many cities of this country and Europe, as proven by the most recent epidemics in Toulon, Marseilles, Naples, and other cities of Italy and Spain, the conditions are present which would furnish the most favorable breeding-place for the cholera-germ if introduced. The dejections and vomited matters of cholera patients con- tain the active agent which produces the disease. The contagi- ous principle contained in these excretions, probably the cholera- germ or "comma bacillus" discovered by Koch, may gain an entrance into the body through the drinking-water or through infected air. Probably both modes are equally competent chan- nels of infection. The prevailing theory is that pollution of the drinking-water is the most frequent source of the rapid spread of the disease. A very striking instance of this occurred in London during the epidemic of 1854, which has already been referred to.1 Another striking instance of the communication of cholera by polluted water has been reported by Mr. John Simon, long the chief medical officer of the English "Local Government Board." The facts are as follow: The Lambeth Water Company drew its supply from the Thames, at Ditton, above the influence of the London sewage and the tidal flux. The Southwark and 1 See ante, page 64. 322 TEXT-BOOK OF HYGIENE. Vauxhall Company drew its supply from the river near Vauxhall and Chelsea. The water of the Lambeth Company was toler- ably pure, and that of the Southwark and Vauxhall Company was very impure. The water of both companies was distributed in the same district at the same time and among the same class of people, the pipes of the two companies being laid pretty evenly in the same areas, in many places running side by side in the same streets, and the houses supplied being pretty equally distributed. The deaths from cholera in the houses supplied by the Lambeth Company were at the rate of 37, and in the houses supplied by the Southwark and Vauxhall Company at the rate of 130, to every 10,000 persons living. It appears, therefore, that of the drinkers of the foul water about three and a half times as many as those who drank the pure water died of cholera. But the spread of cholera cannot always be referred to pol- lution of the drinking-water. In many epidemics no relation can be shown to exist between the spread of the disease and im- pure water. Professor von Pettenkofer, of Munich, has shown, by a number of carefully-conducted observations, that the prop- agation of cholera often bears a very direct relation to changes in the stage of the subsoil- or ground- water. This does not mean that the subsoil-water is directly or necessarily the agent for the spread of the disease, but that its stage, or variability,- now high, now low,-may be considered as an index of certain processes going on in the soil which are intimately connected with the propagation of cholera as well as of certain other in- fectious diseases, chief among which is typhoid fever. The relations between the ground-water level and cholera outbreaks in India and various cities in Europe and America give strong support to the views of von Pettenkofer.1 In addition to the influence of the ground-water oscillations and polluted drinking-water in spreading the cholera-poison, must be mentioned articles of food contaminated with the in- fectious matter of the disease. It is also no longer open to 1 See page 130. 323 ASIATIC CHOLERA. question that persons may become infected by handling the clothing and bedding of cholera patients. Laundresses are in special danger from this source. Physicians and nurses have, not rarely, been attacked under circumstances which pointed strongly to personal contagion as one of the sources of the disease. The prophylaxis against cholera comprises such measures as will prevent the admission of the cholera-poison into a com- munity, arrest the development of the poison after its introduc- tion, and reduce the individual susceptibility to attack. It is evident from the foregoing that if the introduction of the cholera-poison could be prevented no outbreak of the dis- ease could occur. With this in view, some have urged the en- forcement of a strict policy of non-intercourse with infected localities. But at the present day few sanitarians advocate these extreme measures. A modified system of restricted intercourse is supported by many authorities, who claim that by the adoption of a thorough system of maritime inspection, disinfection, and observation-a rational quarantine, in fact-the poison can be rendered ineffective or its entrace into a commmunity prevented. The best authorities, however, think that it is not only easier, but far more effective to place the threatened locality in such a sanitary condition that the development of the cholera- poison cannot take place. The contrast between the effective- ness of quarantine and local sanitation as safeguards against cholera has been well expressed by von Pettenkofer, who com- pares cholera epidemics to powder explosions. The virus of cholera, he says, is the spark that evades the strictest quaran- tine ; the powder is the ensemble of local conditions which pre- dispose to the outbreak. " It is wiser, therefore, to seek out and remove the powder than to run after and try to extinguish each individual spark before it drops upon a mass of powder, and, igniting it, causes an explosion which blows us into the air with our extinguishers in our hands." The measures of local sanitation to be enforced are such as will secure cleanliness of person, of habitation and surround- 324 TEXT-BOOK OF HYGIENE. ings, of air, of water, and of soil. Pollution of the soil should be especially guarded against, for a polluted soil means impure air and water, and these mean, if not an infectious disease, at least a heightened receptivity to its influence. The quality of the drinking-water used must be above suspicion of con- tamination by the poison. Unless the latter can be positively excluded all drinking-water should first be boiled. It may then be cooled by pure ice. Filtering the water may not remove the poison. The individual predisposition to cholera is best guarded against by keeping the body clean and well nourished, and the mind free from worry. Underfeeding, anxiety, overwork, ex- posure to extremes of temperature, intemperance in eating and drinking should all be avoided, as they tend to reduce the re- sistance of the system to the influence of the morbid poison. Certain measures of personal prophylaxis which have proven useful heretofore should be adopted wherever cholera prevails. One of the best of these is the use of sulphuric-acid lemonade as a drink. Ten to 15 drops of dilute sulphuric acid in a glass of water, sweetened with sugar, may be drunk instead of water. Experience with it during the epidemic of 1866 has demonstrated its great value as a preventive of cholera. The later researches of Koch have also shown that the "comma bacillus," or spirillum, cannot live in acid solutions. Hence, it is probable that if the contents of the stomach were always kept acid no infection could occur through absorption from the stomach. A painless diarrhoea, called cholerine, attacks many persons during cholera epidemics. This disorder is easily curable if promptly attended to, but if allowed to run on it may develop into a malignant attack of cholera. Among the means of securing prompt treatment of the poorer classes in times of epidemics is the establishment of numerous public dispensaries, where medical aid can always be obtained. The establishment of such dispensaries and, if 325 ASIATIC CHOLERA. possible, of temporary hospitals in the crowded portions of cities is a very important part of the prophylactic treatment. Inasmuch as it seems definitely established that the dis- charges from the stomach and intestines are the active agents in propagating the disease, the immediate disinfection of such dis- charges is vitally important. The stools and vomited matters must be rendered innocuous by germicidal agents, such as mer- curic chloride, carbolic acid, or chloride of lime. Clothing and bedding should be disinfected with super- heated steam, thorough boiling, or fumigation with sulphur dioxide or chlorine. Infected articles of this kind should not be sent to a laundry until they have been thoroughly disinfected by one of the above-mentioned means. Apartments which have been occupied by cholera patients should be thoroughly fumigated, before being re-occupied, with burning sulphur, and afterward freely exposed to the air by opening doors and windows. The walls may also be washed with a solution of mercuric chloride. The most efficient disinfectant is mercuric chloride in the proportion of 1 part in 2000 of the material to be disinfected. The readiest way of securing disinfection with this agent is to add a solution of 1 to 1000 to an equal proportion of the dis- charges to be rendered innocuous. The mercuric chloride acts slowly, and hence the infected material should be exposed to the action of the disinfecting agent for at least two hours before it can safely be thrown into sewers or cess-pools. There are several serious objections to the indiscriminate use of mercuric chloride by the public as a disinfectant. In the first place, it is intensely poisonous, and its perfectly transparent and inodorous solution might readily be accidentally drunk and cause fatal results. To reduce this danger, the Committee on Disinfectants of the American Public Health Association recom- mended the addition of permanganate of potash or of sulphate of copper (blue vitriol) to color the solution. Another serious objection to mercuric chloride is that it cannot be used where 326 TEXT-BOOK OF HYGIENE. the disinfected material must pass through lead pipe, as this is rapidly corroded by the sublimate. In many water-closets it can therefore not be used. Chloride of lime (bleaching-powder) has been found to be a very rapid and efficient disinfectant, as well as a deodorizer; but the chlorine, upon which its effectiveness depends, is often so deficient in proportion, and the compound so readily deterio- rates that, unless a preparation can be obtained that contains at least 25 per cent, of available chlorine, it may prove injurious by causing a false sense of security. A trustworthy preparation may be dissolved in water, when required, in the proportion of 1 to 100. An objection to its use is the pungent odor of chlorine, which is very offensive to many persons. Dr. Koch recommends carbolic acid, which he has shown will kill the " comma bacilli " in a dilution of 1 to 20 of water. The ordinary preparations of carbolic acid sold as disinfectants are, however, not to be relied on, many of them not containing more than 2 per cent, of the acid. Further dilution of these agents would altogether destroy their disinfecting power. The purer article is, on the other hand, too expensive to be used as a disinfectant. Little's soluble phenyle is an efficient disinfectant in the proportion of 2 per cent. (1 to 50). It is furnished of uniform strength, is moderately cheap, non-poisonous, and readily miscible with water. In addition to its disinfecting power, it is also an excellent deodorizer, promptly removing all odors of decomposition and putrefaction. Its only objection is a rather pungent though not unpleasant odor, which somewhat resembles creasote. In the very beginning of an epidemic, prompt isolation of the sick and thorough disinfection of the surroundings of the patient may check the spread of the disease. Much cannot be expected from these measures, however, unless the local sanitary conditions are such as offer a hindrance to the development of the cholera-poison. It is plain, therefore, that prophylactic measures 327 RELAPSING FEVER. against cholera, to be effective, must be brought into requisition before the epidemic has begun. After the outbreak of the disease it may be too late to put the threatened locality in a good sanitary condition. It is of the highest importance that preventive measures be enforced early. RELAPSING FEVER. Relapsing fever was first clearly described by Dr. John Rutty, in his "Chronological History of the Weather, Seasons, and Diseases of Dublin from 1725 to 1765."1 Near the end of the last and in the first half of the present centuries relapsing fever was frequently met with in an epidemic form in Ireland and Scotland. In 1847 the disease invaded a number of the larger cities of England. From 1868 to 1873 it prevailed extensively in England and Scotland. On the continent of Europe it was first observed in Russia in 1833. In Germany it was not recognized as a distinct disease until 1847, but did not prevail epidemically until 1868. Since then it has often been observed in that country. Relapsing fever is very prevalent in India, where it was first observed in 1856 by Sutherland. In China and in the countries of Africa bordering on the Red Sea the disease has been recognized by observers. In the United States it was first observed among emigrants in Philadelphia in 1844, and again in 1869. It was conveyed to other places, but has never prevailed extensively in this country. It has not been observed in the United States since 1871. The predisposing causes of relapsing fever are, above all, bad sanitary surroundings. Want and overcrowding seem to be much less important factors than in typhus fever. Although relapsing fever has, since it was first clearly dis- tinguished from typhus and other continued fevers, been recog- nized as an eminently contagious and infectious disease, it was 1 London, 1770. 328 TEXT-BOOK OF HYGIENE. not until 1873 that its immediate cause became known. In that year Obermeier discovered in the blood of patients ill with this disease a minute, spiral, mobile organism, now known as the spirillum or spirochoete Obermeieri. Obermeier and other observers, prominent among whom is Dr. Henry V. Carter, have demonstrated the constant presence of these organisms in the blood during the attack. Carter and Koch have induced the disease in monkeys by inoculation of the parasite, and Moschutkowski has successfully inoculated it in the human subject. No doubt can exist at the present day that the spirillum of Obermeier is the true cause of relapsing fever. The preventive measures consist in attention to details of personal hygiene; in other words, local sanitation, disinfection of infected materials (fomites), and complete isolation of the sick. TYPHOID FEVER. The first accurate clinical accounts of typhoid fever date from the seventeenth century, when Baglivi, Willis, Sydenham, and others described cases of fever which in their clinical char- acters correspond to the disease now known as typhoid fever. Strother, however, in 1729, first gave a description of the anatomical characters of the disease, which he says is a " symp- tomatical fever, arising from an inflammation, or an ulcer, fixed on some of the bowels." Bretonneau and Louis, in France; Hildenbrand, in Germany; William Jenner, in England; and Drs. Gerhard and Pennock, in this country, clearly pointed out the essential distinction between typhoid and other fevers, during the first half of the present century. At the present day typhoid fever is met with everywhere throughout the world. It is at nearly all times a constituent of mortality tables. It affects by preference persons between the ages of 15 and 30 years, although no age is entirely exempt. It is always more prevalent in the autumn and winter. The disease is probably due to an organic poison, which gains entrance into the body through the respiratory or digestive TYPHOID FEVER. 329 tract. Recent observations of Klebs and Eberth seem to indicate that the morbific agent is a micro-organism termed the bacillus typhoideus. The exact relation of this organism to the disease has not been clearly worked out. It is found in the intestinal canal, and especially in the characteristic intestinal lesions of this fever. The infective agent is probably contained in the dejections of patients. The disease is not immediately conta- gious, like typhus fever. The medium through which the poison is introduced into the body may be drinking-water, food, milk, or other articles containing the infective agent. Localized epidemics due to infected water or milk have been frequently reported.1 The typhoid poison is supposed to be developed in cess- pools, sewers, and soil polluted by the products of animal decom- position. Whether it ever originates de novo in such places is a much-disputed proposition. At present the evidence is in favor of the view that cases of typhoid fever are always derived from pre-existing cases. The germ may develop in sewers and be carried in the sewer-air from place to place ; it may be carried into the soil from cess-pools receiving typhoid dejections, and there, undergoing development, may ascend through houses with the ground-air, or may drain into wells and pollute the drinking-water. By the admixture of such water with milk or other food the disease may be propagated. It is also believed that the effluvia from typhoid discharges may be absorbed by water or milk, and thus infect these articles. The prophylactic measures against typhoid fever comprise isolation of the sick, prompt disinfection of the discharges, and cleanliness in the widest sense. The water- and food- supplies must be carefully guarded against contamination with the poison, and all decomposing animal matter and excreta must be removed from the immediate vicinity of dwellings. The requisites for prevention may be summed up as pure air, pure water, uncon- taminated food, and a clean soil. 1 See ante, pp. 61-64. 330 TEXT-BOOK OF HYGIENE. TYPHUS FEVER. Wide-spread pestilences are nearly always accompaniments of famine and war. Of all pestilential diseases, none is so regu- lar in its coincidence with these conditions as typhus fever. The earliest accounts which unquestionably refer to this disease date from the eleventh century, when it was observed at a number of places in Italy. In the succeeding centuries isolated accounts of it appeared in the chronicles of the times, but no scientific description of it appeared until the sixteenth century. During the seventeenth, eighteenth, and the early part of the nineteenth centuries it prevailed extensively throughout Europe. The constant wars and consequent disturbances of the social rela- tions of the people, famines, overcrowding, filth, excesses of all kinds, contributed largely to the development and spread of typhus fever. For a number of years past no extensive epi- demic of the disease has been observed, although both in this country and in Europe localized outbreaks are frequently met with. Typhus fever is somewhat more prevalent in the winter and early spring months than during the rest of the year, but not very markedly so. At present, typhus fever is nearly always limited to times and places where the conditions favoring its development exist. Wherever overcrowding, in connection with filth, insufficient food, and bad habits are present, typhus fever is likely to be a visitor. Thus, in overcrowded and ill-ventilated emigrant ships, in jails and work-houses, and in camps, especially when stress of weather compels the crowding together of soldiers in close huts or barracks, the disease frequently breaks out. When typhus fever appears in a community, those classes of the people who are subjected to the conditions just mentioned are almost exclusively attacked. In cities, the dwellers in crowded tenements, or in courts and alleys, suffer most severely- are, in fact, almost the only ones attacked. An exception must, however, be made in the case of hospital physicians and attend- YELLOW FEVER. 331 ants where typhus-fever patients are treated. The mortality among these is always large. Typhus fever is contagious and infectious. An exposure for a length of time to an atmosphere impregnated with the poison may suffice to induce an attack. The poison may also be conveyed from place to place in fomites. Physicians may carry it in their clothing, if they have been exposed to a typhus atmosphere. The prevention of typhus fever consists in the institution of such measures as will secure pure air, pure water, a clean soil and dwellings, and cleanliness of body and clothing. When an outbreak occurs, the sick should be promptly isolated, the well persons removed from the building in which the cases have occurred, and efficient measures of disinfection carried out. The sick should be treated in the open air as much as possible. YELLOW FEVER. The West India Islands, the Gulf coast of Mexico, the northern part of the Atlantic coast of South America, and a limited section of the west coast of Africa constitute the present home of yellow fever. From this area (the so-called " yellow- fever zone ") the disease is frequently transported to contiguous or distant countries. The South Atlantic and Gulf coasts of the United States and the shores of the Caribbean Sea are most liable to the epidemic visitation of this pestilence. The first trustworthy account of an epidemic of yellow fever dates from the year 1635, when it prevailed on the Island of Guadeloupe. This and the adjoining islands of Dominica, Martinique, and Barbadoes were invaded a number of times in the fifty years following the above date. Jamaica was invaded in 1655 and Domingo the year after. In 1693 the first appear- ance of the disease is mentioned in the United States, being observed in Boston, Philadelphia, and Charleston. In 1699 it appeared as an epidemic in Vera Cruz, and re-appeared in Phila- delphia and Charleston. Since the year 1700, the disease has 332 TEXT-BOOK OF HYGIENE. appeared in an epidemic form, at one or more places within the present limits of the United States, eighty times, the last consid- erable invasion being at Jacksonville and other places in Florida, and Decatur in Alabama, in 1888. In South America yellow fever appeared for the first time in 1740. In 1819 the disease was imported into Brazil, and has since then been endemic. Peru and the Argentine Republic have also suffered several severe visitations of yellow fever since 1854. On the west coast of Africa, yellow fever seems to be en- demic in the peninsula of Sierra Leone, where it has been fre- quently observed since 1816. It has also prevailed epidemically in Senegambia and a number of the islands off the northern portion of the west African coast. In Europe, Spain and Por- tugal have been the only countries to suffer from yellow-fever epidemics. Although the causes of yellow fever cannot be definitely stated, it is well-known that it only occurs endemically within the tropics, and prevails epidemically elsewhere only during the summer. Of 180 epidemics observed in the United States and Bermudas, 154 began in July, August, and September. Of the remaining 26, none began in the six months from November to April. A temperature of 26° C. and a high humidity are gener- ally considered essential to produce an outbreak of the disease. Of other necessary meteorological conditions nothing is known. That the specific cause of yellow fever is a micro-organism appears probable from a consideration of the clinical history of the disease and its mode of propagation. Up to the present time, however, none of the various organisms described as causa- tive have made good the claims advanced by their discoverers. It can be stated without reserve that neither the organism of Freire, of Carmona, of Babes, of F. S. Billings, of Finlay, or of Gibier, is the true cause of yellow fever. It seems to be well established that the most filthy and 333 YELLOW FEVER. insanitary portions of cities are those principally ravaged by yellow fever. The author is convinced from personal observa- tion in Savannah, Memphis, and New Orleans, that filth is one of the principal factors in the spread of yellow fever. This opinion is also forcibly expressed by many of the most eminent authorities on the subject. Yellow fever is not endemic within the limits of the United States, and has probably never originated here. The instances in which it has appeared to do so may be explained by the per- sistence of the morbific agent through one or more winters, or by a new importation which has escaped observation. Yellow fever frequently breaks out on shipboard and causes much loss of life. There is no evidence that it originates on ships; it is only acquired after intercourse with an infected ship or infected place. The question of the personal contagion of yellow fever has been decided negatively. The disease is infectious and its cause may be transported in fomites, but persons sick with the disease do not communicate it. An infected atmosphere, or one favor- able to the poison, is necessary to the propagation of the disease. The preventive measures indicated against yellow fever appear from the foregoing: they are strict sanitary inspection to prevent the introduction of a person sick with the disease; to prevent the introduction of clothing or other fomites from a suspected locality without thorough disinfection, and such a con- dition of public and private sanitation as will prevent the devel- opment of the poison, should the latter, perchance, be introduced. When the disease becomes epidemic in a city, the inhabi- tants should be removed to temporary camps beyond the infected area. The experience of the city of Memphis in 1879, and of various localities in Florida in 1888, encourages the hope that by prompt depopulation of cities and strict enforcement of sani- tary measures in the camps the terrors of yellow fever can be largely averted. The sick should be promptly isolated, and no one except attendants permitted to have intercourse with them. 334 TEXT-BOOK OF HYGIENE. SCARLET FEVER AND MEASLES. The early history of these two contagious eruptive fevers is inextricably blended together. Up to the latter half of the seventeenth century the distinction between the two was not made by writers. Sydenham was among the first who clearly separated scarlet fever from measles and gave it a distinct name. Since the great English Hippocrates, the essential character of scarlet fever has been recognized by all physicians, and it is now never, or but rarely, confounded with measles. Of the two diseases, measles is somewhat more generally prevalent, although both occur usually in epidemics. There is hardly a country in which measles has not been observed, while the continents of Asia and Africa have remained measurably exempt from scarlet fever up to the present time, although epi- demics have been recorded in India and Japan. Hirsch states that scarlet fever was first observed in this country in 1735, at Kingston, Mass., quoting as authorities Dr. Douglass, of Boston, and Dr. Colden, of New York. The latter, however, in a letter to Dr. Fothergill,1 clearly describes diphtheria, and not scarlet fever. Its distribution is now general, but it is said to be much milder in the southern than in other portions of the United States. The prevalence of measles is not limited to any geographical section. Epidemics of measles usually begin during cold weather. Of 530 epidemics observed in Europe and North America, 339 occurred during the colder and 191 during the warmer months. In 213 of these, the height of the epidemic occurred 135 times in winter and spring, and only 78 times during summer and autumn. Scarlet fever epidemics occur more frequently in autumn than at any other season. The cause of scarlet fever or of measles is not to be sought in climatic influences, insanitary surroundings, or special natural conditions of air, water, or soil. Both diseases are contagious and infectious, and the contagion is transmitted either 1 Medical Observations and Inquiries, vol. i, p. 211. London, 1776. DIPHTHERIA. 335 by fomites (clothing, letters, etc.), infected air, drinking-water, or milk. Several observers have claimed the discovery of the specific organism of scarlet fever, but no trustworthy evidence has yet been furnished that the problem is solved. On a previous page (93) reference has been made to the probable connection between a disease of milk-cattle and scarlet fever. The measures for the prevention of both diseases are isola- tion and thorough disinfection. DIPHTHERIA. Under the names of Syriac and Egyptian ulcers, Aretseus, a writer of the second century, described various forms of malig- nant sore throat. The disease now called diphtheria prevailed at various places in Europe during the Middle Ages. In this country it was first observed about the middle of the last century, and in 1771 Dr. Samuel Bard, of New York, described it very accurately. Although repeated severe outbreaks occurred in Europe in the early part of the present century, it was not until 1857 that it again attracted attention by its epidemic prevalence in the United States. Since that time it has spread throughout the country, and is at present one of the most generally diffused, as well as one of the most fatal, of the contagious diseases. In certain epidemics its malignancy is very marked, while in others it seems to be a rather mild affection. Diphtheria is personally contagious; it may be transmitted by inoculation, as well as by inhaling an infected atmosphere. The virus is supposed by some investigators to dwell in a micro- organism, but no agreement has been reached as to the character of the specific microbe.1 The question as to the identity of diphtheria and croup is not merely a clinical one, but has an important bearing upon preventive medicine. If croup is a non-contagious and non- infectious disease, as is held by many, no precautions will be * Wood and Formad, Klebs and Loffler, Emmerich, and T. Mitchell Prudden. 336 TEXT-BOOK OF HYGIENE. necessary to prevent its spread to healthy persons. If, on the other hand, diphtheria and croup are identical in nature, the danger of infection is equally great in both diseases. Inasmuch as it is frequently impossible to positively decide upon a diagnosis, it would be well to consider the identity of the two diseases as established, and act, as far as preventive measures are concerned, as if all were cases of diphtheria. Diphtheria is inoculable upon animals, and may through this medium be transmitted to man. Persons sick with diphtheria should be carefully isolated ; no one but the immediate attendants should be allowed to come in contact with the patients. Table utensils, bedding, and cloth- ing used by the sick should be thoroughly disinfected by steam or boiling water before being used by others. Intimate contact with the sick, such as kissing, should be strictly prohibited. There seems no room to doubt that the virus of the disease can also be carried in the clothing. Hence, physicians and nurses should be especially careful in personally disinfecting themselves after contact with a case of diphtheria. After death or recovery of the patient, the apartment occupied during the illness should be disinfected with chlorine or sulphurous-acid gas. Children recovering from diphtheria, scarlet fever, measles, or small-pox, should not be permitted to attend school for at least four weeks after recovery. It is believed that there is danger of infection for a period about as long as this, and, besides, the patients are apt to be weakened from the effects of the dis- ease, and not able to resist the strain of continuous mental effort. DENGUE. The disease known as break-bone fever, dandy fever, and by various other names, was first observed in the United States in 1780 by Dr. Benjamin Kush. Dr. Kush describes an epi- demic which prevailed during the summer and early autumn of that year under the name of " bilious remittent fever," but the symptoms of the disease hardly leave any doubt that it was DENGUE. 337 dengue. In 1779 and 1780 it was also observed on the Coro- mandel coast, in Egypt, and on the island of Java. In 1784 to 1788 dengue also prevailed in various cities of Spain. In 1818 an epidemic appeared in Lima, in which nearly every one of the 70,000 inhabitants was attacked. In 1824-25 the disease again prevailed widely in India, where it was known as the " three-day fever." Isolated out- breaks occurred in that country until 1853, when it again ap- peared as a wide-spread epidemic, and in 1872 another epidemic outbreak occurred in the East, extending from Eastern Africa to Arabia, India, and China. In 1826 an epidemic of dengue appeared in Savannah, and in the following two years spread over the southern portion of the United States and the West Indies, reaching the northern coast of South America. In 1845 to 1849 the disease was observed in Rio Janeiro; in 1848 to 1850 in the South Atlantic and Gulf States. In 1854 it was observed in Southern Alabama, and in the same year in the West Indies. In 1873 another epidemic appeared in the lower Mississippi Valley, and in 1880 an outbreak of some extent occurred in New Orleans, Charleston, and other places on the Gulf and South Atlantic coasts. Dengue always begins in the summer or early autumn, and ceases abruptly with the advent of cold weather. It is almost exclusively limited to hot countries. It spreads with extreme rapidity wherever it appears. It is not contagious; the man- ner of its propagation is not known. The susceptibility to the disease appears to be almost universal; it frequently prostrates the majority of the inhabitants where an outbreak occurs. During the epidemic in Calcutta in 1871-72, 75 per cent, of the population were attacked. In the United States similar epi- demics have been repeatedly observed. Dengue is rarely fatal. It seems to be propagated through the atmosphere. No measures of prevention are known or available. 338 TEXT-BOOK OF HYGIENE. EPIDEMIC INFLUENZA. Accounts of epidemic influenza can be traced back to the year 1173, when the disease was observed coincidently in Italy, Germany, and England. It has prevailed epidemically, at vary- ing intervals, to the present time. In the fourteenth century 3 epidemics are recorded ; in the fifteenth, 4; in the sixteenth, 7; in the seventeenth, 46. Of these, 15 were very extensive, some of them prevailing over both hemispheres contempo- raneously. On the American continent influenza was first recorded in 1627, when it prevailed in New England, where it again broke out in 1625. Following this there is no notice of the disease in America until 1732, when an epidemic began in the New England States, which extended over the entire globe. Epi- demics occurred during the remainder of the eighteenth cen- tury in 1737, 1757, 1761, 1767, 1772, 1781, 1789, and 1798. During the present century the disease has prevailed more or less extensively in this country at thirteen different times, the last epidemic of any considerable extent being in 1879. At the time of writing (February, 1890) a very wide- spread epidemic, which began in Russia in November, 1889, is prevailing in the United States, complicated in many cases by pneumonia of a fatal character. The disease manifests itself in two principal forms, the catarrhal and the nervous. Weich- selbaum, of Vienna, claims to have discovered a micro-organism which he believes to be the cause of the affection, but this claim has not yet been verified. A curious feature of epidemics of influenza is the coinci- dent occurrence of outbreaks of a somewhat similar affection among animals, horses and dogs being especially attacked. Influenza is an acute, specific, infectious disease, not di- rectly contagious. The infection is apparently produced or trans- mitted in the air. The disease frequently appears over a large area of country almost simultaneously. Peculiarities of climate, season, meteorological conditions, geological formation, or racial EPIDEMIC CEREBRO-SPINAL MENINGITIS. 339 characteristics have no apparent influence upon the causation or spread of the disease. It occurs more frequently in the winter and spring than during the summer or autumnal months. The investigation into the epidemic of influenza among horses, re- ferred to in a previous chapter,1 seems to indicate, however, that a moist and impure atmosphere intensifies the disease. No measures of prophylaxis can be indicated except avoid- ance of anything tending to depress the vital powers. EPIDEMIC CEREBRO-SPINAL MENINGITIS. This disease was first recognized in Geneva in 1805. In the following year it was noted in various places in the United States. Both in Europe and this country localized outbreaks of the disease occurred between the dates above mentioned and 1816. At this time the disease seemed to die out altogether, but in 1822 it re-appeared in various parts of Europe and America. Cerebro-spinal meningitis appeared in 1857 in the south- west of France, and during the following ten years spread over a large part of the country. Algiers, Italy, Denmark, and Ire- land were also visited by the scourge. In 1854 and 1861 Sweden experienced its ravages, and in 1859 Norway was invaded by the disease, which continued for nearly a decennium in the latter country. From 1860 to 1867 the disease prevailed in Holland, Portugal, Germany, Ireland, and Russia. After the termination of what may be called the first epi- demic, in 1816, cerebro-spinal meningitis was not again observed in this country until 1842. In the eight years succeeding, it prevailed epidemically throughout almost the whole United States. From 1861 to 1873 it was noted frequently in various parts of the country. Since the latter year the reports of its occurrence in this country have been limited to sporadic cases or localized outbreaks. Cerebro-spinal meningitis is an acute infectious disease, 1 Chapter I, p. 29. 340 TEXT-BOOK OF HYGIENE. very fatal in its tendency. It is probably not personally con- tagious. Climate has no influence upon its origin, but season seems to stand in a positive relation to its causation. About three-fourths of the epidemics noticed have occurred during the winter and spring months. The disease seems to show no preference for peculiarities of topographical or geographical formation. Overcrowding, overwork, and uncleanliness have an important influence in determining an outbreak. It is especially a disease of youth and adolescence. Out of 975 cases occurring in New York only 150 were over 20 years of age, while of the remainder 665 were under 10. The prophylactic measures to be adopted against cerebro- spinal meningitis consist in careful attention to the sanitary conditions of dwellings and streets, avoidance of overwork and overcrowding during times of epidemic, isolation of the sick, and disinfection of the sick-room after the termination of the disease. SYPHILIS. In the year 1494, Charles VIII, of France, in command of a large army invaded Italy, and early in the following year be- sieged Naples. During the investment of the city a very severe disease, characterized by ulcers of the genitals, violent pains in the head and limbs, and generalized cutaneous eruptions broke out among the besiegers and spread rapidly throughout the army and civil population. On the return of the army to France, after the termination of the war, the disease rapidly spread throughout Europe, and the literature of the early part of the sixteenth century, both medical and lay, teems with references to it. From the locality and other circumstances connected with its epidemic appearance the disease acquired various names. Thus, the French called it morbus Neapolitan's^ or mal d'Italie, while the Italians termed it morbus Galllcus, or mala Franzos. At a very early period it was, however, clearly recognized that the disease was communicated during sexual intercourse, and SYPHILIS. 341 hence it was usually described in medical writings under the name lues venerea, while in the popular literature it still figured as the Frenchman's disease (morbus Gamous'). The name syphilis was first used in a poem descriptive of the disease, written in 1521 by Fracastor, a physician of Verona. The extraordinary outbreak of the disease toward the end of the fifteenth century led to many speculations concerning its origin. As it attacked persons in all ranks and conditions of life, " sparing neither crown nor cross," in the words of a con- temporary poet, the favorite explanation was that meteorological influences had much to do with its causation. Many ascribed it to the malign influence of the stars. The Neapolitans attrib- uted it to the wickedness of their enemies, the French, while the latter laid the blame on the filth and immorality of the Italians. The Spaniards claimed that it had been imported from America by Columbus, whose first expedition returned to Europe in 1-193. There are records, however, which prove that the dis- ease already existed in Italy in the latter year. In other parts of Europe the Jews, who had been driven out of Spain by the terrors of the Inquisition, were accused of this, as of many other misfortunes which befell the people. When it was definitely established that the disease was communicated almost solely by sexual intercourse, the theory of its transatlantic origin became very popular. It is characteristic of human nature to refer the origin of troubles resulting from its own vices to some other source, if possible. This theory of the American origin of syphilis is still held by some writers. Within a few years, Dr. Joseph Jones, of New Orleans, claims to have found evidences of syphilitic disease in the skulls and other bones from some of the prehistoric Indian mounds in Mississippi. These observa- tions of Dr. Jones have, however, not yet been verified by others. Although the first great epidemic of syphilis is clearly trace- able to the period between the years 1493 and 1496, an ex- amination of the older literature reveals many descriptions of disease which can only be explained by assuming them to refer 342 TEXT-BOOK OF HYGIENE. to syphilis. The Old Testament Scriptures contain numerous references to diseases of the genital organs. In most instances these troubles are ascribed to the wrath of God, although in some cases a pretty shrewd hint is given as to the causation of the affections. Finaly1 remarks that the Hebrew word trans- lated in all versions of the Bible by " flesh" signifies also the virile member. In this light, the references in Leviticus, XIII- XV; Numbers,XXV, 1-9, XXXI, 16-18; Deuteronomy, IV, 3; Joshua, XXII, 17; I Samuel, V, 6, 9, 12; Psalms, CVI, 28-30; I Corinthians, X, 8; Ephesians, II, 11; and Colossians, II, 13, receive a new interpretation. Numerous innuendoes in the Latin classics, and more or less exact descriptions in the medical writings of Greece, Rome, China, and India, leave no room for doubt that venereal diseases, and probably among them syphilis, have existed from the earliest times. At the present day syphilis is the most widely prevalent of all contagious diseases. In 1873 Dr. F. R. Sturgis estimated that in New York 1 person out of every 18 suffered from it. This is considered a moderate estimate. Dr. J. Wm. White, of Philadelphia, pronounces the opinion that "not less than 50,000 people of all classes in that city are affected with syphilis." On this basis Gihon estimates the number of syphilitics in the United States at one time at 2,000,000.2 The disease is transmitted, in the vast majority of cases, during the performance of the sexual act, but there are numerous other ways in which it may be and frequently is communicated. In the special literature of the subject are records of many cases in which the disease was acquired through a kiss, a bite, the act of suckling (from infant to nurse, and conversely), using a pipe, glass-blowers' mouth-piece, the finger of a midwife, the instru- ments of the dentist or surgeon, inoculation of syphilitic secretion mixed with saliva in the process of tattooing, and many other ways. Numerous cases have been reported where physicians were inoculated on the finger while examining a syphilitic patient. 1 Arch. f. Dermat. u. Syphilis, II Jahrg. 1 Heft., p. 126. 'The Prevention of Venereal Diseases by Legislation, Sanitarian, June, 1882. DISEASES OF ANIMALS COMMUNICABLE TO MAN. 343 The prophylactic measures which suggest themselves from a consideration of the nature of the disease are isolation of those infected, regular inspection of the class of persons through whom the disease is most frequently transmitted, i.e., prostitutes, and individual precautions against acquiring it. Greater attention to cleanliness of the genital organs on the part of those indulg- ing in promiscuous intercourse would aid largely in reducing the number of cases of syphilis. DISEASES OF ANIMALS COMMUNICABLE TO MAN. Sheep-pock.-This is a highly contagious and infectious disease of sheep, resembling, in its symptoms, course, and fatality, small-pox as it occurs in the human race. It is believed by Bollinger to be different from the form of small-pox produced in sheep, goats, horses, and other animals by the inoculation of human small-pox. Sheep-pock can be inoculated upon other animals and man, but only produces a local disease at the point of inoculation in the latter. Sheep may be protected against this disease by inoculation with sheep-pock virus (ovination), or by vaccination with vaccine lymph. The peculiarity of sheep vaccinia is that it is a more or less generalized disease, the pustules being distributed over the body. Sheep-pock, when inoculated upon human beings, does not produce a generalized infectious disease, but remains entirely local. Actinomycosis.-Veterinarians have frequently observed a disease attacking the jaws of cattle and producing tumors, often with ulcerated surfaces. The bone is usually involved. The disease has heretofore been generally considered a sarcomatous growth. It is not seldom observed among the cattle in the western stockyards, where it is known in the vernacular as " swell-head." Recent investigations by Ponfick have shown that the growth consists of a vegetable parasite (actinomyces), and that it is inoculable upon other animals, and may be conveyed to man. A considerable number of cases have been observed in human beings in Germany, where the disease was 344 TEXT-BOOK OF HYGIENE. first described by Politick, and very recently 4 cases have been reported in this country.1 Bovine Tuberculosis (Perlsucht).-In cattle, tuberculosis occurs in two forms, miliary tubercles and cheesy masses in the lungs, and firm, pearly nodules on the serous membranes. These nodules do not break down, but may become calcified. Bovine tuberculosis is a frequent disease among cows kept in damp, dark, and ill-ventilated stables. The disease, which is essentially the same as human tuberculosis, tubercle bacilli being present in the neoplasms, is believed by many to be trans- missible to human beings by means of the milk or flesh of tuberculous animals. The sale of the meat of tuberculous cattle should be prohibited. Rabies.-Hydrophobia in the brute, and its communi- cability to man through a bite, has been known from the remotest antiquity. It occurs in dogs, foxes, wolves, horses, and other animals, and may be transmitted from any of them to human beings. The contagium of rabies, the infective poison, is contained principally in the saliva, and is usually inoculated by the teeth of the mad animal. Pasteur has shown that the greatest virulence of the rabies poison resides in the brain and spinal cord of the animal suffer- ing from the disease. By cultivation of this virus, the nature of which has not yet been definitely determined, its virulence could be diminished, and by inoculation of men and animals with the attenuated virus protection against the disease could be secured. The fact seems likewise established that the period of incubation of the inoculation-rabies is much shorter than that acquired in the usual way by bites of rabid animals. Hence, inoculation with the attenuated virus protects the bitten individ- ual against the fatal outbreak of the unmodified disease. Anthrax.-Anthrax, or splenic fever (milzbrand), is an * Boston Med. and Surg. Journal, Oct. 16, 1884, p. 377, and Journ. Am. Med. Ass'n, Nov. 27, 1886. Also, N. E. Med. Monthly, Sept. 15,1886. DISEASES OF ANIMALS COMMUNICABLE TO MAN. 345 acute, highly contagious and infectious disease of herbivorous animals, which may be transmitted by inoculation or the ingestion of the virus to other animals and to man. The disease is due to a minute vegetable organism which is found in the blood and tissues of the diseased animals. This organism, bacillus anthracis, was first discovered by Pollender, and has been thoroughly investigated by Davaine, Pasteur, Koch, and others. Inoculation of these bacilli or their spores always produces the disease in susceptible animals. Skins of animals not infre- quently contain the virus, which may then gain access to the blood of persons engaged in handling them. Knackers, butchers, wool-sorters, and other persons liable to come in contact with sick animals, or handling their flesh or hides, are subject to the infection, either by direct inoculation (through abrasions of the skin, etc.) or by inhalation of the spores of the bacillus. An intestinal form of anthrax in man, mycosis intes- tinalis, is sometimes produced by the consumption of meat of animals suffering, when killed, of splenic fever. Numerous instances have been reported. The diagnosis has been verified by discovering the bacillus of anthrax in the blood and various organs of the individuals attacked.. In view of the dangerous character of the disease, persons coming in contact with animals suffering from anthrax should be warned of their peril. In order to protect other animals in a herd, strict isolation of the infected, thorough disinfection of the stables occupied by them, and deep interment of the cadavers of those dead from the disease are indicated. Glanders.-Glanders, or farcy, is a very fatal contagious disease of horses which may be communicated to other animals and to man. The cause of glanders has recently been discovered by Loftier to be a bacillus resembling the bacillus tuberculosis. Pure cultures of this bacillus were inoculated into animals, and followed by glanders in a number of the cases. The infection in man may occur either upon the seat of 346 TEXT-BOOK OF HYGIENE. excoriations of the skin or mucous membranes, especially those of the nose, conjunctiva, and possibly by inhalation of infective particles floating in the air. Animals with glanders should be promptly killed and their cadavers cremated or deeply buried. No part of the body of any animal dead with glanders should be allowed to be used. Infected stables should be thoroughly disinfected. [The works of especial value to students who desire fuller information upon the subjects treated in this chapter are the following:- Hirsch, Handbuch der Historisch-Geographischen Pathologic, 2te Aufl., Stuttgart, 1883.-Haeser, Geschichteder Epidemischen Krankheiten. -Hecker, The Black Death, translated by B. G. Babington.-Defoe, Jour- nal of the Plague in London.-Rohlfs, Die Orientalische Pest.-Marson, Small-pox, in Reynolds's System of Medicine, vol. i.-Seaton, Vaccina- tion, ibid.-Trousseau, Clinical Medicine, vol; i.-Fifth Annual Report Illinois State Board of Health.-Hardaway, Essentials of Vaccination.- Crookshank, History and Pathology of Vaccination.-Wood worth and McClellan, Cholera Epidemic in United States in 1873.-ChailM, Report of Yellow Fever Commission, Annual Report National Board of Health for 1880.-Wood and Formad, Memoir on the Nature of Diphtheria, ibid., 1882.-Thompson, Annals of Influenza.-StilM, Epidemic Meningitis.- Mueller, Die Venerischen Krankheiten im Altherthum.-Lancereaux, Traits de la Syphilis.-Bollinger, Ueber Menschen u. Thierpocken, etc., Sammi. Klin. Vortr., No. 116.-Ponfick, Die Actinomycose des Men- schen.-Gamgee, Hydrophobia and Glanders, in Reynolds's System of Medicine, vol. i.-Bollinger, Anthrax, in Ziemssen's Cyclopaedia, vol. iii.J CHAPTER XX. Antiseptics, Disinfectants, and Deodorants. Much confusion exists in the popular mind, and even among physicians, as to the exact meaning of the terms at the head of this chapter. By many they are used synonymously, and hence frequently give rise to ambiguity and misunderstanding. Antisepsis, which is so frequently confounded with disin- fection, should be more accurately defined than is usual by writers. An antiseptic is an agent which retards, prevents, or arrests putrefaction, decay, or fermentation. It does not neces- sarily destroy the vitality of the organisms upon which these processes depend. An antiseptic may also arrest the develop- ment of the organisms which cause infectious diseases, and may hence be used as a preventive of such diseases. But antiseptics do not destroy the life of disease-germs, and hence cannot be relied upon when such organisms are present. By disinfection, in the proper and restricted use of the term, is meant the destruction of the specific infectious material which causes infectious diseases. If the view is accepted that all in- fectious diseases are due to micro-organisms or germs, then a disinfectant is equivalent to a germicide. In sanitary practice and experimental investigations this view is, in fact, adopted. In testing the action of various disinfecting agents upon infec- tious material, the biological test is the one universally relied upon by experimenters, and no observations upon disinfection based upon chemical tests alone would be accepted by sanitarians as conclusive. It may therefore be assumed for practical pur- poses that no agent can be accepted as a disinfectant if it is not also a germicide. From this it follows that disinfection, to be trustworthy, must be thorough. " There can be no partial disinfection of infectious material; either its infectious power is destroyed, or it is not. In the latter case there is a failure to disinfect."1 Obviously, also, there can be no disinfection in the 1 Report of Committee on Disinfectants of the American Public Health Association^. 236. 347 348 TEXT-BOOK OF HYGIENE. absence of infectious material. Faecal discharges, a diseased body or corpse, clothing, bedding, an apartment, a ship, or a hospital ward may or may not be infected. In the former case we may speak of disinfecting them; in the latter, it would be an inappropriate use of the word. Confusion is also liable to arise by considering disinfectants and deodorizers as synonymous. Deodorants merely remove offensive odors, and may not possess any disinfecting power whatever. Thus, one of the most efficient disinfectants at our command (mercuric chloride) is not a deodorizer at all, except by preventing putrefaction. On the other hand, some of the most effective deodorants have only a subordinate position in the scale of disinfectants. Careful investigations have shown that there is a wide divergence between various disinfecting agents in their influence upon disease-germs, some being efficient in high dilutions, while others require to be brought in contact with the germs in great concentration. For example, mercuric chloride will act as an efficient poison to certain disease-germs (anthrax spores) in the proportion of 1 to 1000, while zinc-chloride must be used in the proportion of 1 to 5 (or 20 per cent.). It has been, further, discovered that different disease-germs present varying resisting power to the same disinfecting agent, some being easily destroyed, while others are much more resistant. For example, the following table shows a number of experiments made by Dr. Meade Bolton for the American Committee on Disinfectants:- Organism. Chloride of Lime. Mercuric Chloride. Carbolic Acid. Typhoid bacillus 1:2000 1 :10,000 1:100 Cholera spirillum .... 1:2000 1:10,000 1:100 Anthrax spores 1 : 100 1:1000 1:50 (Uncertain.) Staphylococcus aureus. . . 1: 200 1 :100 Staphylococcus citreus . . 1:50 • • • • • 1 : 100 Staphylococcus albus . . . 1 : 200 1 : 100 Table XXVII. ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 349 Assuming that infectious diseases are caused by micro- organisms, and that these are different from the micro-organisms of ordinary decay or putrefaction, it can be readily understood that the processes of organic decomposition may themselves act as disinfectants. It is known, for example, that when a fer- menting liquid putrefies, the organisms of fermentation disap- pear and give place to the organisms of putrefaction (bacterium termo, etc.). So, likewise, the bacilli of anthrax and of tuber- culosis are killed by the putrefactive process, if this takes place in the absence of free oxygen. Furthermore, the reproduction of organisms of a certain kind ceases when certain chemical (?) changes take place in their environment. Fermentation in a saccharine liquid ceases and the ferment-organisms die when the accumulation of the product of the fermentation (alcohol) has reached a certain proportion, although there may still be un- decomposed sugar present. In like manner it is intelligible that the products of micro-organisms may eventually destroy their producers, and so place a limit to the morbid process. The specific cause of small-pox, yellow fever, cholera, and similar infectious diseases is rapidly destroyed when decomposition of the corpses of those dead with such diseases sets in. Hence, the reason why infectious diseases are not spread from cemeteries. From the foregoing it may be gathered that disinfection consists chiefly in a struggle against organized disease-germs.1 As, however, experiments and observations have shown that the life-history of disease-germs varies with the different organisms involved, it becomes evident that specific directions concerning disinfection can be given only when the life-history of the specific organism is known. The American Committee on Disinfectants, to whose work reference has already been made, divides disinfectants into two classes: those efficient for the destruction of infectious material containing spores, and those which will destroy infectious ma- terial only in the absence of spores. The recommendations of i Mueller und Falk, in Realencyclopaedie d. ges. Heilk., Bd. IV., p. 62. 350 TEXT-BOOK OF HYGIENE. the committee, covering not only the appropriate disinfectant to be used for the destruction of the organisms, but also the con- ditions under which the agent should be used, are as follow:- The most useful agents for the destruction of spore-containing infectious material are :- 1. Fire. Complete destruction by burning. 2. Steam, under pressure. 105° C. (221° F.) for ten minutes. 3. Boiling in water for half an hour. 4. Chlorinated lime.1 A 4-per-cent. solution. 5. Mercuric chloride. A solution of 1 to 500. For the destruction of infectious material which owes its infecting power to the presence of micro-organisms not containing spores, the committee recommends :- 1. Fire. Complete destruction by burning. 2. Boiling in water for ten minutes. 3. Dry heat. 110° C. (230° F.) for two hours. 4. Chlorinated lime.1 A 2-per-cent. solution. 5. Solution of chlorinated soda.2 A 10-per-cent. solution. 6. Mercuric chloride. A solution of 1 to 2000. 7. Sulphur dioxide. Exposure for twelve hours to an atmosphere containing at least 4 volumes per cent, of this gas in presence of moisture.3 8. Carbolic acid. A 5-per-cent. solution. 9. Sulphate of copper. A 5-per-cent. solution. 10. Chloride of zinc. A 10-per-cent. solution. The committee would make the following recommendations with reference to the practical application of these agents for disinfecting purposes:- For Excreta. (a) In the sick-room :- 1. Chlorinated lime in solution, 4 per cent. In the absence of spores :- 2. Carbolic acid in solution, 5 per cent. 3. Sulphate of copper in solution, 5 per cent. (5) In privy-vaults :- 1. Mercuric chloride in solution, 1 to 500.4 2. Carbolic acid in solution, 5 per cent. For Excreta. 1 Should contain at least 25 per cent, of available chlorine. s Should contain at least 3 per cent, of available chlorine. 3 This will require the combustion of between 1% to 2 kilogrammes of sulphur for every 28 cubic metres of air-space. 4 The addition of an equal quantity of potassium permanganate as a deodorant, and to give color to the solution, is to be recommended. ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 351 (c) For the disinfection and deodorization of the surface of masses of organic material in privy-vaults etc.:- Chlorinated lime in powder. For Clothing, Bedding, etc. (a) Soiled underclothing, bed-linen, etc.:- 1. Destruction by fire, if of little value. 2. Boiling for at least half an hour. 3. Immersion in a solution of mercuric chloride of the strength of 1 to 2000 for four hours. 4. Immersion in a 2-per-cent. solution of carbolic acid for four hours. (5) Outer garments of wool or silk, and similar articles, which would be injured by immersion in boiling water or in a disinfecting solution:- 1. Exposure in a suitable apparatus to a current of steam for ten minutes. 2. Exposure to dry heat at a temperature of 110° C. (230° F.) for two hours. (c) Mattresses and blankets soiled by the discharges of the sick :- 1. Destruction by fire. 2. Exposure to superheated steam (105° C. = 221° F.) for ten minutes. (Mattresses to have the cover removed or freely opened.) 3. Immersion in boiling water for half an hour. Furniture and Articles of Wood, Leather, and Porcelain. Washing, several times repeated, with solution of carbolic acid, 2 per cent. For the Person. The hands and general surface of the body of attendants of the sick, and of the convalescents, should be washed with- 1. Solution of chlorinated soda diluted -with nine parts of water (1 to 10). 2. Carbolic acid, 2-per-cent. solution. 3. Mercuric chloride, 1 to 1000. For the Dead. Envelop the body in a sheet thoroughly saturated with- 1. Chlorinated lime in solution, 4 per cent. 2. Mercuric chloride in solution, 1 to 500. 3. Carbolic acid in solution, 5 per cent. 352 TEXT-BOOK OF HYGIENE. For the Sick-room and Hospital Wards. (a) While occupied, wash all surfaces with- 1. Mercuric chloride in solution, 1 to 1000. 2. Carbolic acid in solution, 2 per cent. (b) When vacated :- Fumigate with sulphur dioxide for twelve hours, burning at least 1| kilogrammes sulphur for every 28 cubic metres of air-space in the room ; then wash all surfaces with one of the above-mentioned disinfecting solutions, and afterward with soap and hot water; finally throw open doors and windows and ventilate freely. For Merchandise and the Mails. The disinfection of merchandise and of the mails will only be required under exceptional circumstances ; free aeration will usually be sufficient. If disinfection seems necessary, fumigation with sulphur dioxide will be the only practicable method of accomplishing it without injury. Rags. (a) Rags which have been used for wiping away infectious discharges should at once be burned. (&) Rags collected for the paper-makers during the prevalence of an epidemic should be disinfected, before they are compressed in bales, by- 1. Exposure to superheated steam (105° C.= 221° F.) for ten minutes. 2. Immersion in boiling water for half an hour. Ships. (a) Infected ships at sea should be washed in every accessible place, and especially localities occupied by the sick, with- 1. Solution of mercuric chloride, 1 to 1000. 2. Solution of carbolic acid, 2 per cent. The bilge should be disinfected by the liberal use of a strong solution of mercuric chloride. (b) Upon arrival at a quarantine station, an infected ship should at once be fumigated with sulphurous-acid gas, using 1| kilogrammes of sulphur for every 28 cubic metres of air-space; the cargo should then be discharged on lighters ; a liberal supply of the concentrated solution of mercuric chloride (1 to 32) should be thrown into the bilge, and at the end of twenty-four hours the bilge-water should be pumped out and replaced with pure sea-water; this should be repeated. A second fumi- gation after the removal of the cargo is recommended. All accessible ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 353 surfaces should be washed with one of the disinfecting solutions here- tofore recommended, and subsequently with soap and hot water. For Railway-cars. The directions given for the disinfection of dwellings, hospital wards, and ships apply as well to infected railway-cars. The treatment of excreta with a disinfectant before they are scattered along the tracks seems desirable at all times, in view of the fact that they may contain infectious germs. During the prevalence of an epidemic of cholera this is imperative. For this purpose the standard solution of chlorinated lime is recommended. From the foregoing it would appear that heat, chlorinated lime, mercuric chloride, solution of chlorinated soda (Labar- raque's solution), carbolic acid, sulphate of copper, zinc chloride, and sulphur dioxide (sulphur-fumes) are the most generally available disinfectants. The following " general directions " for the practical appli- cation of disinfection are given by the committee:- Disinfection of Excreta, etc.-The infectious character of the dejec- tions of patients suffering from cholera and typhoid fever is well estab- lished ; and this is true of mild cases and of the earliest stages of these diseases, as well as of severe and fatal cases. It is probable that epidemic dysentery, tuberculosis, and perhaps diphtheria, yellow fever, scarlet fever, and typhus fever may also be transmitted by means of the alvine discharges of the sick. It is, therefore, of the first importance that these should be disinfected. In cholera, diphtheria, yellow fever, and scarlet fever all vomited material should also be looked upon as infectious. And in tuberculosis, diphtheria, scarlet fever, and infectious pneumonia the sputa of the sick should be disinfected or destroyed by fire. It seems advisable, also, to treat the urine of patients sick with an infectious disease with one of the disinfecting solutions below recommended. Chloride of lime, or bleaching powder, is perhaps entitled to the first place for disinfecting excreta, on account of the rapidity of its action. The following standard solution is recommended :- Dissolve chloride of lime {chlorinated lime, bleaching powder} of the best quality1 in pure water in the proportion of 6 ounces to the gallon {45 grammes to the litre}. Use 1 quart (1 litre) of this solution for the disinfection of each dis- charge in cholera, typhoid fever, etc.2 Mix well, and leave in the vessel 1 Good chloride of lime should contain at least 25 per cent, of available chlorine. 2 For a very copious discharge use a larger quantity. 354 TEXT-BOOK OF HYGIENE. for at least one hour before throwing into privy-well or water-closet. The same directions apply for the disinfection of vomited matters. Infected sputum should be discharged directly into a cup half full of the solution.1 A 5-per-cent. solution of carbolic acid may be used instead of the chloride-of-lime solution, the time of exposure to the action of the disinfectant being four hours. Disinfection of the Person.-The surface of the body of a sick person or of his attendants, when soiled with infectious discharges, should be at once cleansed with a suitable disinfecting agent. For this purpose, solu- tion of chlorinated soda (liquor sodfe chlorinatae-Labarraque's solution) diluted with 9 parts of water, or the standard solution of chloride of lime diluted with 3 parts of water, may be used. A 2-per-cent. solution of carbolic acid is also suitable for this purpose, and under proper medical supervision the use of a solution of corrosive sublimate (1 to 1000) is to be recommended. In diseases like small-pox and scarlet fever, in which the infectious agent is given off from the entire surface of the body, occasional ablu- tions with the above-mentioned solution of chlorinated soda are recom- mended. In all infectious diseases the body of the dead should be enveloped in a sheet saturated with the standard solution of chlorinated lime, or •with a 5-per-cent. solution of carbolic acid, or a 1 to 500 solution of cor- rosive sublimate. Disinfection of Clothing.-Boiling for half an hour will destroy the vitality of all known disease-germs, and there is no better way of dis- infecting clothing or bedding which can be washed than to put it through the ordinary operations of the laundry. No delay should occur, however, between the time of removing soiled clothing from the person or bed of the sick and its immersion in boiling water, or in one of the following solutions until this can be done :- Corrosive sublimate, 1 gramme to the litre (1 to 1000), or carbolic acid (pure), 8 grammes to the litre. The articles to be disinfected must be thoroughly soaked with the disinfecting solution and left in it for at least two hours, after which they may be wrung out and sent to the wash.2 Clothing or bedding which cannot be washed should be disinfected 1 Recently a small spitting-cup made of stiff paper lias been introduced especially for the use of consumptives. The cup is carried about by the patient or kept within reach. When the cup has been in use for a time, and before the sputa can become desiccated, it is thrown into the fire and burned. 9 Solutions of corrosive sublimate should not be placed in metal receptacles, for the salt is decomposed and the mercury precipitated by contact with copper, lead, or tin. A wooden tub or earthen crock is a suitable receptacle for such solutions. ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 355 by steam in a properly-constructed disinfection chamber. In the absence of a suitable steam disinfecting apparatus, infected clothing and bedding should be burned. Disinfection of the Sick-room.-In the sick-room no disinfectant can take the place of free ventilation and cleanliness. It is an axiom in sani- tary science that it is impracticable to disinfect an occupied apartment for the reason that disease-germs are not destroyed by the presence in the atmosphere of any known disinfectant in respirable quantity. Bad odors may be neutralized, but this does not constitute disinfection in the sense in which the term is here used. These bad odors are, for the most part, an indication of want of cleanliness or of proper ventilation, and it is better to turn contaminated air out of the window or up the chimney than to attempt to purify it by the use of volatile chemical agents, such as carbolic acid, chlorine, etc., which are all more or less offensive to the sick, and are useless so far as disinfection-properly so called-is con- cerned. When an apartment which has been occupied by a person sick with an infectious disease has been vacated, it should be disinfected. The object of disinfection in the sick-room is mainly the destruction of infec- tious material attached to surfaces or deposited as dust upon window- ledges, in crevices, etc. If the room has been properly cleansed and ventilated while still occupied by the sick person, and especially if it was stripped of carpets and unnecessary furniture at the outset of his attack, the difficulties of disinfection will be greatly reduced. All surfaces should be thoroughly washed w'ith the standard solu- tion of chloride of lime, diluted with 3 parts of water, or with 1 to 1000 solution of corrosive sublimate. The walls and ceiling, if plastered, should be subsequently treated with a lime-wash. Especial care must be taken to wash away all dust from window-ledges and other places where it may have settled, and thoroughly to cleanse crevices and out- of-the-way places. After this application of the disinfecting solution, and an interval of twenty-four hours or longer for free ventilation, the floors and wood-work should be well scrubbed with soap and hot water, and this should be followed by a second, more prolonged exposure to fresh air, admitted through open doors and windows. As an additional precaution, fumigation with sulphurous-acid gas is to be recommended, especially for rooms which have been occupied by patients with small-pox, scarlet fever, diphtheria, typhus fever and yel- low fever. But fumigation with sulphurous-acid gas alone, as commonly practiced, cannot be relied upon for disinfection of the sick-room and its contents, including bedding, furniture, infected clothing, etc., as is popu- larly believed. 356 TEXT-BOOK OF HYGIENE. When fumigation is practiced, it should precede the general washing with a disinfecting solution heretofore recommended. To insure any results of value, it will be necessary to close the apartment to be disin- fected as completely as possible by stopping up all apertures through which the gas might escape, and to burn not less than 3 pounds of sulphur for each 1000 cubic feet (1| kilogrammes to 28 cubic metres) of air-space in the room. To secure complete combustion of the sulphur, it should be placed, in the form of powder or small fragments, into a shallow iron pan, which should be set upon a couple of bricks in a tub partly filled with water, to guard against fire. The sulphur should be thoroughly moistened with alcohol before igniting it. Disinfection of Privy-vaults. Cess-pools, etc.-When the excreta (not previously disinfected) of patients with cholera or typhoid fever have been thrown into a privy-vault this is infected, and disinfection should be resorted to as soon as the fact is discovered, or whenever there is reasonable suspicion that such is the case. It will be advisable to take the same precautions with reference to privy-vaults into which the ex- creta of yellow fever have been thrown, although we do not definitely know that this is infectious material. For this purpose the standard solution of chloride of lime may be used in quantity proportioned to the amount of material to be disin- fected, but where this is considerable it will scarcely be practicable to sterilize the whole mass. The liberal and repeated use of this solution, or of a 5-per-cent. solution of carbolic acid, will, however, disinfect the surface of the mass, and is especially to be recommended during the epi- demic prevalence of typhoid fever or of cholera. All exposed portions of the vault, and the wood-work above it, should be thoroughly washed down with the disinfecting solution. In- stead of the disinfecting solutions recommended, chloride of lime in powder may be daily scattered over the contents of the privy-vault. Disinfection of Ingesta.-It is well established that cholera and typhoid fever are very frequently, and perhaps, usually, transmitted through the medium of infected water or articles of food, and especially milk. Fortunately, we have a simple means at hand for disinfecting such infected fluid. This consists in the application of heat. The boiling temperature maintained for half an hour kills all known disease-germs. So far as the germs of cholera, yellow fever, and diphtheria are concerned, there is good reason to believe that a temperature considerably below the boiling-point of water will destroy them. But in order to keep on the safe side, it is best not to trust anything short of the boiling-point (100° C. = 212° F.) when the object is to disinfect food or drink which is open to the suspicion of containing the germs of any infectious disease. ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 357 During the prevalence of an epidemic of cholera it is well to boil all water for drinking purposes. After boiling, the water may be filtered, if necessary, to remove sediment, and then cooled with pure ice if desired. The following substances are antiseptics, but in the strength given cannot be depended upon as disinfectants:- Thymol, 1:80,000. Bichloride of mercury, . . . . . 1:40,000. Oil of mustard, 1 :33,000. Acetate of alumina, 1:6310. Bromine, . . 1:5597. Picric acid, 1:5000. Iodine, 1:4000. Sulphuric acid, 1: 800-1 :3353. Permanganate of potassium, . . . . 1 :3000. Camphor, . . . . . . . . 1:2500. Eucalyptol, ........ 1:2500. Chromic acid, . . . . . . . 1 :2200. Chloride of aluminum, . . . . . . 1 :2000. Hydrochloric acid, . . . . . . 1:1700. Benzoic acid, . . . . . . . 1:1439. Quinine, ........ 1:1000. Boric acid, 1:200-1:800. Salicylic acid, ..... .1:200-1:800. Carbolic acid, ....... 1:500. Sulphate of copper, 1:400. Nitric acid, ........ 1:400. Biborate of soda, 1: 200. Sulphate of iron, 1 :200. Creasote, . . 1:200. Arsenious acid, . 1:100. Pyrogallic acid, .1:62. 'Tr. chloride of iron, . . . . . . 1 :25. Alcohol, 40 to 95 per cent. Table XXVIII. The agents mentioned in the above list may all be used with satisfactory results in surgical and obstetrical practice as antiseptics, but it must be borne in mind that the great danger in treating wounds comes from carrying infectious particles to them in the hands or instruments of the operator. In order to 358 TEXT-BOOK OF HYGIENE. render these aseptic the most thorough measures of disinfection, such as heat, strong chemical disinfectants, and physical as well as chemical and biological cleanliness are indicated. In a sur- gical wound, or in the vagina and uterus of the parturient woman, the use of antiseptics is entirely secondary to disinfec- tion, under which may primarily be understood rigid cleanliness. In public and private sanitation, antiseptics have, as in practical surgery, a subordinate importance. Deodorizers are sometimes useful in sanitary practice, but care must be taken not to look upon deodorization as equiva- lent to disinfection. Among the most useful deodorizers are chloride of zinc, chloride of lime, permanganate of potassium, and a number of the agents mentioned in Table XXVIII. [The following additional works are recommended for study in connection with this chapter:- Sternberg and Magnin, The Bacteria, 2d ed.-Fluegge, Fermente und Mikroparasiten, in von Pettenkofer und Ziemssen's Handb. d. •Hygiene, I Th., 2 Abth., 1 lift.-Wernich, Desinfectionslehre zum prak- tischen Gebrauch.-Tallin, Traite des Disinfectants etde la Disinfection. -Final Report of the Committee on Disinfectants of the American Public Health Association.-Sternberg, Disinfection and Personal Prophylaxis Lomb Prize Essay. 1886.] CHAPTER XXL Vital Statistics. The registration of vital statistics comprises the recording of the births, marriages, deaths, and diseases of a city, State, or nation. In no other way can a knowledge of the health of the inhabitants of such communities be obtained. For smaller, or special communities, such as armies, navies, schools, or special classes of workmen, the health status may be ascertained by direct methods; but for larger communities this is clearly impracticable, and the sanitarian is obliged to depend upon the census and the registration of births, marriages, and deaths. From a sanitary point of view, the most important object of a registration of vital statistics is to " give warning of the undue increase of disease or death presumed to be due to preventable causes, and also to indicate the localities in which sanitary effort is most desirable and most likely to be of use." 1 The duty of registration should devolve upon the sanitary administration. Local and State boards of health would seem to be the most appropriate media for collecting information bear- ing upon births, diseases, and deaths. It would seem also to be most appropriate to require the attending physicians to make reports of deaths and of cases of contagious diseases to the health authorities. REGISTRATION OF DEATHS. The data entered upon the record of death should com- prise the name, age, sex, color, nativity, descent, occupation, and civil condition of decedent, with date, place, and cause of death. Under the heading " Descent," the birthplace of each parent should be given. Occupation should be accurately *J. S. Billings, Registration of Vital Statistics, Am. Jour Med. Sciences, voL Ixxxv, p. 37. 359 360 TEXT-BOOK OF HYGIENE. specified. The place of death should indicate the exact locality (number of street) where it occurred. Both proximate and predisposing causes of death should be entered, and any com- plications which may have influenced the fatal termination should be noted on the record. This record should be in the possession of the local health authority before a permit for the burial of the deceased is granted. If this is not insisted upon, the report will soon be omitted and the registration become defective. REGISTRATION OF BIRTHS. The collection of data for an accurate registration of births is much more difficult than the record of deaths. Instead of requiring physicians and midwives in attendance at the confine- ment to report births, it would be more equitable and probably more effectual to compel the parents, under a penalty for failure, to record the birth of each child at the board of health. The items usually included in birth returns are: date and place of birth, sex and color of child, names of father and mother, parents' nativity and age, and father's occupation. Sometimes the residence of the mother, number of children previously borne by the same mother, whether the child is legitimate or not, and various other details are also added. It is evident that for sanitary purposes most of this information is entirely irrele- vant. It seems to the author that, for the purpose of the sani- tarian and medical statistician, the date and place of birth, sex and color of the child, and age, nativity, and occupation of both parents are sufficient. REGISTRATION OF MARRIAGES. The record of marriages is of no interest to the sanitarian. If, however, the registration could be made by a competent medical man, and the physical condition of the contracting par- ties noted, valuable deductions might be made in time, especially if the parties themselves and their offspring could be kept under VITAL STATISTICS. 361 observation for many years. This, however, is so manifestly impracticable that it barely deserves notice in this place. REGISTRATION OF DISEASES. As has been seen in Chapter XIX, a large class of diseases are communicable from one individual to another, either directly, by contact, or mediately, by infection. In large com- munities it is therefore important that the sanitary authorities should possess information of the presence and prevalence of these diseases, in order that measures may be instituted for their restriction. It is true that in most cases the registration of deaths gives but too mournful evidence of the more fatal of the diseases of this class, but destructive epidemics could probably be frequently averted if preventive measures could be enforced early. Besides, in the case of dengue and epidemic influenza, the death-rate is so small that, if the registration of deaths were alone depended upon, no evidence whatever might be attain- able of the epidemic prevalence of such diseases. The registration of prevailing diseases is, therefore, one of the most important duties of the registrar of vital statistics. Prompt notice of all cases of infectious, miasmatic, or contagious diseases coming under their professional notice should be required of all physicians. It is unquestionably just, however, that the physicians required to perform this duty should be properly com- pensated by the public, whose interests they serve. DEATH-RATE AND BIRTH-RATE. In order to calculate the annual death-rate of a place, two facts are required to be known: first, the actual or estimated population (generally obtained from the census), and, second, the number of persons who died within the district. The num- ber of deaths is then divided by the population, which gives the death-rate for each individual for the year. To find the death- rate per 1000, the death-rate as found above is multiplied by 1000. Thus, the total number of deaths in the city of Baltimore 362 TEXT-BOOK OF HYGIENE. during 1883 was 9380, and the estimated population 408,520. The death-rate for the year was 22.96 per 1000, obtained as follows:- 9380 X 1000 408,520 22-96 per M' To calculate the annual death-rate of a place for each 1000 of the population from the returns for one week, the weekly population for the place is first ascertained, and then the total number of deaths for the week divided by the weekly popula- tion, and the quotient multiplied by 1000. The following con- crete example will render this clear:- The exact number of weeks in a year is 52.17747. The total population is divided by this figure, giving the weekly population. This gives for Baltimore, assuming the above esti- mate to be correct, a weekly population of 7829. For the week ending November 1, 1884, the deaths in that city numbered 148. The annual death-rate per 1000-that is to say, the number of deaths in each 1000 of population, if the same ratio were main- tained throughout the year-is obtained as follows:- 148 X 1000 1QO = 18.9 per M per annum. Out of the above 148 deaths, 32 were from infectious dis- eases. To find the annual death-rate per 1000 of population for this class of diseases, the same calculation is made, thus:- 32 X 1000 -=3^-,- = 4.1 per M per annum. Or, if the percentage of deaths of infectious diseases be desired, the procedure would be as follows:- 32 X 100 n n 7-75- = 21.6 per cent, of the total deaths. 148 1 Sixty-four of the decedents were under 5 years of age. The death-rate for this class is found in the same manner; for example:- 64 X 1000 -7829- - 8-17 per AI per annum. Or the percentage of these to the total deaths is found as in the last example. VITAL STATISTICS. 363 If it be desired to find the rate of infant mortality, i.e., the proportion of deaths among infants under 1 year of age to the total number of births for the same period, the following formula may be used. In the record just quoted the decedents under 1 year of age numbered 37; the total number of births for the same week was 157. Hence- 37 X 1000 = 235.7 per 1000 births, 157 or nearly 1 to 4. Thirty-three of these 148 deaths were of colored persons. The death-rate of these to the total population is found in a similar manner to the above; but if it is desired to ascertain the death-rate of the colored population alone, the weekly colored population must first be obtained and the rate calculated from this by the above formula. Birth-rates are found in a similar manner. The average age at death is ascertained by adding up the ages of all the decedents, and dividing the sum by the number of deaths. It will be evident, on a little thought, that there must be many sources of error in calculations based upon such uncertain data as are derived from the registration of births and deaths as conducted in most cities in this country. Besides, the subject of vital statistics is essentially abstruse, and requires no little readi- ness in mathematics to appreciate its profounder bearings. Hence, in the foregoing chapter no attempt has been made to penetrate beyond the immediate practical aspects of the ques- tions involved. [ To those desiring fuller information upon this subject, the following works are recommended:- Curtis, Vital Statistics, in Buck's Hygiene and Public Health.- Billings, Registration of Vital Statistics, American Journal Medical Sci- ences, vol. Ixxxv.-Oldendorff, Morbilitsets and Mortalitsets-Statistik, in Realencyclopaedie d. ges. Heilk., Bd. IX.-Billings, Papers on Vital Sta- tistics, Sanitary Engineer, vol. viii, ix.-Ibid., Cartwright Lectures on Vital and Medical Statistics, 1890.] CHAPTER XXII. Quarantine. (By Walter Wyman, M.D., Surgeon United States Marine-Hospital Service.) By quarantine is meant the adoption of restrictive measures to prevent the introduction of diseases from one country or locality into another. The term itself conveys no definite idea, being derived through the Italian from the latin " quadraginta," meaning "forty" and implying forty days, the period of deten- tion imposed on vessels by the first quarantines established at Venice in 1403. The old significance of the term is entirely lost in its present application, which is quite general. Thus, besides regular maritime quarantine, mention is often made of land, railroad, cattle, shot-gun, house, and even room quaran- tines. The name of a disease or article of merchandise may be used in prefix, as in "yellow-fever quarantine," small-pox, cholera, or rag quarantine. Moreover, quarantines are described as properly beginning at the port of departure, and as quaran- tines of inspection only, the fumigation and detention being- imposed at some neighboring station. The term, therefore, is applied not only to establishments, but indifferently to persons, animals, diseases, localities, and measures. There is need of a clear understanding with regard to the term, for when, as occasionally, quarantine is ridiculed, or the assertion is made that the English disbelieve in quarantine, a wrong impression will be received, unless it is understood that only particular and obsolete forms of quarantine are meant, and not quarantine in the broad sense just mentioned. The subject admits of two natural divisions-maritime and land quarantine; but before describing them attention is called to the following table, containing a list of diseases that are ordi- narily found in official quarantine proclamations:- 365 366 TEXT-BOOK OF HYGIENE. Quarantinable Diseases.-Table XXIX. Disease. Period of Incubation, in Days. Shortest. Longest. Usual. Authority and Remarks. Plague Bristow. Undetermined. Yellow fever . . . 1 9 Da Costa, Bartholow. Cholera 2 14 2 to 4 Bartholow. Typhus fever . . . 1 21 5 to 14 Bristow. Small-pox .... 5 20 10 Da Costa. Measles 7 14 10 Da Costa. Diphtheria.... 2 10 2 to 5 Bartholow. Typhoid fever . . 7 28 21 Bartholow. Scarlet fever . . . 1 weeks. 4 to 7 Da Costa. Relapsing fever . . 5 7 6 Bartholow. Dengue 1 10 5 Bartholow. Leprosy • • • • .... Undetermined. The above list illustrates the growth of the sanitary idea and belief in quarantine. For many years, as now at some ports, the list was limited to yellow fever, typhus, cholera, and small-pox. It was thus limited at Boston prior to 1881, since which date diphtheria, scarlet fever, typhoid fever, and measles have been added. The statutes of New York define as quaran- tinable "yellow fever, measles, cholera, typhus or ship fever, small-pox, scarlatina, diphtheria, relapsing fever, and any dis- ease of a contagious, infectious, or pestilential character, which shall be considered by the health officer dangerous to the public health." At Gibraltar, the English sanitary authorities include dengue and epidemic rose-rash among the diseases subject to their quarantine regulations. The most recent addition to the list in this country is leprosy, to prevent the introduction of which, and in accord- ance with a resolution of the American Public Health Associa- tion, a prohibitory circular was issued by the Surgeon-General of the Marine-Hospital Service, December 23, 1889. Other diseases which may properly call for quarantine are mumps, whooping-cough, chicken-pox, epidemic dysentery, MARITIME QUARANTINE. 367 glanders, tetanus, beriberi, epidemic influenza, and pulmonary tuberculosis. Influenza may be considered quarantinable under certain circumstances, a successful quarantine being reported by Dr. Trudeau, whose cottage sanitarium, in the Adirondacks, New York, was thus kept exempt during the epidemic of 1890. With regard to pulmonary tuberculosis the ground is taken by the writer that this disease, at least among immigrants, should be excluded from the United States by quarantine. MARTTIME QUARANTINE. In describing a maritime quarantine it should be borne in mind that the details in the plant must vary in accordance with the special demands of each port. Thus, it is not to be expected that at Charleston, where immigration is limited, there should be the same provisions for detention of immigrants as at New York, through whose portals more than one-third of a million of immigrants pass each year; or San Francisco, where enter the throng of travelers and immigrants from the far East. We should not expect that Boston, in the more salubrious North, would have the means or adopt the practice of emptying, cleaning, and fumigating every vessel from an infected port, which process has proven to be the sine qua non of exemption to the State of Louisiana. Nor should we expect Pensacola, with a completely- equipped national refuge-station near at hand (at Chandeleur Island), to erect an expensive disinfecting-house, with modern steam disinfecting-chambers, as has been recently done for the port of Galveston by the health authorities of Texas. But, leaving these variations for subsequent notice, the first thing to be considered in the establishment of a complete maritime quarantine is proper location. This must be at a point remote from city or village boundaries, and not likely to be encroached upon by urban growth. It should be more or 368 TEXT-BOOK OF HYGIENE. less removed from the channels of commerce, and yet be easily accessible. Indifference to proper location could readily make the quarantine a source of danger instead of a protection. After proper location, the main requirements may be stated as follows:- 1. A boarding-station. This includes a boat-house with boatmen's quarters, so located as to avoid possible infection from the lazaretto and to be within easy reach of passing commerce. 2. A boarding-boat, preferably a steamer. 3. An anchorage. The anchorage is the place of detention of the infected vessel. It should be conveniently removed from the main establishment and safely remote from the track of commerce. Its position should be sheltered, and good holding- ground for vessels' anchors is of the first importance. The channel to the anchorage, and, if necessary, its boundaries, should be plainly marked by buoys. 4. A fumigation steamer, to be described under " Quaran- tine Contrivances." 5. A wharf. The wharf should be in water of at least 20 feet depth, and there should be constructed upon it a ware- house, tanks for holding disinfecting-solutions, and a disinfection- house containing steam disinfecting-chambers. 6. A lazaretto or hospital for treatment of contagious diseases. 7. A hospital for treatment of non-contagious diseases. 8. Barracks for the detention in groups of " suspects," or persons who have been exposed to contagion or infection. 9. Quarters for medical officers. 10. A cremation-furnace. No better understanding of the subject can be had than by a brief survey of the several varieties of maritime quarantines that are now maintained on the coasts of the United States. First should be mentioned the national quarantine stations, eight in number, established at points of danger where either local quarantine is defective, or where, by reason of peculiar advan- 369 MARITIME QUARANTINE. tage in location, protection is afforded to several States by one station. These stations are as follow:- Delaware Breakwater Quarantine Station, Lewes, Del.; Cape Charles Quarantine Station, Fisherman's Island, Va.; South Atlantic Quarantine Station, Blackbeard Island, Sapelo Sound, Georgia; Key West Quarantine Station, Tortugas Islands, Fla.; Gulf Quarantine Station, Chandeleur Island, Miss.; San Diego Quarantine Station, San Diego, California; San Francisco Quarantine Station, Angel Island, San Francisco Bay, California; and Port Townsend Quarantine Station, Port Townsend, Washington. Most of these stations will be complete in plant and equip- ment within a short time, but pending completion active quaran- tine is maintained the whole year through at all of them, San Francisco excepted,-there being a local quarantine at this port. The estimated cost of the national quarantine station at Angel Island, San Francisco Bay, is $175,000, exclusive of the site, which was in previous possession of the government. Surgeon-General Hamilton, in a recent report, says:- "It is evident that a few complete stations of this kind will take the place of the many municipal quarantines. The latter will become, eventually, simply boarding-stations, and vessels requiring treatment will be sent to the nearest govern- ment quarantine station." No fees are exacted at the national stations. Many of the local quarantine establishments, while entirely effective for ordinary quarantine, the occasional detection and care of a few contagious cases, would prove insufficient and become, in fact, more dangerous than beneficial in the presence of a heavy inroad of an epidemic disease, such as the appearance of a ship with a thousand emigrants aboard, having a history of many deaths at sea from cholera, and cholera still prevailing among them. Deficiencies in the plant and the want of modern appli- ances and proper accommodations would create embarrassment, while the location, once remote from populous centres, but now 370 TEXT-BOOK OF HYGIENE. no longer isolated, would at once be recognized as hazarding the safety of the neighboring population. It is in recognition of these facts that the health authorities of the various States and cities interested have contributed their influence to the establishment of the national quarantines, using them as refuge-stations. Among the State and local quarantines, variety of type is presented by those of Boston, New York, Louisiana, Galveston, Philadelphia, Baltimore, and Charleston. The first four of these are complete in themselves, and independent of extraneous aid. The others make use of the national stations, particularly for the anchorage and cleansing of foul ships. The city of Charleston, for example, has a complete plant of approved modern design for the disinfection by steam of clothing, baggage, and bedding, but use is made of the neighboring national station at Blackbeard Island for the treatment of the infected vessel. To complete this description of maritime quarantines it only remains to mention the special characteristics of the State quarantine establishments of New York and Louisiana. THE NEW YORK QUARANTINE. This consists of- 1. A ship, or hull, anchored in the lower bay,-the bay farthest from the city. The hull is anchored about 4 miles inside of Sandy Hook, and about 11 miles from New York. This is the boarding-station from May until November, vessels being visited by means of a row-boat. 2. Swinburne Island,-called also Dix Island,-located two or three miles from the boarding-station, nearer to New York, with an area of two or three acres, on which are erected the hospitals for the treatment of the sick, and also a cremation- furnace. 3. Hoffman Island,-like the former, an artificial island,- still nearer to New York by about one mile, on which are build- ings for the accommodation of two thousand immigrants, with THE LOUISIANA QUARANTINE. 371 interior arrangements for their division into groups, while await- ing the development of any contagious or infectious disease among them. A steam disinfecting-apparatus for the dry or moist heat disinfection of baggage, clothing, etc., has been established upon this island. 4. Residence of the health officer, on the "Narrows," near Clifton, Staten Island, 6 miles from New York. 5. The Anchorage, where infected vessels are treated. This is also in the lower bay, which is of so great area that a safe location of the vessel is easily effected. THE LOUISIANA QUARANTINE. To the Louisiana State Board of Health and its successive presidents, Hrs. C. B. White, Samuel Choppin, Joseph Jones, Joseph Holt, and C. P. Wilkinson, is due the credit both of combating the pernicious theory of non-quarantine and of per- fecting a system of quarantine that is recognized as the most extensive and efficient ever devised, and from which a number of others have been modeled. Though utilizing the devices of others, notably that of Quarantine Officer Dr. Perry, for gener- ating and forcing into vessels' holds sulphur dioxide, and though his plant has been improved by his successor, neverthe- less the credit of this new and thorough system is justly given to Dr. Joseph Holt, President of the Board of Health from 1884 to 1888, to whose determined energy and genius sanitary and commercial interests are equally indebted. The improved quarantine consists of, first- The Mississippi River Quarantine Station. This is located about 90 miles below New Orleans and 4 miles above the " Head of the Passes," or point where the river divides into its three main outlets. The plant consists of five buildings exclusive of out-houses, viz., a disin fecting-shed and boiler-room, quarters and mess-hall for the disinfecting-crew, boat-house and boatmen's quarters, and two residences for the quarantine officer and his assistant. 372 TEXT-BOOK OF HYGIENE. The disinfecting-shed immediately adjoins a wharf built in water of sufficient depth to allow the largest vessels to be moored alongside. The following description is from the report of Dr. C. P. Wilkinson, President of the Louisiana State Board of Health:- The disinfecting apparatus consists of three cylindrical steel cham- bers and appurtenances, each cylinder being 50 feet long and 8 feet in diameter. The ends are spherical, and that facing the river or front end is movable, swinging open by means of a crane. At a point 50 feet in front of each cylinder commences a double, iron, elevated track, which, by a movable section, continues into and throughout the length of each cylinder. On this track rolls a truck 48 feet in length, and from this truck are suspended thirty clothes-racks of 5 bars each. The interior of each cylinder contains an arrangement for the employment of moist and dry heat, separately and together. The necessary heat is supplied by a 40-horse-power steam-boiler at 85 to 100 pounds' pressure. Surmounting the shed is a cypress cistern, the bottom of which is 41 feet above the river-surface, capable of holding 7000 gallons of fluid. In this cistern is stored a solution of mercuric chloride, 1 part to 1000 of water by weight. Pipes lead from this cistern to the outer edge of the wharf, and at that point have rubber-hose attachments of sufficient length to lead to all parts of a very large vessel, and the hoses terminate in hard-rubber roses of 6-inch face. The fumigating apparatus, heretofore on a tug, but now proposed to be erected on rail-cars on the wharf, consists of a reverberatory sul- phur-furnace, with 250 feet of gal van i zed-iron conductors, 12 inches in diameter, and a steam fan. The furnace, 24 inches wide, 48 high, and 40 deep, is provided with four cast-iron pans, 30 inches long, 23 wide, and 4 deep, each pan having over 1| cubic feet capacity, or about 175 pounds of sulphur. The pans are set on split brick, and are so placed that the current of air driven by the fan into the bottom passes over each pan of burning sulphur alternately, out through the top and along the conduc- tors down into the holds of vessels. The process of disinfection of vessels consists in placing all baggage, bedding, curtains, carpets, linen, etc.,-in fact, all textile fabrics of vessel, crew, and passengers,-on the suspended clothes-racks, which are then drawn into the cylinders by a windlass, and applying dry heat until the thermometers mark 185° F. (85° C.), at which point moist heat is turned on, the temperature rapidly rises to 215° to 220° F. (102° to 105° C.),and 373 THE LOUISIANA QUARANTINE. the gauges usually record a pressure of 7 pounds to the square inch, at which point the blow-off valves open, preventing any danger of explosion. The contents of the chambers are kept at this temperature and pressure for thirty minutes, the cylinders are then opened, and the goods turned over to their owners. The vessel in the meantime is washed down-cabins, forecastles, decks, and holds-with the mercuric-chloride solution, and fumigated by means of the furnace and fan. In the case of loaded vessels, washing the interior is omitted, on account of danger to cargo. The holds are, however, thoroughly fumigated, and, by a special arrangement of " cargo wells," the gas penetrates every interspace of cargo. These wells are constructed at port of departure, and consist of a long wooden box about two feet across, and reach from the bottom to top of holds, the cargo being stowed around them at loading-point. The conductor from the sulphur-furnace is led into the well, the hatches are tightly closed, and, under pressure, the fumes of sulphur are driven into the vessel, the gas passing around every package envelope, no matter how tightly packed, and chemical examination showed that in the case of sugar-bags it pene- trated to the depth of three-fourths of an inch. The character of cargoes arriving here from infected ports is almost exclusively coffee and sugar, the former always, and the latter nearly always, in bags, neither offering obstacles to good and sufficient fumigation in situ. When necessary, the cargo is shifted to lighters for more thorough disinfection. Passengers are required to don their disinfected wearing-apparel to permit disinfection of that they may be wearing on arrival. Most all of the quarantine work is accomplished at this Mississippi River Station. The second or Lower Quarantine Station is situated in Pass a L'Outre, an unused outlet of the Mississippi, a few miles below the Head of the Passes. At this station is the lazaretto, or hospital for infectious diseases, and it is the anchorage also for infected vessels. Other stations are the Advance Guard Inspection Station at Port Eads, 110 miles below New Orleans, where the waters of South Pass are jettied into the Gulf, and the Rigolets and Atchafalaya Stations. The two latter control the two lateral approaches to New Orleans, and, as the shipping coming through these two channels is light in tonnage and mostly from domestic 374 TEXT-BOOK OF HYGIENE. ports, by imposing a quarantine of forty days' detention the two approaches are practically closed, compelling all vessels to seek the Mississippi as the only available route to New Orleans. The following description is for the most part verbatim, from the pen of Dr. Joseph Holt (see "Transactions of the American Public Health Association," 1887, vol. xiii):- When an inward-bound vessel comes into the offing, she is imme- diately boarded by a thoroughly skilled medical officer, and a careful in- spection is made of her sanitary record and present condition. If from a non-quarantined port, and all is well, she is given pratique and goes on to the city. If from a quarantined port, but presenting a clean health- record of voyage and no evidence of sickness of a dangerous or doubtful character, she-proceeds to the Mississippi River Quarantine Station, where she is subjected to a full course of sanitary treatment, and is de- tained such length of time, not exceeding five days (except in rare in- stances wherein further observation may be deemed necessary), as the Board of Health may provide. If, upon inspection of a vessel entering the river she is found to be foul,-that is, showing positive or suspicious evidence of infection either in a person then ill or in a foul health-record of voyage,-she is at once remanded to the lower station in Pass a L'Outre. The sick, if any, are at once removed to the hospital, where every provision has been made. The vessel with the well on board is dropped dow'n-stream a few hundred yards and anchored. The quarantine tug-boat, with its complete dis- infecting outfit, comes alongside, and the work of disinfection begins, and does not cease until the vessel has been subjected to the most vigor- ous application of the solution of bichloride of mercury, her atmosphere below deck completely replaced with one heavily charged with sulphurous oxide, and every article of baggage and ship's wardrobe has been satu- rated with the mercuric solution. A ship known to be infected with one of the three great pestilential diseases-small-pox, cholera, or yellow fever-can stand and must endure extraordinary treatment, even if clothing is wetted and some articles damaged. The immediate segregation of the sick and the well and disinfection of the ship and all baggage (in the case of a cholera-infected vessel, extended to the disinfectant washing out and refilling of the water-tanks, destruction of the food-supply, and revictualing the vessel) constitute the treatment of an infected vessel at this station. The ship, together with all on board, is held for observation a period of ten days or more, THE LOUISIANA QUARANTINE. 375 according to circumstances, when she is released and proceeds to the Mississippi River Station, where the processes of sanitary treatment are repeated, with the addition of the use of moist heat applied to baggage, ship's apparel, etc.; and the vessel is then allowed to proceed to the city. The tug-boat mentioned is of sufficient power to move a vessel to or from the wharf, and is equipped with a complete outfit for generating and applying germicidal gas for the displacement of the entire atmos- phere within the ship, transported, perhaps, directly from some infected port. In the hold of this tug is constructed a wooden tank of 2000 gallons capacity, to hold the bichloride-of-mercury solution, for treatment of vessels in the lower quarantine. This tank is furnished with a steam- pump made of iron (on account of the greater resistance of that metal to amalgamation), supplied with a f-inch rubber hose. The quarantine procedure at the Louisiana quarantine stations may be further understood through the following quar- antine proclamation by the Governor of the State, May 1, 1890:- Executive Department, State of Louisiana. In conformity with the provisions of Section 3049 of the Revised Statutes of the State, and upon the advice of the State Board of Health, requesting the Governor to issue his annual proclamation of quarantine against the hereinafter enumerated and mentioned ports, to take effect from and after the 1st day of May, A.D. 1890, to wit:- All vessels arriving at the several quarantine stations in this State, together with their crews, cargoes, and passengers, shall be subjected to inspection by the quarantine officers at said stations. All vessels, together with their cargoes, crews, passengers, and baggage arriving at the Mississippi River Quarantine Station from inter- tropical American and West Indian ports shall be subjected to thorough maritime sanitation according to the following schedule, to wit:- First Class.-Vessels arriving from non-infected ports. Second Class.-Vessels arriving from suspected ports. Third Class.-Vessels arriving from ports known to be infected. Fourth Class.-Vessels which, without regard to port of departure, are infected; that is to say, vessels which have yellow fever, cholera, or other contagious or infectious disease on board at time of arrival, or have had same on voyage. Vessels of the first class to be subjected to necessary maritime sanitation at the Mississippi River Quarantine Station, without detention 376 TEXT-BOOK OF HYGIENE. of either vessel or persons longer than may be necessary to place such vessel in perfect sanitary condition. Vessels engaged in the tropical-fruit trade and coming from known non-infected localities, and whose sanitary condition and health-record are satisfactory, may be allowed to pass the quarantine station after inspection, subject, however, to such regulations and sanitary treatment as the Board of Health may prescribe. Vessels of the second and third classes to undergo the same con- ditions as those of the first class, together with detention for observation for a period of five full days from hour of arrival in quarantine. Vessels of the fourth class to be remanded to the Lower Quarantine Station, there to undergo sanitation and detention of vessel and persons such length of time as the Board of Health may determine. All vessels arriving from ports known or suspected to be infected with cholera or small-pox, or which may hereafter become infected, shall be subjected to maritime sanitation and such detention as the Board of Health may determine. Vessels arriving from the above-named ports and places, and be- longing to the second, third, and fourth classes, as is set forth in the above schedule, shall not be allowed to pass the Rigolets, the Atchafalaya, or Lake Charles Quarantine Stations, or other State quarantine stations which may hereafter be established, without having undergone a period of detention of forty days and thorough cleaning and disinfection. Now, therefore, I, Francis T. Nicholls, Governor of the State of Louisiana, have thought proper to issue this, my annual proclamation of quarantine, directing that quarantine shall take effect from and after Thursday, the 1st day of May, A.D. 1890, against the above-mentioned ports, and as contained in the foregoing schedule. Quarantine officers at the several stations in this State are especially charged and required to strictly enforce the execution of this proclama- tion, and the Board of Health in the city of New Orleans is requested to prosecute vigorously all violations of the same, as well as the quarantine laws and regulations of this State. In testimony whereof I have hereunto affixed my signature, authen- ticated with the seal of the State of Louisiana, at the city of Baton Rouge, this eighteenth day of April, in the year of our Lord one thou- sand eight hundred and ninety. Francis T. Nicholls, Governor of Louisiana. By the Governor: Geo. Spencer, Assistant Secretary of State. QUARANTINE CONTRIVANCES. 377 Special Suggestions to Owners, Agents, Masters of Vessels, and Passengers. The Louisiana State Board of Health recommends the following suggestions to agents, owners, masters of vessels, and passengers for the purpose of facilitating the work of quarantine officers and reducing the period of detention to a minimum :- 1. That vessels should be stripped during the quarantine season of all woolen hangings, carpets, curtains, and such-like materials, and upholstered furniture as far as practicable. Hair or moss mattresses to be replaced by wire or wicker beds. 2. That as far as possible vessels trading with tropical ports should be manned with acclimated crews. 3. Masters of vessels and ship and consular agents are earnestly requested to instruct passengers from quarantinable ports to dispense, as far as possible, with baggage which may be injured by wetting, in case of pestilential outbreak on board, while undergoing disinfection. Such passengers are especially warned against bringing silks, laces, velvets, and other fabrics of delicate texture, as they will be compelled to assume all risks of injury. 4. While in ports infected with yellow fever, vessels should be anchored out in the harbor, when this is possible, and the crew prohibited from going ashore, especially at night. 5. When practicable, cargoes should be loaded in such a manner as to allow access to the pumps, and also to enable the quarantine officials to pump out and wash the bilge. 6. Special attention should be given to cleanliness of vessels and persons, and provision should be made for all possible ventilation of the entire vessel. The best disinfectants and instructions for using the same can be obtained by application to the Board of Health or any of its officers. 7. Masters should, before arrival, see that the bilge is thoroughly pumped out and cleansed, and that the entire vessel be put in such good sanitary condition as to permit of the least possible detention. Fruit vessels, particularly, should be kept thoroughly cleansed for the purpose of avoiding delay at the quarantine station. 8. Vessels observing the above recommendations will receive special consideration at the quarantine station, detention and cost of cleaning, disinfecting, etc., being materially lessened thereby. QUARANTINE CONTRIVANCES. Of modern contrivances first should be mentioned the disinfection steamer. This must be a powerful boat on the 378 TEXT-BOOK OF HYGIENE. general plan of a tug-boat, about 85 feet in length on the water-line, provided with iron tanks of at least 2000 gallons' capacity for holding the solution of bichloride of mercury, to which may be attached a steam-pump and rubber-outlet hose. To prevent contact of the mercury with the iron the tanks may be painted with three coats of red lead and two of paraffine paint (Holt). The steamer is also provided with a steam-fan, by means of which fresh air may be made to displace foul air in the hold of the vessel under treatment. A sulphur-furnace is also provided for the generation of sulphur dioxide, which is conveyed into the hold of the adjoining ship after displacement of the foul air. The improved pattern of sulphur-furnace is the design of Assistant-Surgeon Kinyoun, Marine-Hospital Service, who states that it is on the principle of a reverberatory furnace, con- sisting of a series of shelves arranged one above another, each shelf holding a pan of burning sulphur. A forced draught is kept up by means of a fan-blower connected at the bottom. The draught of air charged from the burning sulphur of each shelf is made to reach and pass over the shelf above by means of apertures made by shortening the shelves alternately at their rear and front extremities. With an experimental furnace Dr. Kinyoun states that "repeated experiments gave from 14 to 16 per cent, of SO2, temperature 21° C., while burning sulphur in a closed place gave only 6 per cent, at 21° C., i.e., it would not support the combustion of sulphur above that percentage.1 The furnace belonging to the fumigation vessel of the Louisiana Board of Health is of a special pattern. Dr. Salomon, secretary of the board, states that for each vessel 200 to 800 pounds of sulphur will be used, according to the size of the vessel, and the fumes will be allowed to remain in the hold, with hatches sealed, twenty-four to thirty-six hours, or longer.2 1 See Abstracts of Sanitary Reports, Marine-Hospital Service, vol. iii, pages 347 and 348. 9 See Transactions of the American Public Health Association, vol. xiii, for Dr. Holt's description of his system, and vol. xiv, page 113, for Dr. Salomon's reports and improvements thereon. STEAM DISINFECTING-CHAMBERS. 379 The amount of sulphur used at the New York Quarantine by the pot method (pots of burning sulphur lowered into the hold) is 50 to 100 pounds, according to the vessel's size).1 At Pensacola about 12 pounds of sulphur are used to every 100 tons' register, and the fumigation lasts twelve hours. At the Delaware Breakwater 4 pounds are used to each 1000 cubic feet of space, and the fumes are kept twenty-four hours in the vessel's hold. At Chandeleur, 35 pounds in hold to 100 tons. STEAM DISINFECTING-CHAMBERS. The principle of disinfection by steam was first advocated by Dr. A. N. Bell, of Brooklyn, but the contrivance about to be described was first used by Dr. Joseph Holt, and improved by Dr. Wilkinson and others. These chambers, two or three at one station, consist of jacketed, cylindrical shells, made of strong boiler-iron, each shell being 40 or 50 feet long and 7 or 8 feet in diameter, inside measurement, furnished with doors at each end.2 The jacketing is for the purpose of using the chambers with either dry heat or with superheated steam. Articles of clothing, bedding, etc., are arranged on trucks, which are run into the chamber at one end and taken out at the other. A bacteriological test made by Dr. Kinyoun at the Louisiana Quarantine Station showed that all germs were killed after exposure to a dry heat of 79.4° C., obtained in sixteen minutes, steam then being turned on for twenty minutes.3 Another and simple contrivance for fumigating is the " Liquid Sulphurous Dioxide," the compressed gas furnished in metal reservoirs, which, being opened, the gas rapidly escapes. By this means any proportion of SO2 can be introduced in a vessel without any apparatus. It is manufactured in Hagenau and in Oberhausen, Germany, and may be purchased in New 'See Report by Dr. John H. Rauch upon an Inspection of the Atlantic and Gulf Quar- antines, State Printer, Springfield, Ill., 1886. 2 See description under " Louisiana Quarantine." 3 For plans and specifications, see Annual Report Marine-Hospital Service for 1889, and Abstract of Sanitary Reports, vol. iv, page 443. For Dr. Kinyoun's experiments, see Abstract Sanitary Reports, vol. iii, pages 117 to 147. 380 TEXT-BOOK OF HYGIENE. York, and of Finlay & Brunswig, wholesale druggists, New Orleans, at a cost of five cents per pound when not less than one ton is taken. It has been suggested that this may take the place of the sulphur-furnace and appliances on the steamer. The cost by this method is thought to be but little, if at all, greater than by the furnace method, if the interest on the plant is added to the latter. This method has been occasionally used at the Grosse Isle Quarantine, in Canada, but to establish its complete practicability will require further test. ADMINISTRATION OF MARITIME QUARANTINE. The following are the rules and regulations of- 1. The National Quarantine Stations. 2. State Quarantine Service of Texas. 3. The Local Quarantine at Pensacola, Florida. In these three types will be found all the ordinary admin- istrative regulations, which are, however, subject to minor changes yearly. 1. Regulations for the National Quarantine Stations. (From the Regulations of the Marine-Hospital Service, 1889.) 328. At ports where quarantine may be established by special statute or by the Secretary of the Treasury, every vessel, before being permitted to enter, shall present to the Collector of Customs satisfactory evidence either that said vessel had not, at any time during a period of thirty days immediately preceding its arrival, touched at or communicated with any foreign port where cholera or yellow fever exists, or small-pox was known to exist in an epidemic form ; that there had not been at any time during that period any case of contagious disease on board ; and that said vessel does not convey any person or persons, merchandise, or animals affected with any infectious or contagious disease, or that the said vessel has been thoroughly cleaned and disinfected by the quarantine officer, and is free from infection at the time of entry. The certificate to that effect, of the medical officer of the Marine-Hospital Service, acting as quarantine officer for the United States at the port, shall be accepted by the Collector of Customs as satisfactory evidence, and the medical officer shall, before granting such certificate, satisfy himself that the matters and things therein stated are true. 329. Vessels coming from a foreign port or country where cholera ADMINISTRATION OF MARITIME QUARANTINE. 381 or yellow fever exists, or small-pox is known to have existed in an epi- demic form within thirty days preceding their arrival, and vessels or vehicles conveying any person or persons, merchandise, or animals affected with any contagious disease, or having had on board at any time during the thirty days preceding their arrival any case of contagious disease, shall not enter any port of the United States until such disin- fection or other precautionary measures shall have been performed as prescribed by these regulations, and the certificate of the medical officer of the Marine-Hospital Service, or other designated agent of the Treasury Department, shall, in such cases, as in the cases referred to in the pre- ceding paragraph, be accepted by the Collector of Customs as satisfactory evidence of compliance with the regulations. 330. Quarantine stations will be governed by the general regulations of the Service, so far as applicable. 331. No pilot or other person will be allowed to leave a vessel until the vessel shall have been inspected by the quarantine officer, and any person violating this regulation shall be reported to the nearest United States attorney for prosecution under the act of August, 1888, and no person will be allowed to leave the quarantine reservation, or a vessel placed in quarantine, without permission of the quarantine officer. 332. Quarantine officers are hereby empowered and authorized to cause the temporary arrest of any person violating the quarantine regu- lations, and turn them over to the custody of the nearest United States marshal, and notify the United States attorney to that effect ; or, if that be impracticable, to confine them on the quarantine reservation, subject to the orders of the said marshal or attorney. 333. When a vessel arrives at a United States quarantine boarding- station, the inspecting officer will examine the papers of the vessel to inform himself of her passengers and cargo; he will require all persons named on the passenger-list and crew-list to present themselves and answer to their names at muster. Should any person have died on the voyage, the circumstances of the death will be inquired into, and, in case of there being any person sick, such person will be carefully examined by the inspecting officer, the only exception being, in case of naval vessels, the statement of the senior surgeon or medical officer as to the sanitary condition of the vessel will be accepted. 334. When persons are found sick of cholera, small-pox, yellow fever, plague, or diphtheria, they shall be immediately removed to the quarantine hospital, and the vessel be thoroughly disinfected. 335. In order to stimulate ship-masters to aid in securing a clean ocean-going fleet, the following regulations concerning the treatment of foul ships will be observed at all national quarantine stations:- 382 TEXT-BOOK OF HYGIENE. When a vessel arrives at any national quarantine station from an infected port, and requires disinfection, she will be subjected to ordinary disinfection, as provided in former regulations. When any vessel shall arrive at a national quarantine station in such foul condition as to render her dangerous from a sanitary point of view, and is found to require cleansing and disinfection, having at any former time within one year been subjected to ordinary disinfection, such vessel will be required to undergo extraordinary disinfection, which, in addition to the ordinary measures, will include holy-stoning, scraping, the taking out of rotten wood, a second disinfection, and interior repainting, all of which will be required before granting a certificate of free pratique. 336. The recognized method of disinfection of vessels will be, for all vessels: a, by bichloride of mercury; b, by sulphurous oxide; c, by flushing with sea-water. 337. For disinfection of clothing and other fomites, dry heat will be used whenever practicable, and when it is not practicable to use dry heat the sulphurous-oxide fumigation will be used. 338. The Supervising Surgeon-General will from time to time issue detailed instructions for the practice of disinfection, under these regula- tions, which instructions will include such improvements as may be suggested by the advance of science. 2. Quarantine Regulations, State of Texas. General Rules. No. 1. After the declaration of quarantine by the Governor, every vessel, before entering any port on the coast of Texas, shall be boarded by quarantine officers, and the crew and passengers be subjected to such questions by said officers as will be necessary to determine their probable connection with epidemic influence or infectious diseases. No. 2. Vessels hailing from infected districts, or having communi- cated with others from such districts, by contact or otherwise, shall be placed in quarantine, casting anchor at such place or places as may be designated by quarantine officer of port, and a complete list of both crew and passengers taken. Notice in writing shall be given captains, holding them responsible for strict non-communication of both passengers and crew with other vessels or with any one from shore. Violation of this rule shall be punished by fine against vessel and captain, not less than $500 or more than $1000. No. 3. From the masts of all vessels in quarantine shall be displayed a yellow flag, of such dimensions as to warn off others approaching. No. 4. All vessels held in quarantine shall be under the direction of port quarantine officer, and put in thorough sanitary condition by fumi- gation of hold, washing decks with disinfecting fluids, and purifying bilges, etc. ADMINISTRATION OF MARITIME QUARANTINE. 383 No. 5. Costs of fumigation, disinfection, etc., shall be at expense of vessels. No. 6. A complete muster of crew and passengers must again be taken before vessels are given free pratique, and a concise report made to State health officer. No vessel shall be finally released without per- mission of State health officer. No. 7. Families of quarantine officers will not be allowed at stations without special permission from State health officer during the existence of quarantine. Pilots. Pilots will not be allowed to visit, or board, or communicate with any vessels without permission of port quarantine officer, under penalty of forfeit of their commissions as such. Market Vessels. Market vessels-meaning those which belong at the port, and which furnish daily supplies to vessels at anchor or in quarantine-shall, in every instance, apply to quarantine officer for permission before attempt- ing to trade or communicate with such vessels; and in case of violation of this rule shall themselves be placed in quarantine and held at discre- tion of officer in charge. Vessels with Cargo to be Disinfected. Any vessels from infected districts which may desire to enter such cargo shall, upon arrival at outer bar, make known their intention to quarantine officer. Quarantine officers receiving this cargo at quarantine warehouse shall employ, as far as possible, only acclimatized men, and said employes shall be kept under quarantine themselves a sufficient number of days to determine their probable infection, their clothing and other articles capable of conveying infection be subjected to a high tem- perature, say 220° F. (105° C.), before being allowed to return to cities or shore. The crews of said vessels shall be subject to rules as above, and such other precautions as may be deemed requisite at the time by State health officer. Costs in this instance, as in others, are chargeable to owners of cargoes. 3. Quarantine Regulations at Pensacola, Florida. (Issued by the Escambia County Board of Health.) 1. The port inspector shall visit and inspect every vessel entering the bay of Pensacola, and ascertain and report her sanitary condition; and until such inspection and report, and the release of such vessel by said officer, no person shall visit her, and no person from her shall visit 384 TEXT-BOOK OF HYGIENE. any other vessel or the shore. The master or owner of each vessel so inspected shall pay to this Board for such services $5. 2. No vessel coming into the port of Pensacola, having on board any contagious or infectious disease, or from a port where any such dis- ease prevails, shall remain within the territory under the jurisdiction of this Board, except at a point designated and under restrictions imposed by this Board, according to the exigencies of each case. 3. It shall be the duty of any person coming into the county of Escambia or port of Pensacola, from any locality where any disease in an epidemic form prevails, to report at once to this Board or some officer thereof, and no person coming from any such locality shall remain in said county without the permit of this Board, and then only at such point as may be designated, and under such restrictions as may be imposed by this Board, according to the exigencies of each case. 4. No ballast brought into the bay of Pensacola by vessels shall be discharged in the county of Escambia, or the waters separating that county and the county of Santa Rosa, except at such point as may be designated in a permit obtained from this Board or granted on its authority ; and in case this Board or its sanitary inspector or other officer, with approval of this Board, deem it expedient for the preserva- tion of the public health to require fumigation, disinfection, or discharge of ballast at quarantine station, the same shall be done at the expense of the vessel, and in accordance with the system in use by this Board. 5. All pilots and tow-boats of the port of Pensacola shall be sup- plied with copies of these rules, and every pilot or tow-boat master speak- ing or boarding a vessel coming into said port shall hand a copy thereof to the master of said vessel. 6. In case any vessel shall be required, by authority of this Board in the exercise of its powers to preserve the public health, to discharge ballast at quarantine station or be fumigated, she shall pay 25 cents per ton for the ballast discharged, and for the fumigation shall pay as follows : Steam-ships, $75 ; ships, $50; barks and other vessels other than brigs and two-masted schooners, $40 ; brigs, $20 ; two-masted schooners, $15. 7. No pilot, tow-boatman, or other person shall remove, transfer, or receive, or assist in removing, transferring, or receiving any person from any vessel entering the bay of Pensacola until such vessel shall have been inspected and released by the port inspector. QUARANTINE PRACTICE. The practical duties of administration, particularly the inspection and treatment of vessels, are well described by the 385 QUARANTINE PRACTICE. medical officers in command of the several stations named in the following letters:- Gulf Quarantine Station, Chandeleur Island, Miss. (Letter from P. A. Surgeon H. R. Carter, U. S. M.-H. S.) I board the incoming vessel while under way and give her such a berth as in my judgment is suitable. When she is at anchor I first examine her papers, bills of health, crew-list, and log; questioning the master at the same time on such points as may bear on the sanitary condition of his vessel; and, except in the case of Dr. Burgess's papers, given at Havana, far more valuable infor- mation will be given by, or may be extracted from, the master than is conveyed by the bills of health. The master is asked how long he lay at the port of clearance, especially where he discharged and where he lay; there being, for instance, as much difference in the liability to infection between different wharves in Havana, or between the Gamboa and the Coal Islands in Rio, as between different ports. I especially ask for the cause of discharge of men left (generally in hospital) at the port of clearance, and mark the substitutes shipped there for special examination. These men having probably been ashore for some time and quite frequently just out of hospital, where they were left by other vessels, are occasionally the means of introducing yellow fever aboard a vessel healthy until they are shipped. The statements of the master and even the log (except in British vessels) are naturally to be taken with some " personal correction " dependent on circumstances, and which has wide limits. In general, I think intentional false statements are extremely rare, but statements of damaging facts may not readily be volunteered. The vessel is then inspected. I go all over it, into every place, noting especially the sleeping-places and bedding, water-closets, character of ballast, and condition of the hold and forecastle, as regards cleanliness, ventilation, and dryness ; whether the air streaks are open ; if the ports have been open recently, or the wind-sails show signs of recent use. In the hold, aft and forward are most apt to be dirty. If the ballast has been recently trimmed and the crew is healthy it is a good sign; on the other hand, it may account for a sudden outbreak of fever after she puts to sea, in a ship previously healthy. The bilge is examined by pumping, if in ballast; by lifting a timber- plank if not; and on the smell more stress is laid than on the color. I inspect the ship before I do the crew, so that I may see the crew when they are not aware they are under observation. I then inspect the crew. All stand together, and as I call the roll each man answers, 386 TEXT-BOOK OF HYGIENE. comes to me, and passes to another place. Any I wish to examine more closely are told to step aside. These would in general be : Those who look sick, or as if they had been sick; those who by the log or master's statement had been sick; those who had shipped at port of clearance. They are examined as may be deemed necessary. In these cases little dependence can be placed on the accounts sailors give of their past ail- ments, and a kind of inverse malingering is universal. For instance, the cabin-boy of the " Maria," with yellow fever, was standing up, although holding by a chair, and reported himself as perfectly wrell and " could eat much," then staggered and had fallen had I not caught him in my arms, vomiting as he fell. We have no cargoes, save occasionally a schooner with fustic, log- wood, or sisal. The baggage is examined when unpacked for disinfection. If the vessel is infected and has sick men aboard, I attend to the sick first, and remove them if possible. Right here I may say that in some stages of yellow fever removal is not possible with safety to the patient-it means death to him. In this event, he should be isolated on board ship, having already had the disease two or three days, and thereby having already exposed the vessel. As soon as possible, however, he should be removed. A preliminary fumigation and disinfection is done immediately before doing anything else, in the hope of destroying the contagium at its source, and preventing the sickness of others of the crew. This is done as thoroughly as possible without removing ballast or much prelimi- nary mechanical cleaning, but particular attention being given to the probable source of infection. The vessel is then treated in the routine manner, as follows :- The bilge is first pumped out and washed until clean, after which the disinfectant is put in,-generally bichloride of mercury. At Chande- leur we have practically no cargoes to deal with. The ballast therefore is next removed. All sand, earth, porous stone, or other foul ballast is removed-thrown overboard. The work is done by the ship's crew. Clean, sharp stone-as much as may be necessary to hold the vessel, i.e., prevent her capsizing-may be allowed to remain, each stone having been immersed in a 1 to 800 solution of bichloride of mercury. This is done by the crew while trimming ballast,-a necessary procedure, irre- spective of disinfection. The hold is washed down with sea-water by means of a force-pump, birch and whalebone brooms being also used, and, if necessary, scrapers. The same is done to the forecastle and other parts, if necessary. The vessel being mechanically clean in its accessible portions, the QUARANTINE PRACTICE. 387 disinfection is begun. All soiled or used clothing, and all bedding that can be so treated without destruction, is soaked for half an hour in bichloride solution. The remainder is hung up loosely for fumigation. Not unfrequently there are articles-cotton-stuff comforts, etc.-which cannot be disinfected, and are, therefore, destroyed. All articles not capable of conveying infection, as chronometers and articles made from the precious metals, are removed. The cabin, forecastle, and hold are then fumigated. For close vessels the amount of sulphur used in the hold is 35 pounds per 100 tons. The cabin and forecastle are kept closed twenty-four hours, the hold from forty-eight to seventy-two hours. In an ordinarily tight ship it is impossible to enter the hold, even after seventy-two hours, until the fumes have been displaced by air from wind- sail and open ports. When the doors are opened all surfaces are washed with a solution of bichloride, either with hose and brooms or with mops. Gilt-work, being utterly destroyed by this agent, is washed with water as near boiling as it can be used. The quarantine detention of the vessel now begins. The proper time in quarantine is not less than the period of incubation. The number of days of passage from foreign ports counts for nothing, as does also the time on the quarantine grounds previous to completion of dis- infection. In estimating the probability of a vessel being infected, it makes quite a difference whether the yellow fever she has had in passage devel- oped at such time that it could have been contracted elsewhere than on board ship, or so long after clearing as of necessity to have been com- municated by the ship or fomites aboard her. In the latter case she was infected. This has a direct bearing on her treatment. South Atlantic Quarantine Station, Blackbeard Island, Ga. (Description of Quarantine Methods, by Passed-Assistant-Surgeon J. H. White, U.S.M.-H.S.) On boarding a newly-arrived vessel, I first demand the crew-list and passenger-list (if any). I have the roll called, and, when all have answered, inspect each and every person, with a view to the discovery of any signs of present or recently-passed sickness, of any character. The cabin, forecastle, galley, and any other rooms are then in- spected, and every chest and locker opened and contents seen. The hold and between decks are next inspected. All sick are removed to hospital. This constitutes the first step. The second consists in putting into all these places a preliminary fumigation with sulphur of sufficient quantity, this process occupying about twenty-four hours. 388 TEXT-BOOK OF HYGIENE. Third.-All ballast is removed when possible, and when not so it is dipped stone by stone in bichloride solution of the strength of 1 to 300 or 1 to 500, and the whole vessel is washed as clean as water can make her,-hold, deck-houses, and all. Fourth.-Another, and even stronger fumigation than the first, with sulphurous-acid gas. Fifth.-With a force-pump and hose, a solution of bichloride (1 to 500, or stronger) is freely applied to every part of ship and con- tents. Clothing, both in use and not, is either burned, boiled, or soaked in a 1 to 500 solution of bichloride; sometimes both the latter measures. Soaking lasts ten to fifteen minutes. Clothing is boiled twenty minutes; bedding two to three hours. Bedding is most often burned, and always after small-pox. Delaware Breakwater Quarantine Station. (Inspection and Treatment of Vessels, by William P. Orr, A. A. Surgeon U. 8. M.-H. S.) The plan which I have followed in inspecting vessels at this station is as follows:- I first go down into the cabin and examine the bill of health (and manifest, if the vessel has a general cargo). From these I learn the following important facts : The sanitary condition of the port of depart- ure at the time of sailing; the date of departure; number of crew and passengers, and whether the vessel sails in quarantine or free pratique. I will say just here that the bills of health issued by Dr. Burgess, an Inspector of the Marine-Hospital Service, stationed at Havana, are the most complete and satisfactory bills of health that I examine, and we have vessels coming to the Breakwater from all over the world. He always gives the sanitary history and condition of the vessel, cargo, crew, and passengers, and the number of cases and number of deaths from contagious diseases during the week previous to the departure of the vessel. If on arrival there is no sickness on the vessel, and there has been none during the passage, and there is no infectious or contagious disease at the port whence she sails, then the vessel is discharged from quaran- tine. If there is any contagious disease on board on arrival, the sick are brought ashore and cared for in hospital, and the vessel fumigated, disinfected, and detained for a variable period, usually ten days, in order to observe the crew and see whether any new cases are going to appear. If the crew are all well on arrival, but have had sickness (by sickness I mean yellow-fever, small-pox, or cholera) during the passage, the vessel receives the same treatment as above. In case the crew are all well, and there has been no sickness during the passage, but the vessel comes from 389 SPECIAL MEASURES AGAINST CHOLERA. an infected port, then the treatment of the vessel depends upon the number of days' passage, the condition of the vessel, the statement of the captain (which is made under oath) as to whether the crew were allowed to visit the shore, and the length of time the vessel was in port discharging the cargo and reloading, and other considerations which enable us to decide whether any danger need be apprehended in allowing the vessel to enter. After careful inspection of a vessel from an infected port, if I find everything neat and clean, I usually allow her to proceed, provided she has had a passage of ten days or more; but if she has not been out for that length of time I detain the vessel, during the summer season, for observation until the ten days from date of departure have expired. At the end of this time, if no sickness appear, the vessel is discharged. To clean an infected vessel, we begin the first day by fumigating,- that is, burn about 4 pounds of sulphur for every 1000 cubic feet of air-space, the hatchways, doors, and windows being closed and caulked, so as to make the hold, cabin, and forecastle as nearly air-tight as possible. The sulphur-fumes are allowed to remain in the hold twenty- four hours, and in the cabin and forecastle about ten hours; the second day all beds, pillows, and furniture which cannot be satisfactorily disin- fected are burned, and all clothing, blankets, curtains, carpets, and cotton and woolen goods are soaked in a bichloride solution (1 to 2000). The third day the floors, walls, and ceilings of the cabin and forecastle, and all furniture, drawers, and chests in them washed with the same solution. The vessel is now supposed to be clean, and is discharged at once, pro- vided the average period of incubation for the disease from which the crew have suffered has elapsed since there was any one sick on board. SPECIAL MEASURES AGAINST CHOLERA. Other features of quarantine administration are well ex- pressed in the following extract from the editorial pages of the Philadelphia Medical News of October 15, 1887, showing the measures necessary to extinguish an incipient epidemic of cholera and to prevent its spread. Such measures are as follow:- (a) Speedy recognition and isolation of the sick ; their proper treatment; absolute and rapid destruction of the infectious agent of the disease, not only in the dejecta and vomit, but also in clothing, bedding, and in or upon whatever else it finds a resting-place. (6) The convalescents should remain isolated from the healthy so long as their stools possibly contain any of the infecting agent; before 390 TEXT-BOOK OF HYGIENE. mingling again with the well they should be immersed in a disinfecting bath, and afterward be clothed from the skin outward with perfectly clean vestments, which cannot possibly contain any of the infectious material. (c) The dead should be well wrapped in cloth thoroughly saturated in a solution of corrosive sublimate (1 to 500), and, without delay, cortege, or lengthy ceremonial, buried near the place of death in a deep grave, re- mote as possible from water which may, under any circumstances, be used for drinking, washing, culinary or other domestic purposes. (Cremation, of course, is by far the safest way of disposing of cholera cadavers.) (d) Those handling the sick or the dead should be careful to dis- infect their hands and soiled clothing at once, and especially before touch- ing articles of food, drinking, or culinary vessels. (e) In the case of maritime quarantine, the well should be disem- barked and placed under observation in quarters spacious enough to avoid crowding, and so well appointed and furnished that none will suffer real hardships. (/) Once having reached the station, those under observation should be separated in groups of not more than twelve to twenty-four, and the various groups should, under no pretext, intermingle. The quar- ters for each group should afford stationary lavatories and water-closets in perfect working condition, adequate to the needs of the individuals constituting the group, and supplied with proper means of disinfection. There should be a bed raised above the floor, proper coverings, and a chair for each member of the group, each person being required to use only his own bed. There should be a common table of sufficient size to seat around it all the members of the group, who should be served their meals from a central kitchen, and with table furniture belonging to the station and cleaned by the common kitchen scullions. (^) Drinking-water, free from possible contamination and of the best quality, should be distributed in the quarters of each group as it is needed, and in such a manner that it is received in drinking-cups only. There should be no water-buckets or other large vessels in which hand- kerchiefs, small vestments, children's diapers, etc., can be washed by the members of any group. (A) Immediately after being separated into groups in their respec- tive quarters, every person under observation should be obliged to strip and get into a bath (a disinfecting one is preferable), and afterward be clothed with fresh, clean vestments from the skin outward. Every article of clothing previously worn should be taken away and properly disin- fected. (t) Then all of the personal effects should be at once removed to a 391 SPECIAL MEASURES AGAINST CHOLERA. separate building, washed (if possible), and thoroughly disinfected, or, if necessary, destroyed. After disinfection they should be temporarily returned to the members of groups, when occasion requires a further change of clothing. (k) Under no circumstances whatever should washing of clothing by those under observation be permitted. All used clothing should be first thoroughly disinfected (by boiling, when possible),and then should be cleansed, the disinfection and washing being done by a sufficiently trained and absolutely reliable corps of employes supplied with adequate appliances. (Z) All those under observation should be mustered in their own quarters, and be subjected to a close medical inspection, while on their feet, at least twice every day, in order to discover and isolate, as soon as possible, new cases which may develop ; and, of course, the clothing and bedding of these new cases should be treated without delay in the manner already mentioned. In the meantime, a watch should be set over the water-closets for the purpose of discovering cases of diarrhoea, and, when discovered, such cases should be temporarily separated from the rest. They should receive judicious medical attention at once, and precautions should be taken as if they were undoubted but mild cases of cholera. (m) The quarters should be kept thoroughly clean, and every sur- face upon which infectious material could possibly be deposited, includ- ing the floors, should be washed with a strong disinfectant twice daily, and oftener when necessary. Evacuations from the bowels should be passed into a strong disinfectant; the hopper of the closet should be then flushed and finally drenched with a quantity of the same dis- infectant. (n) For the proper attention to the sick, there should be two or more competent and experienced physicians, assisted by a sufficient corps of intelligent and efficient nurses, with hours of duty so arranged that a physician, with a sufficient number of nurses, be in constant attendance in the wards of the hospital. (o) For the prompt recognition and separation of new cases, their temporary medical attention, the proper treatment of discovered cases of diarrhoea or cholerine and of other maladies, and the immediate cor- rection of every insanitary practice or condition by constant, vigilant, and intelligent supervision, there should be at least two or more competent and experienced physicians, with hours of service so arranged that a phy- sician is on duty night and day among those under observation; and he should have, subject to his orders at any and every moment, a sufficient and efficient corps of nurses and laborers to carry out properly and promptly his directions. 392 TEXT-BOOK OF HYGIENE. (p^ In order to prevent the intermingling of the various groups, to enforce obedience and order, and to make it absolutely impossible for the quarantined and their personal effects to have any communication with the exterior, a well-organized and sufficiently large police corps should patrol the borders of the stations and the buildings day and night. (7) Any group among whom there have developed no new cases of cholera or of choleraic diarrhoea, during the preceding eight or ten days, may be regarded as harmless, and allowed to leave quarantine after each one is finally immersed in a disinfecting bath and re-clothed with clean garments from the skin outward, the garments removed being destroyed or thoroughly disinfected and cleansed, as already indicated. As yet no reference has been made to the crew, ship, and cargo. What has been said of the treatment of those under observation applies to every one of the ship's inhabitants. The observation, isolation, and cleansing of the crew and their effects could safely be performed aboard ship if necessary. The ship should be thoroughly cleansed and disin- fected, particular attention being given to the quarters of the emigrants and crew. AIDS TO QUARANTINE. In aid of the national quarantines, sanitary inspectors are appointed by the Marine-Hospital Service at special points of danger, either in the United States or abroad. Through the State Department consular notification from foreign ports is received regularly by mail, or, in emergency, by cable, and the information thus received, and that received also from home ports, is communicated, by the Marine-Hospital Bureau, to all quarantine authorities and others, by means of a weekly publi- cation known as the "Abstract of Sanitary Reports." An important source of information concerning the move- ments of vessels in every portion of the world is the "Maritime Register," published in New York. The United States Col- lectors of Customs are efficient aids, having, by law, the power of search and detention of vessels, and having exceptional knowledge of the sanitary condition of the shipping at their respective ports. The Revenue-Cutter Service, a national coast patrol, renders efficient aid, and the light-house establishment and coast survey render valuable assistance in locating and buoying the anchorages. INLAND QUARANTINE. 393 Finally, the Marine-Hospital Service, having, besides the quarantines, the care of the sick of the merchant vessels of the United States, with 126 physicians stationed at all the larger and many of the smaller ports, is ready at a moment's notice to extend indefinitely its quarantine service. To the surgeon- general of this service, at Washington, are entrusted all national quarantine matters. INLAND QUARANTINE. Under Inland Quarantine will be mentioned The Sanitary Cordon, Camps of Probation, Railroad Quarantine, Disinfection Stations, and Inspection Service. The Sanitary Cordon.-This consists of a line of guards, military or civil, thrown around a district or locality, either to protect the same from the surrounding country when infected, or to protect the surrounding country from the infected district or locality. When a given locality is infected, and the adjacent territory is regarded as suspicious, it may be necessary to establish a double cordon, the first one embracing the whole suspected territory at its outer edge, the second investing more closely the well-defined infected locality. After the expiration of a sufficient time to prove that the area between the cordons is not infected, or has been cleared of infection, the first cordon may be re- moved. Hospitals and camps of probation may be necessary adjuncts to the cordon. The most noted example of the sanitary cordon is found in the history of the plague epidemic in Russia in 1878. A colony on the river Volga, called Wetljankaja, with a population of 1700 inhabitants, became infected with the Oriental plague, which extended to the neighboring villages. A military cordon was made to embrace all the infected district. The inhabitants of the focus of infection, Wetljankaja, were removed, property appraised for re-imbursement by the govern- ment, and the village burned. An additional cordon was thrown around Zarizin, a neighboring commercial city of importance and terminus of the Russian railway system. The cordons were maintained several months, and the plague was stamped out. 394 TEXT-ROOK OF HYGIENE. (See Abstract Sanitary Reports, vol. i [Bulletin's], page 78.) The sanitary cordon is the customary method of preventing the spread of epidemic disease in the eastern countries. In the United States, when yellow fever prevailed in Pen- sacola in 1882, to the extent of 2200 cases, the navy-yard reservation, whose boundary-line is within two miles of the city limit, with a population of about 1500, was successfully guarded by means of a cordon and non-intercourse. The following year, 1883, the navy-yard itself was infected, and a cordon was thrown around it to protect the city of Pen- sacola, and was maintained for a period of sixty days. This cordon was under the management of the Surgeon-General of the Marine-Hospital Service, aid having been requested of the na- tional government. The Collector of Customs of Pensacola was made the agent to execute the orders of the Marine-Hospital Bureau, and to the president of the local Board of Health was entrusted the immediate command of the line and guards. The cordon entirely surrounded the land boundary of the naval reservation. Its line was four miles in length, one mile of it through a dense thicket, and was marked by blazed trees and flags. Forty men were employed as guards, an equal number being selected from each of the two political parties. Two cap- tains were appointed, and were obliged to supervise the line night and day. The sentinel posts were furnished with tents, and two guards were allotted to each post, taking alternate watches of four hours each. A detention or probation camp was established and placed in charge of a physician, where persons wishing to leave the reservation were obliged to pass a probationary period of twenty days. Not more than half a dozen persons were received in this camp. The government expended about $20,000 in these restrictive measures, which were entirely suc- cessful. Not one person got through the cordon line. The success was due largely to the thorough discipline maintained by the Collector and the President of the Board of Health. INLAND QUARANTINE. 395 Yellow-Fever Cordon in Texas.-In 1882, yellow fever pre- vailing in Mexico along the Rio Grande, and in Brownsville, Texas, a sanitary cordon was established by the Surgeon-General of the Marine-Hospital Service, on request of the Governor of the State, extending along the line of the railroad from Corpus Christi, on the Gulf of Mexico, inland to Laredo, on the Rio Grande. This line was 180 miles northeast of Brownsville, the triangular territory thus hemmed in by the cordon on one side, the Rio Grande on another, and the Gulf on the third, being all suspected territory, although the fever prevailed in only one corner of it, viz., in Brownsville. All persons were detained at least ten days at the cordon before being allowed to pass north- ward,-a period of probation to insure that no one having the disease should carry it farther north. As soon as practicable another cordon was established much nearer to Brownsville, only 30 miles from it, the line extending from the mouth of the Sol Colorado, on the Gulf of Mexico, to Santa Maria, on the Rio Grande. After a time sufficient to prove that no more fever prevailed between the two cordons, the first one was removed. Within the second line, where the fever prevailed, chiefly in Brownsville, a hospital was established and dispensa- ries opened for the gratuitous treatment of all applicants. Upon the Mexican side of the Rio Grande the fever con- tinued to spread northwardly, and, in order to oppose it, still another cordon had to be established on the American side of the river, extending from Santa Maria on the south to Laredo on the north, a distance of 500 miles. Three hundred guards well mounted (Texan cow-boys) were employed in this cordon, and, while the disease was being stamped out in Brownsville, any further importation from Mexico was thus prevented. In Mexico the fever continued to spread until the authorities finally adopted measures similar to the above. Much violent language has been used concerning the hard- ships imposed by the sanitary cordon, but in the presence of an epidemic the authorities who are responsible need to pay more 396 TEXT-BOOK OF HYGIENE. heed to the efficiency of the cordon than to individual com- plaints. It should be borne in mind that the sanitary cordon is not intended to bottle up all the people who are caught within an infected district. On the contrary, it is intended as a means of exit to those who will not carry with them contagious disease to the people beyond. The cordon, then, imposes simply a period of detention corresponding to the incubative period of the prevailing disease. Ample preparation must be made for housing and feeding, in camps or other quarters, persons awaiting the expiration of the detention period; and hospitals must be provided for the treat- ment of those who develop sickness. Provision must also be made for the disinfection of suspected baggage. Camps of Probation.-Camps of probation or detention should be established with all the precision of arrangement and regard for site, water, and drainage that pertain to a military camp. Every effort should be made to make the camp as com- fortable and cheerful as possible, and to this latter end amuse- ments and entertainments such as might be suggested by the campers themselves should be encouraged. Every necessity in the matter of food, bedding, and the ordinary comforts of life should be anticipated to prevent any just cause of complaint. Such a natural division of the inhabitants should be made as seems desirable at the time, those of equal intelligence and refinement naturally seeking each other's company. The greatest concern is to prevent the camp itself from becoming infected. To this end no baggage should be allowed within the camp boundary without previous disinfection; and every refugee should be examined by a physician before being admitted to the camp. No one should be received who does not intend to pro- ceed to an uninfected locality after his probation. In other words, a camp of probation should not be used as one of refuge. The camp must be surrounded by guards to prevent egress or ingress, excepting through the established portal. At least INLAND QUARANTINE. 397 twice or three times in the twenty-four hours all refugees should be inspected in their quarters, and any case of sickness at once be isolated and watched until the diagnosis is certain. If the case is one of the prevailing disease, the patient must be re- moved immediately to the hospital, which should be at a safe distance, half a mile or more, from the camp. Before leaving the camp, each refugee's clothing should be fumigated, and he should be given a certificate that he has passed the required period of probation. A clear distinction must be made between camps of probation and camps of refuge. Camps of refuge are simply residence camps established to receive the population of an infected community when it has been determined to depopu- late the infected district. Depopulation of a house, a block, a district, or a whole city, if possible, the people moving into camps, is now recog- nized as a valuable means of controlling an epidemic; and there may be either camps of probation or simply camps of refuge, or both, according to the requirements of the situation. Camps of refuge, in connection with depopulation, were sug- gested by the late Surgeon-General Wood worth, in 1878, and the measure was practically carried out at Memphis, in 1879, by the establishment of Camp Mitchell. " But the establish- ment of a camp to which persons from infected points could go, be kept under observation a sufficient length of time to demon- strate they were not infected, have their baggage disinfected, and be given ' free pratique,' is apparently a new departure in inland quarantine." Camp Perry, Fla.-Such was Camp Perry, Florida, de- scribed by the surgeon in charge, W. H. H. Hutton, in the Marine-Hospital Service Report for 1889. The site was admir- ably chosen by Passed-Assistant-Surgeon John Guiteras, upon a bluff on the south side of St. Mary's River, the dividing line between Florida and Georgia, about forty miles north of Jack- sonville, Fla., which city was in the throes of a yellow-fever epidemic. The camp was opened August 20, 1888. It con- 398 TEXT-BOOK OF HYGIENE. sisted, in its completed stage, first, of 50 wooden cottages built elsewhere and transported on cars. Their dimensions were 12 feet by 10, and 10 feet in height, constructed of plain lumber, with cracks battened, and windows on each side with swinging shutters. Each held four cots, chairs, and toilet-stand, while unused clothing was neatly arranged on the rafters above. Besides the 50 cottages there were a quartermaster and guard- house, commissary building, dining-room, and kitchen, and laundry, built of rough lumber; 2 Ducker portable barracks, each 18 by 35 feet, provided with 12 beds each, and 350 tents, used principally by the single men, the employes and guards, and the colored refugees. The camp was laid out and its military discipline established under the temporary personal command of Surgeon-General Hamilton. So far as known this is the first camp of the kind ever established, at least in the United States. The cottages were arranged in a quadrangle around a parade-ground two acres in extent, and the tents were arranged in streets and alleys in the rear of the cottages. The accommodations were sufficient for 600 people, and extra tents were on hand so that if required 1000 persons could have been provided for, or 3000 per month, allowing for only ten days' detention of each person. Two hundred hospital-tents will accommodate 1200 people comfortably, according to Surgeon Hutton, who states that the small A-tents are unsuited for women and children, but will answer for men or boys. Wire- mattress cots should be provided. The marine-hospital officer at Savannah, Ga., was the purchasing agent for the camp, and promptly forwarded all subsistence supplies on requisition by mail or telegraph. Discipline of the Camp.-On arrival of a train, each pas- senger was personally examined by a physician, his health- certificate scrutinized, and he was made to await the examination of others. Hand-bags, clothing, and loose wearing-apparel were left in the baggage-car for disinfection. The refugees were then marched to the quartermaster's room for registration and INLAND QUARANTINE. 399 assignment to quarters. On first arrival they were placed in the southern part of the camp, and in two days, there being no sickness, were moved forward several cabins, and this progres- sion was repeated until the time for discharge. Twelve guards were employed, under the command of a captain, and were divided into squads of four each. The schedule was so arranged that each guard was on duty two hours and off duty four. A bugler announced the several calls as follows:- 5.30 A.M., .... Reveille. 6.00 a.m., .... Breakfast, employes. 7.00 a.m., .... Breakfast, guests. 9.00 a.m., .... Surgeon's call and inspection. 12.00 m., . . . Dinner, employes. 1.20 p.m., .... Dinner, guests. 4.30 p.m., .... Surgeon's call and inspection. 5.30 p.m., .... Supper, guests. 6.00 p.m., .... Supper, employes. 6.30 p.m., .... Retreat and change of guard. 9.00 p.m., .... Retiring taps. The yellow-fever hospital-camp, under the special charge of Dr. Faget, was located one-half mile from the probation camp. It consisted of 2 frame buildings, 2 hospital and 12 smaller tents, arranged in a double-crescent shape, the avenue in the middle presenting an attractive appearance. Of the 12 small tents, 4 were for nurses, 3 for employes, 2 for convalescents, and 1 each for drug-store, storage- and dead- house. One of the hospital-tents was used as a dining- room for employes, convalescents, and parents of the sick. The hospital was established September 3, 1888, and be- tween that date and November 24th 35 cases of yellow fever were admitted and treated, 3 died, and 32 were discharged. Twelve hundred and eleven refugees were received into Camp Perry, nearly all of whom were from the infected district of Jacksonville. Thirty-five cases of yellow fever were caught by the ten 400 TEXT-BOOK OF HYGIENE. days' detention, but no case of fever was contracted at the camp, and of the 1208 refugees who passed the required detention and proceeded to different parts of the country, so far as known, not one subsequently developed or carried the disease elsewhere. The general plan of the preventive measures adopted during this epidemic will be described under Railroad Quarantine. Railroad Quarantine, Inspection Service, and Disin- fection Stations.-Railroad quarantine, disinfection stations, and inspection service may be described by a brief account of the actual measures of this nature, made use of during the yellow-fever epidemic in Florida in 1888, of which Camp Perry, just described, was an important adjunct. (For details, see annual reports marine-hospital service, 1888 and 1889.) The Governor of Florida made application to the national authorities, July 16th, for aid, and it was determined to prevent further spread of the disease by disinfecting all baggage from infected localities before permitting its transportation into other States, and by enforcing upon all persons from infected localities seeking to leave the State a probationary detention of ten days. Accordingly, disinfection-stations were established at two points, through which all persons leaving Florida by rail were obliged to pass. One of these was at Live Oak, in Northwestern Florida; the other at Way Cross, Georgia, near the boundary- line of Northeastern Florida. The only other means of egress from the State was from the sea-ports; but healthy sea-ports maintained a vigorous quarantine against people from the in- fected districts, and infected sea-ports were not visited by the steam-ship lines, because their vessels would thereby be made liable to quarantine detention at other ports. The fumigation of baggage at Live Oak and Way Cross was accomplished by means of box-cars specially prepared, and subsequently in warehouses, the agent being sulphur dioxide. Regarding persons, the inspectors, properly uniformed and wearing official shields, boarded the trains when the latter arrived at the inspection-stations, and demanded of each passenger a INLAND QUARANTINE. 401 certificate, showing where he had been during the previous ten days, which certificate was considered valid only when it bore the seal or signature of some officer of health, or recognized municipal authority. The inspectors themselves were kept informed regarding all infected or suspected localities, and a person coming from such locality was either made to return to it, or given the option of going to the camp of probation, there to spend the ten days' period of probation before being allowed to enter other States. This was Camp Perry, previously described, located 38 miles south of the Way Cross Station, and 40 miles north of Jacksonville, where the epidemic prevailed chiefly. All egress from Jacksonville was, perforce, through Camp Perry and its ten days' probation. This camp was a means of protecting not only other States, but the uninfected portions of Florida itself, more particularly Southern Florida, whose health authorities refused to admit within their limits the refugees from the infected districts unless they had passed the period of probation at Camp Perry. To assist in this protection to Southern Florida, no person was allowed to board a south-bound train between Way Cross, on the north, and Orange Park, a station 20 miles south of Jacksonville. Moreover, through south-bound trains were boarded at WayCross, and all passengers compelled to furnish evidence of coming from healthful localities. The evidence consisted of certificates from local authorities, baggage-checks, or railroad- tickets showing they were purchased in the North, and in some instances letters showing by the superscription and stamps where the person had been. No train, excepting the special government train, was allowed to stop at Camp Perry. A government train also carried those who had passed the period of probation from Camp Perry to a point 3i miles distant, Folkstone, where they were transferred to a regular train running as far north as Way Cross, 402 TEXT-BOOK OF HYGIENE. Ga., where another transfer had to be made to a regular north- bound train. No Florida passenger-car was allowed to go north, and more than 1000 baggage and freight cars were disinfected by government officers before being allowed to leave the State. The methods of railroad quarantine may also be studied in a review of the action taken to prevent the introduction of small-pox into the United States from Canada, where it prevailed extensively in the fall and winter of 1885, and January and February, 1886. The following regulations were issued by the Surgeon- General of the Marine-Hospital Service, October, 10, 1885:- The act approved April 29, 1878, entitled, " An act to prevent the introduction of contagious or infectious diseases into the United States," provides that no vessel or vehicle coming from any foreign port or country where any contagious or infectious disease exists, or any vessel or vehicle conveying persons, merchandise, or animals affected with any contagious disease, shall enter any port of the United States, or pass the boundary-line between the United States and any foreign country, except in such manner as may be prescribed under said act. Attention is now directed to the prevalence of the contagious and infectious disease of small-pox in Montreal and other places in the Dominion of Canada, and the law referred to is held to apply alike to trains of cars and other vehicles crossing the border, and to vessels entering ports on the northern frontier. Because, therefore, of the danger which attaches to the transporta- tion of persons and baggage, and articles of merchandise, or animals, from the infected districts, the following regulations are framed, under the direction of the Secretary of the Treasury, and subject to the approval of the President, for the protection of the health of the people of the United States against the danger referred to :- 1. Until further orders all vessels arriving from ports in Canada, and trains of cars and other vehicles crossing the border-line, must be examined by a medical inspector of the Marine-Hospital Service before they will be allowed to enter the United States, unless provision shall have been made by State or municipal quarantine laws and regulations for such examination. 2. All persons arriving from Canada, by rail or otherwise, must be examined by such medical inspector before they will be allowed to enter the United States, unless provision has been made for such examination. INLAND QUARANTINE. 403 3. All persons coming from infected districts, not giving satis- factory evidence of protection against small-pox, will be prohibited from proceeding into the United States until after such period as the medical inspector, the local quarantine, or other sanitary officer duly authorized, may direct. 4. The inspectors will vaccinate all unprotected persons who desire, or are willing to submit to, vaccination free of charge. Any such person refusing to be vaccinated shall be prevented from entering the United States. 5. All baggage, clothing, and other effects, and articles of mer- chandise, coming from infected districts, and liable to carry infection, or suspected of being infected, will be subjected to thorough disinfection. 6. All persons showing evidence of having had small-pox or vario- loid, or who exhibit a well-defined mark of recent vaccination, may be considered protected, but the wearing-apparel and baggage of such pro- tected persons who may come from infected districts, or have been exposed to infection, will be subjected to thorough disinfection as above provided. 7. Customs officers and United States medical inspectors will con- sult and act in conjunction with authorized State and local health author- ities so far as may be practicable, and unnecessary detention of trains or other vehicles, persons, animals, baggage, or merchandise, will be avoided so far as may be consistent with the prevention of the introduction of diseases dangerous to the public health into the United States. 8. Inspectors will make full weekly reports of services performed under this regulation. 9. As provided in Section 5 of said act, all quarantine officers or agents acting under any State or municipal system, upon the application of the respective State or municipal authorities, are empowered to en- force the provisions of these regulations, and are hereby authorized to prevent the entrance into the United States of any vessel or vehicle, person, merchandise, or animals prohibited under the act aforesaid. 10. In the enforcement of these regulations there shall be no inter- ference with any quarantine laws or regulations existing under or to be provided for by any State or municipal authority. The following are the special instructions for the guidance of sanitary inspectors, issued by Surgeon H. W. Austin, in charge of the inspection service on the Canadian frontier from Buffalo, N.Y., to the Atlantic coast during the epidemic above referred to (See Marine-Hospital Report, 1886):- 404 TEXT-BOOK OF HYGIENE. Regulations for Sanitary Inspectors. The following instructions will be observed by the sanitary inspector on the following-mentioned railroads crossing the United States boundary- line, viz., the Grand Trunk Railway, at Rouse's Point, N. Y., and Island Pond, Vt.; the Passumpsic Railroad, at Newport, Vt.; the Cen- tral Vermont Railroad, at Highgate Springs or Saint Albans ; the Canada Atlantic, at Rouse's Point, N. Y.; and the Southeastern Railway, at Richford, Vt.:- All persons bound for the United States coming from Montreal, or other places in Canada where small-pox prevails, must produce satisfac- tory evidence to the inspector that they are protected by a recent vaccina- tion, or submit to this operation before they are allowed to cross the boundary-line. Inspectors will vaccinate all unprotected persons free of charge. Persons coming from Montreal, or suburban villages, will be care- fully questioned as to their residence, whether small-pox has occurred in their families, or whether they have been in contact with the disease. Inquiries should also be made relative to their baggage, whether it consists of bedding, household goods, etc., likely to be infected ; and if any person or article of baggage is considered by the inspector infected or likely to introduce the disease into the country, he or it should not be permitted to cross the line into the United States. You may consider persons protected who may show evidence of having had the small-pox or varioloid, or who exhibit a well-defined mark of vaccination. Accept as evidence of protection a certificate from any physician in good standing that the person presenting the same has been successfully vaccinated. Should you doubt the validity or authenticity of the certificate, you may refuse any such person presenting the same the privilege of crossing the border unless he submits to vaccination. Baggage known to have come from any infected district, and believed to be infected, will be thoroughly fumigated with sulphur at Rouse's Point, Saint Albans, Richford, Newport, and Island Pond. Weekly reports should be made to Surgeon H. W. Austin, United States Marine-Hospital Service, Burlington, Vt., of the number of trains inspected, number of persons examined, number of persons vaccinated, number of pieces of baggage fumigated, and any other information relative to services performed by the inspector. It will be observed that all the railroads, five in number, over which passengers or freight might be brought direct from Canada into the New England States were guarded. INLAND QUARANTINE. 405 Besides the line commanded by Surgeon Austin (Atlantic coast to Buffalo), another line was under the direction of Passed- Assistant-Surgeon Wheeler, at points east of Buffalo, and still another on the Michigan frontier, under command of Surgeon W. H. Long. These lines were established at the request and with the co-operation of the authorities of the respective States. Thirty-six inspectors were employed at 37 stations, who exam- ined 49,631 persons on railroad-trains, vaccinated 16,547, and detained or sent back 603. The contents of more than 7000 pieces of baggage were disinfected. The measures taken were successful. The following are the rules for railroad quarantine adopted by the Quarantine Conference held in Montgomery, Ala., March 5th to 7th, 1889:- 1. Quarantine should not be macle against any place until it is officially known that yellow fever or other infectious or contagious dis- ease exists at such place. 2. Only competent physicians should be put in charge of quaran- tine stations, and only thoroughly-qualified persons should be employed as inspectors on rail way-trains. 3. Quarantine stations located on railroads should be established at convenient points, on one or both sides of a town or station, as may be deemed necessary. 4. If an epidemic of yellow fever or other infectious or contagious disease exist at a town or station, trains carrying passengers or freights should be required to pass through the limits of such towns or stations at a speed of not less than ten miles per hour, without stopping at such towns or stations, but should stop at the quarantine station. 5. Passengers to or from such infected point should only be received or delivered at the quarantine station, under the supervision of the quar- antine officer in charge of the station. 6. Railway-tickets may be sold to persons leaving an infected place to any point willing to receive them. 7. All baggage from any infected point should be properly disin- fected. 8. As far as practicable, the same rules proposed for railroads should be applied to vessels of every kind, stage-coaches, or other means of travel. 406 TEXT-BOOK OF HYGIENE. 9. The passage of railroad-trains through any point on the line of road, whether infected or not, should not be prohibited by any quaran- tine regulations. The conductors of passenger-trains should close the windows and ventilators and lock the doors of cars passing through any place where a train is not permitted to stop. 10. All freight to any infected place should be delivered either at the quarantine station or the nearest railway-station to such infected point where it can be properly cared for. 11. All mail-matter from any infected place should be properly disinfected by the United States Government; and mail-matter intended for infected points should be put off the trains at the quarantine stations. The United States Government should instruct postmasters to receive and deliver mails at such quarantine stations. 12. Railroads and express companies may receive for transporta- tion from any infected place, during the time such infection exists, any merchandise or traffic consigned to places willing to receive it. 13. State authorities should employ competent persons on passen- ger-trains as inspectors of passengers, baggage, and express matter, as additional precaution; but the fact of inspectors being on such trains should not relieve trains carrying passengers or express matter or baggage from stopping at quarantine stations for such inspection as the officer in charge may determine to be necessary. 14. It is recommended that all quarantines, as far as practicable, should be uniform in their requirements and operations, which will greatly contribute to the prevention of panics, and tend to allay un- necessary excitement and fear on the part of the people. 15. The form of health certificate adopted by the Quarantine Con- vention, held at Montgomery, March 5, 1889, should be prepared for health officers to issue to such persons as may be found entitled to re- ceive the same. A copy of this certificate should be printed with these rules, and conspicuously posted at railway-stations. 16. It is the desire and intention of health authorities, as far as practicable, to throw every safeguard around the public health of all localities. Municipal, county, and State authorities are expected to co-operate in every possible way with health officers located in towns, villages, and cities, and in charge of quarantine stations, to enable them to prevent the introduction or spread of yellow fever or other infectious or contagious diseases. It was also resolved by this conference that the best form of disinfectant for personal baggage is moist heat. 407 MUNICIPAL, STATE, AND NATIONAL QUARANTINE LAWS. CORRELATION OF MUNICIPAL, STATE, AND NATIONAL QUARANTINE LAWS. As shown in the foregoing pages, quarantines are admin- istered under three forms of government,-local, State, and national. A vessel arriving at a given port may be refused permission to discharge cargo by authority of either a national statute, a State law, or a city ordinance. At Brooklyn, for example, if the United States officers should consent to a vessel's entry and discharge, restraint could still be imposed by the State officers; and if the latter also should consent, the city author- ities could still prevent. In some instances, as at Philadelphia and New Orleans, municipal officers are included in the State quarantine boards, and harmony of action between city and State is thus assured. But, unfortunately, there are still a few States which exercise either little or no supervision of quaran- tines, so that a county or village quarantine may be purely a local affair conducted without regard to neighboring counties or villages or to the rest of the State. It is this form of quarantine which, in times of epidemic and panic, has for so many years wrought untold misery, which has given rise to the shot-gun quarantines, checked all the currents of trade and social inter- course, arrayed county against county, village against village, and turned the hand of neighbor against neighbor in a ferocious struggle to ward off the pestilence. Instances of this form of quarantine were numerous in the Southern States during the yellow-fever epidemic of 1878, when the policy of non-intercourse between communities was so rigidly enforced that many were cut off from subsistence supplies, and there was danger of starvation. Much has been written upon the folly of the shot-gun quarantines, yet communities employing this method have, under their peculiar circumstances, acted wisely, and the results, as compared with those of similar communities neglecting this method, have demonstrated its merit. The blame for all the hardships and suffering entailed is to be laid upon those whose 408 TEXT-BOOK OF HYGIENE. business it is to make the laws of the State. In the States in- dicated there were no State boards of health, or they were clothed with but little authority, or, being formed in conjunction with the board of some principal sea-board city, gave little atten- tion to inland districts. The most recent illustration of the difficulties made by local quarantines, without State supervision, was in Florida during the yellow-fever epidemic of 1888, when the whole State, there being no central sanitary authority, was in confusion through the enactments of village, county, and city boards of health, all acting independently, with no common plan or guid- ance. When finally, by request of the Governor, the United States authorities assumed control, the petty enactments of these small local boards, and their adherence to their rights, gave great trouble to the government officers, some of whom ex- perienced great delay and personal hardships in getting through the local lines to the points of danger and activity to which they had been ordered. This epidemic demonstrated clearly the need of a State board of health, which the Legislature has since established. State boards of health do not do away with local boards, but make them work in harmony on broad plans laid down in the interest of all. But there are States which yet have no boards of health, where, in case of epidemic, the old confusion might arise were it not for a new exercise of power on the part of the national government, made possible by the Act of Congress, approved March 28, 1890, known as the Interstate Quarantine Act, to which further reference will be made. Having shown the necessity of State supervision over village and county quarantines, it is now pertinent to consider the relation of the States to one another. Theoretically, in maritime quarantine, there is opportunity for clashing. One State might be very rigid in its exactions, while a neighboring State, owing to financial stringency, indifference, or a desire to divert the commerce of the first to its own ports, might be very MUNICIPAL, STATE, AND NATIONAL QUARANTINE LAWS. 409 lax. On this account, and to secure uniformity of procedure, it has been urged that all maritime quarantines should be given over to the national government. It is not intended to enter into this subject exhaustively, but it may be remarked that practically there is little clashing between the State maritime quarantines; and that, while the national government could readily and effectively conduct all the more important quaran- tines upon the coast, to establish or maintain the very numerous smaller ones would be an excess of responsibility and labor. Moreover, it would seem that the people of each section are best qualified to judge of measures of protection required by their own peculiar surroundings; and if they were not it might still be a questionable public policy to relieve the State govern- ments of this sanitary responsibility, and encourage thus a weak leaning upon the national government. But another view of the matter is had from the stand-point of the interior States. The interior States are as much interested in the efficiency of quarantine at New York or New Orleans as are the cities named, for fomites failing of proper disinfection at these points are rapidly carried to innumerable localities in the interior. Thus, in a measure, the people of the whole interior are de- pendent upon these quarantines, that is to say, upon the legis- lative liberality of the States in question, and the efficiency of their executive officers. Should, however, there be a persistently lax maritime quarantine on the part of a State, the interior States could maintain inland quarantine against the offending one, and by thus restricting its commerce compel a greater efficiency. Should an epidemic disease obtain lodgment in a State the others may, and frequently do, quarantine against it. In the Southern States particularly the interruption to interstate com- merce has been frequent by reason of quarantines. The effect of this has been beneficial in that it has stimulated the health authorities in their efforts to exclude epidemic disease. But if there is danger of the spread of cholera, yellow fever, small- 410 TEXT-BOOK OF HYGIENE. pox, or plague from one State to another, the national author- ities, by virtue of the interstate quarantine act, may adopt the necessary preventive measures. The relation which the national government has always borne toward the States in the matter of quarantine is that of a powerful ally, in the absence of local quarantine assuming jurisdiction, giving aid, when requested, to weak quarantines, and establishing quarantines at points, as the Delaware Break- water and Cape Charles, where one establishment serves for the protection of several States. All national quarantines have been located by the request or ready assent of the States in proximity. While it has been urged that quarantine is a function of the general government by reason of the constitutional right of Congress to regulate commerce, the other theory has pre- vailed, viz., that it is a police power appertaining to the State. The first quarantine laws were enacted by the States or colonies, by Massachusetts, for example, as early as 1648. A resolution looking to the national control of quarantine was offered in the Fourth Congress, April 28, 1796, as follows: " Resolved, That the President of the United States be authorized to direct such quarantines to be performed on all vessels from foreign countries arriving at the ports of the United States as he shall judge necessary." This resolution failed to pass, but one was adopted authorizing the President " to direct the revenue officers and the officers commanding ports and revenue-cutters to aid in the execution of quarantine laws, and also in the execution of the health laws of the States respectively, in such manner as may to him appear necessary." From that time until the passage of the interstate quarantine act of 1890, there was no national quarantine legislation that was not distinctively and only in aid of State laws. With regard to quarantine fees, however, without which many State and local quarantines could not be maintained, it is noticeable that Congress, while not forbidding their exaction, de- clares, in Section 4792 of the Revised Statutes, that " nothing in UNITED STATES QUARANTINE LAWS AND REGULATIONS. 411 this Title shall enable any State to collect a duty of tonnage or impost without the consent of Congress." The inference is that Congress, in its constitutional power to regulate commerce, is unwilling to formally surrender this right. The right of the State to impose fees has been affirmed, however, by the Supreme Court of tlie United States. Before extending quarantine aid to a State it is the custom of the government to obtain a formal request from the Governor or State sanitary authorities. The agent of the government is the Surgeon-General of the Marine-Hospital Service, who assumes then the direction of expenditures and measures. When necessary the employes, sanitary guards, etc., of the Marine-Hospital Service are given a proper legal footing by being sworn in as State or local officers, deputy sheriffs, etc., and likewise under the law State officers may be endowed with the authority of United States sanitary officers. In this manner the national and State authorities work together harmoniously. Following are the United States quarantine laws in full:- UNITED STATES QUARANTINE LAWS AND REGULATIONS. Section 4792, Revised Statutes of the United States. The quarantines and other restraints established by the health laws of any State, respecting any vessels arriving in, or bound to, any port or district thereof, shall be duly observed by the officers of the customs revenue of the United States, by the masters and crews of the several revenue-cutters, and by the military officers commanding in any fort or station upon the sea-coast; and all such officers of the United States shall faithfully aid in the execution of such quarantines and health laws, according to their respective powers and within their respective precincts, and as they shall be directed, from time to time, by the Secretary of the Treasury. But nothing in this Title shall enable any State to collect a duty of tonnage or impost without the consent of Congress. NATIONAL QUARANTINE ACT. AN ACT to prevent the introduction of contagious or infectious diseases into the United States. Be it enacted by the Senate and House of Representatives of the United States of America, in Congress assembled, That no vessel or vehicle coming from any foreign port or country where any contagious 412 TEXT-BOOK OF HYGIENE. or infectious disease may exist, and no vessel or vehicle conveying any person or persons, merchandise, or animals infected with any infectious or contagious disease, shall enter any port of the United States, or pass the boundary-line between the United States and any foreign country, contrary to the quarantine laws of any one of said United States, into or through the jurisdiction of which said vessel or vehicle may pass, or to which it is destined, or except in the manner and subject to the regula- tions to be prescribed, as hereinafter provided. Sec. 2. That whenever any infectious or contagious disease shall appear in any foreign port or country, and whenever any vessel shall leave any infected foreign port, or, having on board goods or passengers coming from any place or district infected with cholera or yellow fever, shall leave any foreign port, bound for any port in the United States, the consular officer, or other representative of the United States at or nearest such foreign port shall immediately give information thereof to the Supervising Surgeon-General of the Marine-Hospital Service, and shall report to him the name, the date of departure, and the port of destination of such vessel; and shall also make the same report to the health officer of the port of destination in the United States, and the consular officers of the United States shall make weekly reports to him of the sanitary condition of the ports at which they are respectively stationed ; and the said Surgeon-General of the Marine-Hospital Service shall, under the direction of the Secretary of the Treasury, be charged with the execu- tion of the provisions of this act, and shall frame all needful rules and regulations for that purpose, which rules and regulations shall be subject to the approval of the President, but such rules and regulations shall not conflict with or impair any sanitary or quarantine laws or regulations of any State or municipal authorities now existing, or which may hereafter be enacted. Sec. 3. That it shall be the duty of the medical officers of the Marine-Hospital Service and of customs officers to aid in the enforce- ment of the national quarantine rules and regulations established under the preceding section; but no additional compensation shall be allowed said officers by reason of such services as they may be required to per- form under this act, except actual and necessary traveling expenses. Sec. 4. That the Surgeon-General of the Marine-Hospital Service shall, upon receipt of information of the departure of any vessel, goods, or passengers from infected places to any port in the United States, immediately notify the proper State or municipal and United States officer or officers at the threatened port of destination of the vessel, and shall prepare and transmit to the medical officers of the Marine-Hospital Service, to collectors of customs, and to the State and municipal health UNITED STATES QUARANTINE LAWS AND REGULATIONS. 413 authorities of the United States weekly abstracts of the consular sani- tary reports and other pertinent information received by him. Sec. 5. That whenever, at any port of the United States, any State or municipal quarantine system may now or may hereafter exist, the offi- cers or agents of such system shall, upon the application of the respective State or municipal authorities, be authorized and empowered to act as officers or agents of the national quarantine system, and shall be clothed with all the powers of United States officers for quarantine purposes, but shall receive no pay or emolument from the United States. At all other ports where, in the opinion of the Secretary of the Treasury, it shall be deemed necessary to establish quarantine, the medical officers or other agents of the Marine-Hospital Service shall perform such duties in the enforcement of the quarantine rides and regulations as may bq assigned them by the Surgeon-General of that Service under this act: Provided, That there shall be no interference in any manner with any quarantine laws or regulations as they now exist, or may hereafter be adopted under State laws. Sec. 6. That all acts or parts of acts inconsistent with this act be, and the same are hereby, repealed. Approved April 29, 1878. [Extract from Quarantine Act of August 1,1888.] AN ACT to perfect the quarantine service of the United States. Be it enacted by the Senate and House of Representatives of the United States of America, in Congress assembled, That whenever any person shall trespass upon the grounds belonging to any quarantine reservation, or whenever any person, master, pilot, or owner of a vessel entering any port of the United States, shall so enter in violation of Section 1 of the act entitled, "An act to prevent the introduction of contagious or infectious diseases into the United States," approved April twenty-ninth, eighteen hundred and seventy-eight, or in violation of the quarantine regulations framed under said act, such person, trespassing, or such master, pilot, or other person in command of a vessel shall, upon conviction thereof, pay a fine of not more than three hundred dollars, or be sentenced to imprisonment for a period of not more than thirty days, or shall be punished by both fine and imprisonment, at the discretion of the court. And it shall be the duty of the United States attorney in the district where the misdemeanor shall have been committed to take immediate cognizance of the offense, upon report made to him by any medical officer of the Marine-Hospital Service, or by any officer of the Customs Service, or by any State officer acting under authority of Section 5 of said act. 414 TEXT-BOOK OF HYGIENE. Sec. 2. That as soon after the passage of this act as practicable, the Secretary of the Treasury shall cause to be established, in addition to the quarantine established by the act approved March fifth, eighteen hundred and eighty-eight, quarantine stations, as follows : One at the mouth of the Delaware Bay ; one near Cape Charles, at the entrance of the Chesapeake Bay; one on the Georgia coast; one at or near Key West; one in San Diego Harbor ; one in San Francisco Harbor ; and one at or near Port Townsend, at the entrance to Puget Sound ; and the said quarantine stations when so established shall be conducted by the Marine-Hospital Service under regulations framed in accordance with the act of April twenty-ninth, eighteen hundred and seventy-eight. ************ Approved August 1, 1888. AN ACT to prevent the introduction of contagious diseases from one State to another and for the punishment of certain offenses. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That whenever it shall be made to appear to the satisfaction of the President that cholera, yellow fever, small-pox, or plague exists in any State or Territory, or in the District of Columbia, and that there is danger of the spread of such disease into other States, Territories, or the District of Columbia, he is hereby author- ized to cause the Secretary of the Treasury to promulgate such rules and regulations as in his judgment may be necessary to prevent the spread of such disease from one State or Territory into another, or from any State or Territory into the District of Columbia, or from the District of Columbia into any State or Territory, and to employ such inspectors and other persons as may be necessary to execute such regulations to prevent the spread of such disease. The said rules and regulations shall be prepared by the Supervising Surgeon-General of the Marine-Hospital Service, under the direction of the Secretary of the Treasury. And any person who shall willfully violate any rule or regulation so made and promulgated shall be deemed guilty of a misdemeanor, and upon convic- tion shall be punished by a fine of not more than five hundred dollars, or imprisonment for not more than two years, or both, in the discretion of the court. Sec. 2. That any officer, or person acting as an officer, or agent of the United States at any quarantine station, or other person employed to aid in preventing the spread of such disease, who shall willfully violate any of the quarantine laws of the United States, or any of the rules and regulations made and promulgated by the Secretary of the Treasury as provided for in Section 1 of this act, or any lawful order of his superior UNITED STATES QUARANTINE LAWS AND REGULATIONS. 415 officer or officers, shall be deemed guilty of a misdemeanor, and upon conviction shall be punished by a fine of not more than three hundred dollars, or imprisonment for not more than one year, or both, in the dis- cretion of the court. Sec. 3. That when any common carrier or officer, agent, or employe of any common carrier shall willfully violate any of the quarantine laws of the United States, or the rules and regulations made and promulgated as provided for in Section 1 of this act, such common carrier, officer, agent, or employe shall be deemed guilty of a misdemeanor, and shall, upon conviction, be punished by a fine of not more than five hundred dollars, or imprisonment for not more than two years, or both, in the dis- cretion of the court. Approved March 28, 1890. INDEX. Absolute and relative humidity, 6 Actinomycosis, 343 Adjustable school-desk, 197 Adulterations in milk, 91 of flour, 107 "A. G. M." water-closet, 170 Aids to quarantine, 392 Air-currents and their influence upon health, 18 Alcohol poisoning, 112 Alcoholic beverages, 111 Alkaloidal beverages, 117 Alum as a purifier of muddy water, 59 Ammonia in water, 74 Angus Smith's experiments on carbon dioxide and organic matter, 27 Aniline poisoning, 220 Animal diseases and ground-w'ater, 133 Anthrax, 345 Antiseptics and antisepsis, 347 Arsenic in wall-papers, 163 poisoning, 225 Atmosphere, composition and physical conditions of, 2 its influence upon health, 1 its limit upward, 3 Atmospheric pressure and health, 8 Bacillus anthracis as a cause of diseased meat, 103 Bacillus of anthrax, 345 of glanders, 345 of typhoid fever, 329 Bacteria in the atmosphere, 32 Bacteriological examination of drinking- water, 77 Baker, H. B., on effects of low tempera- ture on health, 15 Barometric pressure, 3 Barracks, 234 Bathing, dangers of, 270 rules for, 269 Baths and bathing, 267 Beer, 116 Berlier's system, 144 Bert's observations on diminished at- mospheric pressure, 10 Birth-rates, 363 Black death, 294 hole of Calcutta, 28 Boccaccio on the plague, 294 Bora, 19 Boudin on malarial fever from drinking- water, 60 Bovine tuberculosis, 344 Bowditch, H. I., on soil moisture and consumption, 131 Brandy, 114 "Brass-founders' ague," 219 Bread, 106 Broad Street pump epidemic of cholera, 64 Buchanan, Dr. G., on earth-closets, 142 on soil moisture and consumption, 132 Burial-grounds, supposed dangers of, 280 Bury ventilator, 161 Butter, 95 Cabiadis on the plague in Bagdad, 297 Cable, G. W., on convict-lease system, 257 Caisson disease, 12 Camp diseases, 236 Perry, 397 Camps of probation, 396 Carbon-bisulphide poisoning, 215 Carbon dioxide in atmosphere, 2, 26 poisoning, 214 Carbon monoxide in air, 29 poisoning, 213 Caterham epidemic of typhoid fever, 61 Cerebro-spinal meningitis, 339 Chamberland's filter, 69 Chambers, J, W., on pollution of hy- drant-water, 66 Chantemesse and Vidal on the bacillus typhoideus in drinking-water, 63 Cheese, 96 Chemical composition of ground-air, 123 Chlorides in water, 72 Chlorine-gas poisoning, 212 Chocolate, 118 "Choke-damp," 214 Cholera and drinking-water, 321 and ground-water, 130 Asiatica, 314 bacillus, 319 causation of, 320 417 418 INDEX Cholera from infected water, 64 prevention of, 323 special quarantine measures against, 389 Cider, 115 Cisterns as storage reservoirs, 47 Civilian camps, 240 Classification of drinking-waters, 78 Clothing, absorption of heat by, 275 howto render non-inflammable, 278 materials, 275 of the soldier, 233 Coal-gas, 30 Coffee, 117 Condiments, 108 Connolly trap, 176 Consumption among school-children, 204 and soil moisture, 131 Contagion and infection, 289 Contagious diseases and schools, 204 Contagium animatum, 285 Contamination of hydrant-water, 66 Cowles, Dr. E., experiments on heating hospitals, 184 Creamometer, 94 Cremation, 282 of sewage and garbage, 150 Cucumber odor in drinking-water, 52 Cultivation of bacteria, 288 Cysticercus in meat, 100 Da Costa, Dr. J. M., on irritable heart, 264 Daily allowance of water in American cities, 46 Dead, disposal of, 279 Death-rate and birth-rate, 361 Decayed meat and fish as causes of dis- ease, 100 "Dececo" closet, 171 DeChaumont's rule regarding ground- water oscillations, 130 Defective hearing among school-chil- dren, 202 Defoe, on the plague, 295 Dengue, 336 Deodorizers, 348 Diarrhoea and dysentery in armies, 236 Dickson, on the plague in India, 297 Digestive derangements among school- children, 203 Diphtheria, 335 Diseases caused by high temperature, 14 from impure water, 58 from infected and spoiled meat, 99 from infected milk, 92 from soil impurities, 129 on shipboard, 252 Disinfectants and disinfection, 347 Disinfection, methods of, 353 Distilled water, 54 Drainage of wet soils, 133 Drowned persons, restoration of, 270 Duration of infection, 291 Dwellings and overcrowding, 151 materials of which to be built, 158 Earth-closets, 141 Eberth's bacillus as a cause of typhoid fever, 63 Eggs as food, 105 Electric light and its dangers, 165 Emmerich on the innocuousness of im- pure water, 61 Entombment, 281 Epidemic diseases, 290 due to defective ventilation, 29 •Erismann on Liernur's system, 143 Exercise and training, 261 physiological effects of, 261 Filtration of water, 69 "Fire-damp," 30, 214 Flushing cistern for water-closets, 173 Fodor, on the production of carbon di- oxide, 27 Fohn, 19 Folsom, C. F., on typhoid fever from infected water, 63 Food necessary to health, 81 of the soldier, 232 Forwood, Dr. W. S., on hydrochloric- acid fumes, 212 Freire, on yellow-fever germ in soil, 125 Fresh-air inlet, 177 Gardner, James T., on Rochdale sys- tem, 139 Gas poisoning, 29 Germ theory, 285 Gihon, Dr. A. L , on naval hygiene, 243 on syphilis in the United States, 342 Gin, 115 Glanders, 345 Green vegetables, 108 Ground air, 122 Ground-water, 127 and cholera, 130 and typhoid fever, 131 Habitations, 151 Hammond's experiment on organic mat- ter in the air, 28 Hardness of water, 56 Harmattan, 19 Heart disease and altitude, 11 Heating and ventilation of dwellings, 160 Hecker on the plague, 294 Holt, Dr. Jos., on Louisiana quarantine, 374 INDEX, 419 Hopper-closets, 169 Hospital administration and manage- ment, 187 records, 189 Hospitals, 179 House-drainage, 166 Howard, John, on hospital construction, 183 Humidity and health, 18 of the atmosphere, 5 Hydrophobia, 344 Illuminating gas, dangers of, 164 Impurities in water, 55 Increased atmospheric pressure, 12 Incubation of infectious diseases, table of, 291 Industrial hygiene, 207 Influence of barometric pressure upon results of operations, 12 Influenza, 338 Inland quarantine, 393 Inoculation of small-pox, 303 Interment, 279 in war, 282 Iodine poisoning, 216 Jenner, Edward, and vaccination, 306 Jesty, Benjamin, 306 Johns Hopkins Hospital, 180 Jones, Dr. Joseph, on syphilis among the mound-builders, 341 Kefyr, 116 Kober, Cl. M., on mountain fever, 49 Koch, R., on the cholera spirillum in drinking-water, 65 Kumys, 116 Lakes and ponds as sources of drinking- water, 51 Lambrecht's polymeter, 8 Lead poisoning, 217 Legumes, 107 Liernur's pneumatic system, 143 Lighting of dwellings, 163 Lortet's observations on diminished at- mospheric pressure, 8 Louisiana quarantine, 371 Low temperature as a cause of respira- tory diseases, 15 Malarial fevers in armies, 237 Marine hygiene, 243 Maritime quarantine, 367 administration of, 380 Marsh-water and malaria, 59 Marshall, John, on cholera from infected water, 64 Maryland Maternite case-record, 189 Mate, 119 McClellan's trap, 174 McSherry, R., on siguatera, 102 Measles, 334 Meat, 97 extracts and essences, 99 Mercurial poisoning, 218 Metabolism during muscular exercise, 88 Methods of cooking, 109 of sewage removal, 136 Michigan method of restoring the appa- rently drowned, 271 Midden privies, 138 Military and camp hygiene, 231 Milk as food, 89 sickness, 94 Mineral poisons in water, 75 Mistral, 18 Montague, Lady M. W., on inoculation, 303 Montgomery quarantine conference, 405 Moore, J. W., on seasonal prevalence of pneumonia, 17 Morin, on fresh air required in occupied apartments, 40 Mortality in prisons, 257 Motion of the atmosphere, 7 Mountain fever, 49 sickness, 10 Myopia of school-children, 199 National quarantines, 368 Blackbeard Island, 387 Chandeleur Island, 385 Delaware Breakwater, 388 stations, regulations for, 380 Naval hygiene, 243 rations, 251 Neirnsee, J. R , on ventilating hospital wards, 184 Nervous disorders among school-chil- dren, 203 New York quarantine, 370 Nichols, A. H., on pollution of drinking water, 52 Nitrates and nitrites in water, 73 Norther, 19 Occupation neuroses, 229 Occupations, hygiene of, 207 Organic matter in water, 71 Organisms in small-pox, 302 Oriental plague, 293 Over Darwen epidemic of drinking- water, 62 Overexertion, 264 Oxygen and CO2 in ground-air, 124 Oxygen in atmospheric air, 3 Ozone in the atmosphere, 7 Pan-closets, 167 Passengers on shipboard, 246 420 INDEX, Pathogenic organisms in ground-air, 124 Pavilion hospitals, 18 Pebrine, 286 Pengra, C. P., on bacteria in drinking- water, 53 Pensacola quarantine regulations, 383 Pepper, William, on consumption and soil moisture, 132 Perlsucht, 344 Peroxide of hydrogen in the atmos- phere, 7 Petroleum vapor as a poison, 217 Pettenkofer, on ground air, 123 on ground-water and cholera, 322 Phosphorus necrosis, 226 Phthisis in armies, 238 Physical training, 262 Physiological action of alcohol, 111 Plague, 293 Plunger-closets, 168 Plymouth epidemic of typhoid fever, 63 Pneumonia and cold weather, 16 Poisonous dust, 221 gases and vapors, 211 Power, W. H., on scarlet fever from milk, 93 Preventive inoculation, 287 Prison hygiene, 255 punishments, 258 Privies, deodorization of contents of, 137 removal of contents of, 137 ventilation of, 137 Privy-vaults, construction of, 136 pits, 138 system, 136 wells, 138 Procopius, on the plague, 293 Prudden, on typhoid bacilli in drinking- water, 53 Ptomaines in meat, 101 Public baths, 273 Purification of drinking-water, 68 Purulent conjunctivitis, 238 Quarantinable diseases, 366 Quarantine, 365 aids, 392 conference at Montgomery, 405 contrivances, 377 correlation of national, State, and municipal laws, 407 laws of United States, 411 practice, 384 regulations, Pensacola, 383 Texas, 382 Rabies, 344 Rag-sorters' disease, 224 Railroad inspection against small-pox, 404 Railroad inspection against yellow fever, 402 quarantine, 400 Registration of births, 360 of deaths, 359 of diseases, 361 of marriages, 360 Relapsing fever, 327 Rennie, on the plague, 297 Restoration of apparently drowned per- sons, 270 River-water, 48 Rochdale system, 139 Roy, A., on carbon-dioxide poisoning, 214 Rum, 115 Sailor-life, 243 Salomon, Dr. L. F., on sulphur disin- fection, 379 Sanitary cordon, 393 Sausage poisoning, 101 Scarlet fever, 334 from milk, 93 Schlagintweit's observations on moun- tain sickness, 9 Schone system, 144 School furniture, 196 house construction, 193 life, diseases of, 199 Scurvy in armies, 238 Sea-bathing, 268 Season and mortality from various dis- eases, 20 Seaton and Buchanan, on protective power of vaccination, 309 Self-purification of flowing water, 50 Separate system, 144 Sewage and sewerage, 135 farms, 149 final disposal of, 149 irrigation at Pullman, 149 Sewer-air, 30 Sheep-pock, 343 Ship sanitation, 246 Simoon, 19 Sirocco, 19 Site for dwellings, 153 Small-pox, 299 Smart, C., on mountain fever, 49 on pollution of cistern-water, 47 Soap test for hardness in water, 56 Soil atmosphere, 122 Soil, character of, for building-sites, 154 its physical and chemical charac- ters, 121 moisture and health, 153 pipe, 175 Sources of drinking-water, 47 Spinal curvature in school-children, 202 Spirillum of relapsing fever, 328 INDEX, 421 Splenic fever, 286 Spongilla fluviatilis, 52 Spring-water, 53 Standards of purity of drinking-water, 55 Steam disinfecting-chamber, 379 Sternberg, G. M., on destruction of pathogenic germs by boiling water, 68 on yellow-fever germs of Freire, 125 Storage of water, 47 Study hours for pupils, 198 Suicide and season, 26 Sun-stroke and humidity, 13 Supervision of sanitary arrangements, 177 Sweating sickness, 298 Swell-head, 343 Swill-milk, 93 Syphilis, 340 Table of constituents of animal foods, 84 of constituents of vegetable foods, 85 Tea, 118 Temperature and health, 13 of the air, 5 of fire-rooms of ships, 250 Tents and huts, 235 Tests for atmospheric impurities, 33 for impurities in drinking-water, 70 Texas quarantine regulations, 382 Thorne on typhoid fever from drinking- water, 61 Tobacco, 119 Toilet's system of barracks, 234 Total solids in water, 71 Tracy, Dr. R. S., on infecundity of tobacco-workers, 223 Traps, 173 Trichina spiralis in meat, 99 Tuberculous meat, 104 Typhoid fever, 328 Typhoid fever and ground-water, 131 causation of, 329 from drinking-water, 61 in armies, 238 Typhus fever, 330 in armies, 238 Tyrotoxicon in milk, 95 Vaccination, 305 and syphilis, 311 mode of performing the operation, 309 Valve-closets, 168 Vaughan, V. C., on the bacillus ty- phoideus in drinking-water, 64 on poisonous cheese, 97 on tyrotoxicon as a cause of cholera infantum, 95 Vaughan's daily ration, 83 Venereal diseases in armies, 239 Ventilation, 38 and heating of hospitals, 183 of prisons, 258 of ships, 248 Vital statistics, 359 Voit's standard diet-tables, 83 Waring system at Memphis, 145 Water-carriage system of sewage re- moval, 144 Water-closets, 167 Water required by human beings, 45 supply in dwellings, 166 Well-water, 53 Whisky, 114 Wilkinson, Dr.C. P., on Louisiana quar- antine, 372 Wines, 115 Wolpert's air-tester, 34 Wyman's case-record, 189 Yellow fever, 331 causation of, 332 Yellow-fever cordon in Texas, 395 MARCH, 1890. CATALOGUE OF THE Medical Publications OF F. A. DAVIS, « Medical Publisher and Bool<«eller, 1231 FILBERT STREET, PHILADELPHIA, U.S.A. BRANCH OFFICES: 45 East Twelfth St., New York, U.S.A. 1 Kimball House, Wall St., Atlanta, Ga., U.S.A. 24 Lakeside Building, 214-220 S. Clark St., 427 Sutter St., San Francisco, Cal., U.S.A. Cor. Adams, Chicago, III., U.S.A. 139-143 Oxford St., London, W., England. SPECIAL NOTICE. In addition to our own Publications, we keep constantly on hand a large stock of Medical, Dental, Pharmaceutical, and Veterinary Books. Complete Catalogue (64 pages) furnished free on application. We give prompt and careful attention to every inquiry, as well as to every order. All New Books Received as soon as Published. Remittances should be made by Express Money-Order, Post- Office Money-Order, Registered Letter, or Draft on New York City, Philadelphia, Boston, or Chicago. We do not hold ourselves responsible for books sent by mail; to insure safe arrival of books sent to distant parts, the package should be registered. Charges for registering (at purchaser's expense), ten cents for each four pounds or less. NEW BOOKS IN PRESS AND IN PREPARATION. BACTERIOLOGICAL DIAGNOSIS-TABULAR AIDS FOR USE IN PRACTICAL WORK. By James Eisenberg, Ph.D., M.D., Vienna. Trans- lated and augmented, with the permission of the author, from the Second German Edition, by Norval II. Pierce, M.D., Surgeon to the Out-Door Department of Michael Reese Hospital; Assistant to Surgical Clinic College of .Physicians and Sur- geons, Chicago, Ill. In one Octavo volume. In Press. LECTURES ON ARTISTIC ANATOMY AND THE SCIENCES USE- FUL TO THE ARTIST. A series delivered at the Art Institute, Chicago, by S. V. Clevenger, M.D., Consulting Physician Reese and Alexian Hospitals ; Member numerous American Scientific and Medical Societies; Author of "Spinal Concussion," "Comparative Physiology and Psychology," etc. Illustrated with Seventeen (17) fine full-page Lithographic Plates. In one handsome Quarto volume. In Press. TWELVE LECTURES ON THE STRUCTURE OF THE CENTRAT. NERVOUS SYSTEM. For Physicians and Students. By Dr. Ludwig Edinger, Frankfort-on-the-Main. Second Revised Edition, with 133 Illustrations. Translated by Willis Hall Vittum, M.D., St. Paul, Minn. Edited by C. Eugeni: Riggs, A.M., M.D., Professor of Mental and Nervous Diseases, University of Minne- sota; Member of the American Neurological Association. In one Octavo volume. In Press. THE PRINCIPLES OF SURGERY. For Students and Practitioners. By N Senn, M.D., Ph.D., Attending Surgeon Milwaukee Hospital; Professor of Principles of Surgery in Rush Medical College, Chicago, Ill., etc. In one Octavo volume. Illustrated. In Preparation. DISEASES OF THE HEART, LUNGS, AND KIDNEYS. By N. S. Davis, Jr., A.M., M.D., Professor of Principles and Practice of Medicine in the Chicago Medical College, Chicago, Ill., etc. In one neat 12mo volume. No. 5 in the " Physicians' and Students' Ready-Reference Series." In Preparation. CHILDBED: ITS MANAGEMENT: DISEASES AND THEIR TREAT- MENT. By Walter P. Manton, M.D., Visiting Physician to the Detroit Woman's Hospital; Consulting Gynaecologist to the Eastern Michigan Asylum; President of the Detroit Gynaecological Society; Fellow of the American Society of Obstetricians and Gynaecologists, and of the British Gynaecological Society; Member of the Michigan State Medical Society, etc. In one neat 12mo volume. No. 6 in the " Physicians' and Students' Ready-Reference Series." In Preparation. Arrangements are being made for volumes upon the "Eye," "Nose and Throat," " Gynaecology," " Medical Microscopy," "Physiology," etc., to follow the above, at intervals, in the " Physicians' and Students' Ready-Reference Series." The Physicians' and Students' Ready-Reference Series Includes publications of great value to students during their attendance at college, and to the busy physician in his daily practice. While they in no way attempt to supplant the various Text-Books, it cannot be doubted that they are necessary to the often overworked student when examination time is approaching, previous to which, for weeks, but little time can be gained from the lectures in which to make careful and thorough preparation for the examination-room. Complete synopses of the several important branches, and valuable monographs on various important subjects, are furnished in the publications of this series in such form and arrangement by competent writers as to render them of special practical value to the busy student and also to the physician in active practice. The volumes are neat and con- venient in size and shape, and appropriately illustrated with many fine wood-engravings. See Pages 3, 20, 21, and 27 for those now published, and the upper part of this page for those in preparation. 2 (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) JUST PUBLISHED-A NEW AND VALUABLE WORK ON Practical Electricity MEDICINE AND SURGERY. -BY-_ ' G. A. LIEBIG, Jr., Ph.D., Assistant in Electricity, Johns Hopkins University; Lecturer on Medical Electricity, College of Phy- sicians and Surgeons, Baltimore; Member of the American Institute of Electrical Engineers, etc., -AND- GEORGE H. ROHE, M.D., Professor of Obstetrics and Hygiene, College of Physicians and Surgeons, Baltimore ; Visiting Physician to Bay View and City Hospitals; Director of the Maryland Maternite; Associate Editor "Annual of the Universal Medical Sciences," etc. PROFUSELY ILLUSTRATED BY WOOD-ENGRAVINGS AND ORIGINAL DIAGRAMS, AND PUBLISHED IN ONE HANDSOME ROYAL OCTAVO VOLUME OF ABOUT 400 PAGES, BOUND IN EXTRA CLOTH. NET PRICE, UNITED STATES and CANADA, $2.00, Post-paid; GREAT BRITAIN, 8s. 6d.; FRANCE, 12 fr. 40. The part on Physical Electricity, written by Dr. Liebig, one of the recognized authorities on the science in the United States, treats fully such topics of interest as Storage Batteries, Dynamos, the Electric Light, and the Principles and Practice of Electrical Measurement in their relations to Medical Practice. Professor Rohe, who writes on Electro-Therapeutics, discusses at length the recent developments of Electricity in the treatment of stricture, enlarged prostate, uterine fibroids, pelvic cellulitis, and other diseases of the male and female genito-urinary organs. The applications of Electricity in dermatology, as well as in the diseases of the nervous system, are also fully considered. THE SECOND VOLUME IN THE PHYSICIANS' AND STUDENTS' READY REFERENCE SERIES. HAND-BOOK OF Materia M edica, piiarou, and Therapeutics By CUTHBERT BOWEN, M.D., B.A., Editor of "Notes-on Practice." EXTRACT FROM THE PREFACE.-" While this is essentially a Student's Manual, a large amount of matter has been incorporated which, it is hoped, will render itauseful reference-book to the young graduate who is just entering on his professional career, and more particularly the individual whose sphere of work demands a more practical acquaintance with pharmaceutical processes than is required of the ordi- nary city practitioner. Great care has been taken throughout the book to familiarize the student with the best methods of administering the various drugs he will be called upon to use, and with this object a large number of standard prescriptions have been selected from the works of the most eminent authorities, which he can either adopt, with modifications to suit particular cases, or use as models on which to const met his own formula:. ' ' This excellent manual comprises in its 366 small criticism we can make on this volume is that it does octavo pages about as much sound and valuable in- not claim enough.-Southern California Prac- formation on the subjects indicated in its title as titioner. could well be crowded into the compass. The book The book is one of the very best of its class.- is exhaustively and correctly indexed, and of aeon- Columbus Medical Journal. venient form. The paper, press-work, and binding This is a very condensed and valuable resume are excellent, and the typography (long primerand | of the drugs recognized by the United States Phar- brevier) is highly to be commended, as opposed to macopoeia, and all the officinal and important the nonpareil and agate usually used incompendsof preparations.-Southern Medical Record. this sort, and which are destructive to vision and Dr. Bowen's work is a very valuable one indeed, temper alike.-St. Louis Med. and Surg. Jour. and will be found "to fill a want" beyond a doubt. In going through it, we have been favorably im- -Cincinnati Medical News. pressed by the plain and practical suggestions in It is short and concise in its treatment of the regard to prescription writing, and the metric sys- subjects, yet it gives sufficient to gain a very correct tein, and the other things which must be known in knowledge of everything that comes under this head- order to write good and accurate prescriptions.- ing. This is a ready work for the country physician, Medical and Surgical Reporter. who must of necessity have a more practical acquain- Many works claim more in their title-pages than tance with pharmaceutical processes.-Medical can be verified further on, but the only adverse Brief. One 12mo volume of 370 pages. Handsomely Bound in Dark-Blue Cloth. Price, post-paid, in the United States and Canada, $1.40, net; in Great Britain, 6s. 6d.; in France, 9 fr. 25. (F. A. DAVIS. Medical Publisher, Philadelphia. Pa., U.S A.) 3 Bashore s Improved Clinical Chart. For the SEPARATE PLOTTING of TEMPERATURE, PULSE, and RESPIRATION. Designed for the Convenient, - Accurate, and Permanent Daily Recording of Cases in Hospital and Private Practice. By HARVEY B. BASHORE, M.B. ('aee Initial Date Name .. - .... - Diagnosis - - Date , _ " m,e Me me gE me me gi Ae m[e Je Be mem|e jiis ij^E b ZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZ ,06'zzzzzzzzzzzzzzzzzzzzzzzzzzzzz"zzzzzzzzzz z~ 1O5'--ZZZZ^ZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZ zz '.Led, > 101-zzzzz;±zziz-zzzz-zzzzzjzzz-zf zzzzzzzzzzzz 160 100 Ezzzzz SEzZZZ_Z 180 98i==li=!l==ii==!=zlh=lb^=p!iphbpii=i I 140 98'zZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZ o 130 97===2ZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZ^ 120 so ^"zzzzEzzzzzzzzzzzzzzzzzzrzzjz pzzzzzzzzz no sozzzzzzzzzzzzzzzazzzzzzzzzzzzzEz : zzzzzzzzzz* ioo 45 EEEE=zzzzzzrzizziizzzzzzzzzzjzEzfzzzzzzzzz 90 40 Ezzzzzs9zE?z5z_zzzzzzzzgz3~"zztzzE-z^zz?zt eo 35 Ezzzzzzzizzzzzzzzzlz?z^z§zzzzzzzzzzzzz^zzz 70 30 = = = ZZZZ1ZZZZZZZZZZ eo 88 ipBiliyfilblOpphliiiOiiihppiii 50 20 Ezzzzz_z_zzz_zzzzz_z„zzzzzzzzzzzzzzzz?z^z 40 i5---=-==-----Ezzzzzzzzzzzzzzzzzzzzzzzzzzzzz > $ ------------------------------------ -LI 1.1 I I I I Aixl I I I I I I I I I I I I > I I I I I A i i i.A.i 1.LJ COPYRIGHTED, 1888, BY F. A. DAVIS. 50 Clxarts, ixx Talolet Form. Size, 8x12 ixxclxes. Price, in the United States and Canada, Post-paid, 50 Cents, Net; Great Britain, 2s. 6d.; France, 3 fr. 60. The above diagram is a little more than one-fifth (1-5) the actual size of the chart and shows the method of plotting, the upper curve being the Temperature, the middle the Pulse, and the lower the Respiration. By this method a full record of each can easily be kept with but one color ink. It is so arranged that all practitioners will find it an invaluable aid in the treatment of their patients. On the back of each chart will be found ample space conveniently arranged for recording "Clinical History and Symptoms" and "Treatment." By its use the physician will secure such a complete record of his cases as will enable him to review them at any time. Thus he will always have at hand a source of individual improvement and benefit in the practice of his profession, the value of which can hardly be overestimated. 4 (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) OOK^ ON The Physician HimseP AND THINGS THAT CONCERN HIS REPUTATION AND SUCCESS. BY D. W. CATHELL, M.D., BALTIMORE. MD. Being the NINTH EDITION (Enlarged and Thoroughly Revised) of the "PHYSICIAN HIMSELF. AND WHAT HE SHOULD ADD TO HIS SCIENTIFIC ACQUIREMENTS IN ORDER TO SECURE SUCCESS." In One Handsome Octavo Volume of 298 Pages, Bound in Extra Cloth. Price, Post-paid, in United States and Canada, $2.00, Net; Great Britain, 8s. 6d.; France, 12 fr. 40. This remarkable book has passed through eight (8) editions in less than five years, has met with the unanimous and hearty approval of the Profession, and is practically indispensable to every young graduate who aims at success in his chosen profession. It has just undergone a thorough revision by the author, who has added much new matter cover- ing many points and elucidating many excellent ideas not included in former editions. This unique book, the only complete one of the kind ever written, will prove of inestimable pleasure and value to the practi- tioner of many years' standing, as well as to the young physician who needs just such a work to point the way to success. We give below a few of the many unsolicited letters received by the author, and extracts from reviews in the Medical Journals of the former editions: " 'The Physician Himself' is an opportune and " 'The Physician Himself' is useful alike to the most useful book, which cannot fail to exert a good tyro and the sage-the neophyte and the veteran. It influence on the morale and the business success of is a headlight in the splendor of whose beams a the Medical profession."-From Prof. Roberts ! multitude of our profession shall find their way to Bartholow, Philadelphia, Pa. । success."-From Prof. J. M. Bodine, Dean Uni- ' I have read 'The Physician Himself' with versify of Louisville. pleasure--delight. It is brimful of medical and «< jt js replete with good sense and sound phi- social philosophy ; every doctor in the land can losophy. No man can read it without realizing that study it with pleasure and profit. I wish I could its author is a Christian, a gentleman, and a shrewd have read such a work thirty years ago."-From observer."-From Prof Edward li'arren (Bey), Prof. John S. Lynch, Baltimore, Md. Chevalier of the Legion of Honor, etc., Paris, '"The Physician Himself' interested me so France. much that I actually read it through at one sitting. «] have rcad < The physician Himself,' care- Iqis brimful ofthe very best advice possible for fully. I find it an admirable work, and shall advise medical men. T, for one, shall try to profit by it. - our janjtor fO keep a stock on hand in the book de- From Prof. William Goodell, Philadelphia. partment of Bellevue."-From Prof. William T. " I would be glad if, in the true interest of the Lusk, New York. profession in - Old England,' some able practitioner .. j im a„ its readers wRh the belicf here would prepare a work for us on the same l.ne as * b b) and honest member of Jhe Th?rC'an A r J 7 'he profession and for the good of the profession."- Styrap, Shrewsbury, England. F^m prg/ Chica^ m " I am most favorably impressed with the . . , wisdom and force of the points made in ' The Phy- is marked with good common sense, and sician Himself,' and believe the work in the hands replete with excellent maxims and suggestions for of a young graduate will greatly enhance his chances the guidanceof medical men. brom I te British for professional success."-From Prof. D. Hayes Medical Journal, London. Agnew, Philadelphia, Pa. "We strongly advise every actual and intend- " This book is evidently the production of an ing practitioner of medicine or surgery to have unspoiled mind and the fruit of a ripe career. I ' The Physician Himself ' and the more it influences admire its pure tone and feel the value of its practi- his future .conduct the better he will be."-From cal points. How I wish I could have read such a The Canada Medical and Surgical Journal, guide at the outset of my career!"-From Prof. Montreal. James Nevins Hyde, Chicago, III. .< \ve would advise every doctor to well weigh " It contains a great deal of good sense, well the advise given in this book, and govern his con- expressed."-From Prof. Oliver Wendell Holmes, duct accordingly."-From The Virginia Medical Harvard University. Monthly. (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 5 AN IMPORTANT PUBLICATION OF GREAT VALUE TO THE MEDICAL AND LEGAL PROFESSIONS. Spinal Concussion: Surgically Considered, as a Cause of Spinal Injury, and Neurologi- cally Restricted to a Certain Symptom Group, for which is Suggested the Designation ERICKSEN'S DISEASE, AS ONE FORM OF THE TRAUMATIC NEUROSES. BY f S. V. CLEVENGER, M.D., CONSULTING PHYSICIAN REESE AND ALEXIAN HOSPITALS; LATE PATHOLOGIST COUNTY INSANE ASYLUM, CHICAGO; MEMBER OF NUMEROUS AMERICAN SCIENTIFIC AND MEDICAL SOCIETIES; COLLABORATOR AMERICAN NATURALIST, ALIENIST AND NEUROLOGIST, JOURNAL OF NEUROLOGY AND PSYCHIATRY, JOURNAL OF NERVOUS AND MENTAL DISEASES; AUTHOR OF "COM- PARATIVE PHYSIOLOGY AND PSYCHOLOGY,*' "ARTISTIC ANATOMY," ETC. For more than twenty years this subject has occasioned bitter con- tention in law courts, between physicians as well as attorneys, and in that time no work has appeared that reviewed the entire field judicially until Dr. Clevenger's book was written. It is the outcome of five years' special study and experience in legal circles, clinics, hospital and private practice, in addition to twenty years' labor as a scientific student, writer, and teacher. The literature of Spinal Concussion has been increasing of late years to an unwieldy shape for the general student, and Dr. Clevenger has in this work arranged and reviewed all that has been done by'observers since the days of Erichsen and those who preceded him. The different and sometimes antagonistic views of many authors are fully given from the writings of Erichsen, Page, Oppenheim, Erb. Westphal, Abercrombie. Sir Astley Cooper, Boyer, Charcot, Leyden, Bigler, Spitzka, Putnam. Knapp, Dana, and many other European and American students of the subject. The small, but important, work of Oppenheim, of the Berlin University, is fully translated, and constitutes a chapter of Dr. Cleven- ger's book, and reference is made wherever discussions occurred in American medico-legal societies. There are abundant illustrations, particularly for Electro-diagnosis, and to enable a clear comprehension of the anatomical and pathological relations. The Chapters are: I. Historical Introduction; 11. Erichsen on Spinal Concussion ; 111. Page on Injuries of the Spine and Spinal Cord: IV. Recent Discussions of Spinal Concussion ; V. Oppenheim on Trau- matic Neuroses; VI. Illustrative Cases from Original and all other Sources; VII. Traumatic Insanity; VIII. The Spinal Column; IX. Symptoms; X. Diagnosis; XI. Pathology: XII. Treatment; XIII. Medico-legal Considerations. Other special features consist in a description of modern methods of diagnosis by Electricity, a discussion of the controversy concerning hysteria, and the author's original pathological view that the lesion is one involving the spinal sympathetic nervous system. In this latter respect entirely new ground is taken, and the diversity of opinion con- cerning the functional and organic nature of the disease is afforded a basis for reconciliation. Every Physician and Lawyer should own this work. In one handsome Royal Octavo Volume of nearly 400 pages, with Thirty Wood-Engravings. Net price, in United States and Canada, $2.50, post-paid ; in Great Britain, Ils. 3d.; in France, 15 fr. 6 (F. 4 DAVIS. Medical Publisher, Philadelphia, Pa.. U.S.A.) JUST READY A NEW AND IMPORTANT WORK. ESS AY -ON- MEDICAL PNEUMATOLOGY HEROTHERAPY: A PRACTICAL INVESTIGATION OF THE CLINICAL AND THERAPEUTIC VALUE OF THE GASES IN MEDICAL AND SURGICAL PRACTICE, WITH ESPECIAL REFERENCE TO THE VALUE AND AVAILABILITY OF OXYGEN, NITROGEN, HYDROGEN, AND NITROGEN MONOXIDE. By J. N. DEMARQUAY, Surgeon to the Municipal Hospital, Paris, and of the Council of State; Member of the Imperial Society of Surgery; Correspondent of the Academies of Belgium, Turin, Munich, etc. ; Officer of the Legion of Honor; Chevalier of the Orders of Isabella-the- Catholic and of the Conception, of Portugal, etc. TRANSLATED, WITH NOTES, ADDITIONS, AND OMISSIONS, By SAMUEL S. WALLIAN, A.M., M.D., Member of the American Medical Association ; Ex-President of the Medical Association of Northern New York ; Member of the New York County Medical Society, etc. In one Handsome Octavo Volume of 316 Pages, Printed on Fine Paper, in the Best Style of the Printer's Art, and Illustrated with 21 Wood-Cuts. United States. Canada (duty paid). Great Britain. France. NET PRICE, CLOTH, Post-paid, S2.OO S2.20 8s. 6d. 12 fr. 40 " %-RUSSIA, " 3.00 3.30 13s. 18 fr. 60 For some years past there has been a growing demand for something more satisfac- tory and more practical in the way of literature on the subject of what has, by common consent, come to be termed " Oxygen Therapeutics." On all sides professional men of standing and ability are turning their attention to the use of the gaseous elements about us as remedies in disease, as well as sustainers in health. In prosecuting their inquiries, the first hindrance has been the want of any reliable, or in any degree satisfactory, literature on the subject. Purged of the much quackery heretofore associated with it, Aerotherapy is now recognized as a legitimate department of medical practice. Although little noise is made about it, the use of Oxygen Gas as a remedy has increased in this country within a few years to such an extent that in New York City alone the consumption for medical pur- poses now amounts to more than 300,000 gallons per annum. This work, translated in the main from the French of Professor Demarquay, contains also a very full account of recent English, German, and American experiences^prepared by Dr. Samuel S. Wallian, of New York, whose experience in this field antedates that of any other American writer on the subject. . ~ - Plain Talks on Avoided Subjects. -BY HENRY N. GUERNSEY, M.D., Formerly Professor of Materia Medica and Institutes in the Hahnemann Medical College of Philadelphia; Author of Guernsey's " Obstetrics," including the Disorders Peculiar to Women and Young Children ; Lectures on Materia Medica, etc. IN ONE NEAT 16mo VOLUME. BOUND IN EXTRA CLOTH. Price, Post-paid, in United States and Canada, SSI.00; Great Britain, 4s. 6d.; France, 6 fr. 20. This is a little volume designed to convey information upon one of the most important subjects con- nected with our physical and spiritual well-being, and is adapted to both sexes and all ages and conditions of society ; in fact, so broad is its scope that no human being can well afford to be without it, and so com- prehensive in its teachings that, no matter how well informed one may be, something can yet be learned from this, and yet it is so plain that any one who can read at all can fully understand its meaning. The Author, Dr. H. N. Guernsey, has had an unusually long and extensive practice, and his teachings in this volume are the results of his observation and actual experience with all conditions of human life. His work is warmly indorsed by many leading men in all branches of professional life, as well as by many whose business connections have caused them to be close observers. The following Table of Contents shows the scope of the book:- CONTENTS. Chapter I.-Introductory. II.-The Infant. III.-Childhood. IV.-Adoles- cence of the Male. V.-Adolescence of the Female. VI.-Marriage: The Husband. VU.- the Wife. VIII.-Husband and Wife. IX.-To the Unfortunate. X.-Origin of the Sex. (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 7 . EDITION Lessons in Gynecology. By WILLIAM GOODELL, A.M., M.D., Etc., Professor of Clinical Gynecology in the University of Pennsylvania. With 112 Illustrations. Third Edition, Thoroughly Revised and Greatly Enlarged. ONE VOLUME, LARGE OCTAVO, 578 PAGES. This exceedingly valuable work, from one of the most eminent specialists and teachers in gynecology in the United States, is now offered to the profession in a much more complete condition than either of the previous editions. It embraces all the more important diseases and the principal operations in the field of gynecology, and brings to bear upon them all the extensive practical experience and wide reading of the author. It is an indispensable guide to every practitioner who has to do with the diseases peculiar to wemen. Fig. 44. wf11 Natural Position of the Womb When the Bladder is Pull. After Briesky. These lessons are so well known that it is en- ! is a directness and simplicity about it which is easier tirely unnecessary to do more than to call attention to admire than to copy. His chain of plain words to the fact of the appearance of the third edition. and almost blunt expressions, his familiar compari- It is too good a book to have been allowed to remain son and homely illustrations, make his writings, like •ut of print, and it has unquestionably been missed. his lectures, unusually entertaining. The substance The author has revised the work with special care, of his teachings we regard as equally excellent.- adding to each lesson such fresh matter as the prog- Phila. Medical and Surgical Reporter. ress in the art rendered necessary, and he has en- Extended mention of the contents of the book is larged it by the insertion of six new lessons. This unnecessary; suffice it to say that every important edition will, without question, be as eagerly sought disease found in the female sex is taken up and dis- fbr as were its predecessors.-American Journal 1 cussed in a common-sense kind of a way. We wish •f Obstetrics. every physician in America could read and carry The former editions of this treatise were well out the suggestions of the chapter on "the sexual re received by the profession, and there is no doubt lations as causes of uterine disorders-conjugal that the new matter added to the present issue makes onanism and kindred sins.'' The department treat - it more useful than its predecessors.-New York ing of nervous counterfeits of uterine diseases is Medical Record. a most valuable one. - Kansas City Medical His literary style is peculiarly charming. There Index. Price, in United States and Canada, Cloth, $5.00; Full Sheep, $6.00. Discount, 20 per cent., making it, net, Cloth, $4.00; Sheep, $1.80. Postage, 27 Cents extra. Great Britain, Cloth, 18s.; Sheep, £1.2s., post-paid, net. France, 30 fr. 80. S (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) AMERICAN RESORTS, WITH NOTES UPON THEIR CLIMATE. ' Ey BUSHROD W. JjClMZES, jPl.M:., 3XE.TD., Member of the American Association for the Advancement of Science, the American Public Health Association, the Pennsylvania Historical Society, the Franklin Institute, and the Academy of Natural Sciences, Philadelphia; the Society of Alaskan Natural History and Ethnology, Sitka, Alaska, etc. WITH A TRANSLATION FROM THE GERMAN, BY Mr. S. KAUFFMANN, Of those chapters of " Die Klimate der Erde" written by Dr. A. Woeikof, of St. Petersburg, Russia, that relate to North and South America and the islands and oceans contiguous thereto. In One Octavo Volume. Handsomely Bound in Cloth. Nearly 300 Pages. Price, Post-paid, in U. S. and Canada, SS2.00, net. Great Britain, 8s. 6d. France, 12 fr. 40. This is a unique and valuable work, and useful to physicians in all parts of the country. It is just such a volume as the Medical Profession have stood in need of for many years. We mention a few of the merits it possesses: First. I.ist of all the Health Resorts of the country, arranged according to their climate. Second. Contains just the information needed by. tourists, invalids, and those who visit summer or winter resorts. Third. The latest and best large railroad map for reference. Fourth. It indicates the climate each one should select for health. Fifth. The author has traveled extensively, and most of his suggestions are practical in reference to localities. Taken altogether, this is by far the most complete ex- I ought, as it deserves, to receive a hearty welcome from the position of the subject of resorts that has yet been put ' profession.-Medical Advance. forth, and it is one that every physician must needs possess The book before us is a very comprehensive volume, intelligent information upon. We predict a large demand giving all necessary information concerning climate, tem- for this useful and attractive book.-Buffalo Med. and perature, humidity, sunshine, and indeed everything neees- Sury. Jour. sarv to be stated for the benefit of the physician or invalid The special chapter on the therapeutics of climate . . seeking a health resort in the United States.-Southern is excellent for its precautionary suggestions in the selec- Clinic. , tion of climates and local conditions, with reference to This work is extremely valuable, owing to the liberal known pathological indications and constitutional predis- and accurate manner in which it gives information regard- positions.- The, Sanitarian. ing the various resorts on the American continent, without It is arranged in such a manner that it will be of great being prejudiced in the least in favor of any particular one. service to medical men whose duty it often becomes to rec- but giving all in a fair manner. . . . All physicians ommend a health resort.-A'. IF. Med. Jour. need just such a work, for the doctor is always asked to A well-arranged map of the United States serves as the give information on the subject to his patients. Therefore, frontispiece of the book ; and an almost perfect index is it should find a place in every physician's library.- The appended, while between the two is an amount of informa- Med. Brief. - tion as to places for the health-seeker that cannot be gotten The author of this admirable work has long made a elsewhere. We most cordially recommend the book to study of American climate, from the stand-point of a phy- travelers and to the doctor.- Virginia Med. Monthly. sician, with a view to ascertaining the most suitable locali- This is a work that has long been needed, as there is ties for the residence of invalids, believing proper climate scarcely a physician who has not had occasion to look up to be an almost indispensable factor in the treatment, pre- the authorities on climate, elevation, dryness, humidity, vention, and cure of many forms of disease. . . . The etc , etc., of the various health resorts, and has had great book evidences careful research and furnishes much useful difficulty in finding reliable information. It certainly information not to be found elsewhere.-Pacific Med. Jour. -JUST PUBLISHED"'-- RECORD-BOOK OF MEDICAL EXAMINATIONS For Life Insurance. In examining for Life Insurance, questions are easily overlooked and the answers to them omitted ; and, as these questions are indispensable, they must be answered before the case can be acted upon, and the examiner is often put to much inconvenience to obtain this information. The need has long been felt among examiners for a reference-book in which could be noted the principal points of an examination, and thereby obviate the necessity of a second visit to the applicant when further information is required. After a careful study of all the forms of examination blanks now used by Insurance Companies, Dr. J. M. Keating has compiled such a record-book which we are sure will fill this long-felt want. This record-book is small, neat, and complete, and embraces all the principal points that are required by the different companies. It is made in two sizes, viz. : No. 1, cover- ing one hundred (100) examinations, and No. 2, covering two hundred (200) examina- tions. The size of the book is 7 x 3f inches, and can be conveniently carried in the pocket. NET PRICES, POST-PAID. U. S. and Canada. Great Britain. France. No. 1, For 100 Examinations, in Cloth, - S .50 2s. 6d. 3 fr. 60 No. 2, For 200 Examinations, in Full Leather, with Side Flap, - - - - 1.00 4s. 6d. 6 fr. 20 (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S A.) 9 DISEASES-"^ OF THE Heart and Circulation IN INFANCY AND ADOLESCENCE. With an Appendix entitled " Clinical Studies on the Pulse in Childhood." BY- JOHN M. KEATING, M.D., Obstetrician to the Philadelphia Hospital, and Lecturer on Diseases of Women and Children; Surgeon to the Maternity Hospital ; Physician to St. Joseph's Hospital; Fellow of the College of Physicians of Philadelphia, etc., -AND- WILLIAM A. EDWARDS, M.D., Instructor in Clinical Medicine and Physician to the Medical Dispensary in the University of Pennsylvania ; Physician to St. Joseph's Hospital; Fellow of the College of Physicians; formerly Assistant Pathologist to the Philadelphia Hospital, etc. ILLUSTRATED BY PHOTOGRAPHS AND WOOD-ENGRAVINGS. About 225 Pages. 8vo. Bound in Cloth. Price, post-paid, in U. S. and Canada, $1.50, net; Great Britain, 6s. 6d.; France, 9 fr. 35. There are many excellent text-books on children's diseases, but they have failed to give a satisfactory account of the diseases of the heart ; and, indeed, as far as known, this work of Keating and Edwards' now presented to the profession is the only systematic attempt that has been made to collect in book form the abundant material which is scattered throughout medical literature in the form of journal articles, clinical lectures, theses, and reports of societies. The authors have endeavored, in their difficult task, to collect these valuable materials and place them within easy reach of those who are interested in this important subject. That they have succeeded will, we believe, be conceded by all who obtain and make use of their very valuable contribution to this hitherto- neglected field of medical literature. An appendix, entitled "Clinical Studies on the Pulse in Childhood," follows the index in the book, and will, we are sure, be found of much real value to every practitionerof medicine. The work is madeavailable for ready reference by a well-arranged index. We append the table of contents showing the scope of the book:- CO1TTE1TTS Chapter I.-The Methods of Study-Instruments- Chapter VII.-General Diagnosis, Prognosis, and Foetal Circulation-Congenital Diseases of the Treatment of Valvular Disease. Heart-Malformations-Cyanosis. Chapter VIII.- Endocarditis-Atheroma - Aneu- Chafter II.-Acute and Chronic Endocarditis- rism. Ulcerative endocarditis. Chapter IX.-Cardiac Neuroses-Angina Pectoris Chapter III.-Acute and Chronic Pericarditis. -Exophthalmic Goitre. Chapter IV.-The treatment of Endo- and Peri- Chapter X.-Diseases of the Blood : Plethora, carditis-Paracentesis Pericardii-Hydropericar- Ana:mia, Chlorosis, Pernicious Anaemia, I eu- dium-Ha.mopericardium-Pneumopericardium. kaemia- Hodgkin's Disease-Haemophilia.Throm- Chapter V.-Myocarditis-Tumors, New Growths, bosis, and Embolism. and Parasites INDEX. Chapter VI.-Valvular Disease: Mitral, Aortic, APPENDIX.-Clinical Studies on the Pulse Pulmonary, and Tricuspid. in Childhood. Drs. Keating and Edwards have produced a work that I] It is not a mere compilation, but a systematic treatise, will give material aid to every doctor in his practice among ■ and bears evidence of considerable labor and observation on children. The stvie of the book is graphic and pleasing, - the pari of the authors. Two tine photographs of dissec- the diagnostic points are explicit and exact, and the thera- I tions exhibit mitral stenosis and mitral regurgitation: peutical resources include the novelties of medicine as well : there are also a number of wood-cuts,-Cleveland Medical as the old and tried agents.-Pittsburgh Med. Review. ' Gazette. A very attractive and valuable work has been given to As the works upon diseases of children give little or no the medical profession by Drs. Keating and Edwards, in attention to diseases of the heart, this work of Drs. Keat- their treatise on the diseases of the heart and circulation ing and Edwards will supply a want. We think that in infancy and adolescence, and they deserve the greatest j there will be no physician, who takes an interest in the credit for the admirable manner in which they have col- | affections of young folks, who will not wish to consult it. lected. reviewed, and made use of the immense amount of - Cincinnati Med. Neers. material on this important subject.-Archives of Pediatrics. - The w ork takes up. in an able and scientific manner. Tim plan of the work is the correct one, viz., the sup- 1 diseases of the heart in children. This is a part of the plementing of the observations of the better class of prac- field of medical science which has not been cultivated to tltioners by the experience of those who have given the the extent that the importance of the subject deserves.- subject systematic attention.-Medical Age. Canada Lancet. 19 (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) PERPETUAL CLINICAL INDEX -TO- MATERIA MEDICA, CHEMISTRY, AND PHARMACY CHARTS. By A. H. KELLER, Ph.G., M.D. Consisting of (1) the " Perpetual Clinical Index," an oblong volume, 9x6 inches, neatly bound in extra Cloth ; (2) a Chart of "Materia Medica," 32x44 inches, mounted on muslin, with rollers ; (3) a Chart of " Chemistry and Phar- macy," 32 x44 inches, mounted on muslin, with rollers. United States. Canada (duty paid). Great Britain. France. Net Price for the Complete Work, $5.00 $5.50 £l.ls. 30 fr. 30 Read the Following Description and Explanation of the Work: In presenting the objects and advantages of these Charts and " Perpetual Clinical Index" it becomes necessary to state that the Author's many years' experience as a physician and Pharmacist enables him to produce, in terse language, a volume of facts that must be of inestimable value to the busy physician and pharmacist, or to any student of either profession. He has endeavored to describe all that have borne inves- tigation up to date. The system will prove to be of great value in this, that so little labor will be required to add new investigation as fast as may be gathered from new books, journals, etc. The classification is alphabetical and numerical in arrangement, and serves so to unite the various essentials of Botany, Chemistry, and Materia Medica, that the very thought of the one will readily associate the principal properties and uses, as well as its origin. The "MATEKIA MEDICA " CHAKT, in the first place, aids at a glance: ist, Botanical or U. S. P. Name: ad. The Common Name; 3d, Natural Order; 4th, Where Indigenous; 5th, Principal Con- stituent; 6th, Part Used-herbs, leaves, flowers, roots, barks, etc. ; 7th, Medicinal Properties-mainly con- sidered; 8th, The Pose-medium and large. On this Chart there are 475 first names; Section A. is numbered from 1 to 59, each section commencing with the capital letter, and having its own numbers on both left-hand and right-hand columns, to prevent mistakes in lining out, all in quite large type. In the centre of the Chart, occupying about 6 inches in width, is a term index of common names. In the second column of Chart, like this : Aconite Leaves, 4 A. Then by reference to 4 A in first column, you there find the Botanical or U. S. P. Name. On this Chart is also found a brief definition of the terms used, under the heading " Medicinal Properties." The "CHEMISTRY" CHART takes in regular order the U. S. Pharmacopoeia Chemicals, with the addition of many new ones, and following the name, the Chemical Formula, the Molecular Weight, and next the Origin. This is a brief but accurate description of the essential points in the manufacture : The Dost, medium and large; next, Specific Gravity; then, whether Salt or Alkaloid; next, Solubilities, by abbreviation, in Water, Alcohol, and Glycerine, and blank columns for solubilities, as desired. Alkaloids and Concentrations are tabulated with reference numbers for the Perpetual Clinical Index, giving Medicinal PropAties, Minute Dose and Large Dose For example, Alkaloids and Concentrations: A. Medicinal Properties. Minute Dose. Large Dose. (a) Aconitine. Narcotic and Apyretic. 1-500 gr. 1-16 gr. Following this, Preparations of the Pharmacopoeia, each tabulated. For example : TINCTURAL. Tinctura. Drug. Amount. Alcohol. Dose. , . 1 - * Aconiti. J Tanaric Acid, 60 f P. 5% oz' tO 24 gr ,O° 1 tO 3 dropS' * 60 Fineness of Powder as per U. S. P. f P. Macerate 24 hours. Percolate, adding Menstruum to complete (1) pint tincture. They are all thus abbreviated, with a ready reference head-note. Next, Thermometers, Metric Table of Weights, Helps to the Study of Chemistry, Examples in Work- ing Atomic Molecular Formula:. Next, Explanation of Terms Used in Columns of Solubilities, List of Most Important Elements Now in Use, and Definitions or Terms Frequently Used in Chemistry and Pharmacy. The "PERPETUAL CLINICAL INDEX" is a book 6 by 9 inches, and one-half inch thick. It contains 135 pages, divided as follows (opposite pages blank) : The Index to Chemistry Chart occupies two pages; Explanations, Abbreviations, etc., forty pages, with diseases, and with an average of ten references to each disease, leaving room for about forty more remedies for each disease. The numbers refer to the remedies used in the diseases by the most celebrated physicians and surgeons, and the abbreviations to the manner in which they are used. Eight pages, numbered and bracketed, for other diseases not enumerated. The Materia Medica, Explanations, Abbreviations, and Remedies suggested for, occupy twenty-six pages. For Abbreviated Prescriptions, seventeen blank pages. Then the Index to Alkaloids and Concentrations. These, already enumerated, with (heir reference, number six blank tabulated pages, for noting any new Alkaloids and Concentrations. Then the Chemistry Index, giving the same number as on Chart, with Name, Doses, Specific Gravity, Salt or Alkaloid in the same line, as for example : Name. ! Doses. i Specific Gravity. Salt or Alkaloid. Memoranda. This Memoranda place" is for Physicians' or Pharmacists' reference notes; and with the addition of several tabulated blank pages, in which to add any new chemical, with doses, etc. The remaining sixteen pages for Materia Medica Index, leaving blanks following each other for new names and reference numbers. To show the ready and permanent use of the "Perpetual Clinical Index" of the "Chemistry" and "Pharmacy" Charts or Index in the book, suppose the Physician reads in a book or journal that Caffeine Citras is useful in the disease Chorea, and he wishes to keep a permanent record of that, he refers to the Chart, and if it does not already appear there, it can be placed opposite and numbered, and thereafter used for reference. But we find its permanent number is No. 99, so he will write down in the line left blank for future use in his book, in line already used, running parallel with other reference numbers in Chorea, the No. 99, and immediately under he can use the abbreviation in the manner in which it is given. Though years may have passed, he can in a moment, by referring there, see that No. 99 is good for Chorea. If fail- ing to remember what No. 99 is, he glances at the Chart or Index. He sees that No. 99 is Caffeine Citras, and he there learns its origin and dose and solubility, and in a moment an intelligent prescription can be constructed. (F. 4. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.J 11 New Edition of an Important and Timely Work Just Published. Electricity in the Diseases of flfomen, With Special Reference to the Application of Strong Currents. By G. BETTON MASSEY, M.D., physician to the Gynecological Department of Howard Hospital; Late Electro-Therapeutist to the Phila- delphia Orthopaedic Hospital and Infirmary for Nervous Diseases ; Member of the American Neurological Ass'n, of the Philadelphia Neurological Society, of the Franklin Institute, etc. Secor-cL ZEcLi-tioxx. ZSe-vised. and. Sxxlarg-ed.- WITH NEW AND ORIGINAL WOOD-ENGRAVINGS. HANDSOMELY BOUND IN CLOTH. OVER 200 PAGES. 12mo. Price, in United States and Canada, $1.50, net, post-paid. In Great Britain, 6s. 6d. In France, 9 fr. 35. Titis work is presented to the profession as the most complete treatise yet issued on the electrical treatment of diseases of women, and is destined to fill the increasing demand for clear and practical instruction in the handling and use of strong currents after the recent methods first advocated by Apostoli. The whole subject is treated from the present stand-point of electric science with new and original illustrations, the thorough studies of the author and his wide clinical experience rendering him an authority upon electricity itself and its therapeutic applications. The author has enhanced the practical value of the work by including the exact details of treatment and results in a number of cases taken from his private and hospital practice. Fig. 15.-Author's Fibroid Spear. Fig. 18.-Ball Electrode for Administering Franklinic Sparks. COlsTTEiTTS Chapter 1, Introductory ; II, Apparatus required in gynecological applications of the galvanic current; III, Experiments illustrating the physical qualities of galvanic currents; IV, Action of concentrated gal- vanic currents on organized tissues ; V, Intra-uterine galvano-chemical cauterization; VI, Operative details of pelvic electro-puncture ; VII, The faradic current in gynecology ; VIII, The franklinic current in gyne- cology ; IX, Non-caustic vaginal, urethral, and rectal applications ; X, General percutaneous applications in the treatment of nervous women; XI, The electrical treatment of fibroid tumors of the uterus ; XII, The electrical treatment of uterine hemorrhage; XIII, The electrical treatment of subinvolution; XIV, The electrical treatment of chronic endometritis and chronic metritis; XV, The electrical treatment of chronic diseases of the uterus and appendages; XVI, Electrical treatment of pelvic pain; XVII, The electrical treatment of uterine displacements; XVIII, The electrical treatment of extra-uterine pregnancy; XIX, The electrical treatment of certain miscellaneous conditions ; XX, The contra-indications and limitations to the use of strong currents. An Appendix and a Copious Index, including the definitions of terms used in the work, concludes the book. The author gives us what he has seen, and of which | sidered, and by means of good wood-cuts the beginner has he is assured by scientific study is correct We before his eye the exact method of W'ork required.-The are certain that this little work will prove helpful to all Medical Register. physicians who desire to use electricity in the management " The author of this little volume of 210 pages ought of the diseases of women.-The American Lancet. to have added to its title, " and a most happy dissertation To say that the author is rather conservative in his upon the methods of using this medicinal agent; " for in ideas of the curative powers of electricity is only another the first 100 pages he has contrived to describe the techni way of saying that he understands his subject thoroughly. of electrization in as clear and happy a manner as no The mild enthusiasm of our author is unassailable, because author has ever succeeded in doing, and for this part of the it is founded on science and reared with experience.-The book alone it is almost priceless to the beginner in the Medical Analytic. treatment with this agent The little book is The work is well written, exceedingly practical, and worthy the perusal of every one at all interested in the can be trusted. We commend it to the profession."-Mary- subject of electricity in medicine.- The Omaha Clinic, land Medical Journal. The treatment of fibroid tumor of the uterus will, The book is one which should be possessed by every perhaps, interest the profession more generally than any physician who treats diseases of women by electricity.- other question. This subject has been accorded ample The Brooklyn Medical Journal. space. The method of treatment in many cases has been The departments of electro-physics, pathology, and recited in detail, the results in every instance reported be- electro-therapeutics are thoroughly and admirably con- ing beneficial, and in many curative.-Pacific Med. Jour. 12 (F. 4. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) g is . . - ■■ . ' . ■ I . ' Practical Surgery. By J. EWING MEARS, M.B., Lecturer on Practical Surgery and Demonstrator of Surgery in Jefferson Medical College; Professor of Anatomy and Clinical Surgery in the Pennsylvania College of Dental Surgery, etc. With 490 Illustrations. Second edition, revised and enlarged. 794 pp. 12mo. PRICE, IN UNITED STATES AND CANADA : CLOTH, $3.00. DISCOUNT, 20 PER CENT., MAKING IT, NET. $2.40; POSTAGE, 20 CENTS EXTRA. GREAT BRITAIN, 13s. FRANCE, 18 fr. 75. Mears' Practical Surgery includes chapters on Surgical Dress- ings, Bandaging, Fractures, Dislocations, Ligature of Arteries, Amputa- tions, Excisions of Bones and Joints. This i work gives a complete account of the J methods of antiseptic surgery. The dif- ferent agents used in antiseptic dressing, V? their methods of preparation, and their L application in the treatment of wounds are B fully described. With this work as a guide Is possible for every surgeon to practice "0 antiseptic surgery. The great advances made in the science and art of surgery are largely due to the introduction of anti- septic methods of wound treatment, and it is incumbent upon every progressive sur- sA geon to employ them. 1 An examination of this work will show that it is thoroughly systematic in its plan, so that it is not only useful to the practitioner, who may be ('ailed upon to perform operations, but of great value to the student in his work in the surgical room, where he is required to apply bandages and fracture dressings, and to perform operations upon the cadaver. The experience of the author, derived from many years' service as a teacher (private and public) and practitioner, has enabled him to present the topics discussed in such a manner as to fully meet the needs of both prac- titioners and students. It is full of common sense, and may be safely tinner who follows it intelligently cannot easily go taken as a guide in the matters of which it treats. astray.-Journal American Medical Asso' n. It would be hard to point out all the excellences of We cannot speak too highly of the volume under thisbook. Wecan heartily recommend it tostudents review.- Canada Med. and Surg. Jozir. and to practitioners of surgery.-American Jour- The space devoted to fractures and dislocations nal of the Medical Sciences. -by far the most difficult and responsible part of We do not know of any other work which would surgery-is ample, and we notice many new illustra- be of greater value to,#ie student in connection with tions explanatory of the text.-North Carolina his lectures in this department.-Buffalo Medical Medical Journal. and Surgical Journal. It is one of the most valuable of the works of its The work is excellent. The student or practi- kind.-New Orleans Med. and SzMg. Jour. (F. A. DAVIS. Medical Publisher, Philadelphia, Pa., U.S.A.) 13 AN ENTIRELY NEW PHYSICIANS VISITING LIST. THE Medical Bulletin Visiting List OR Physician's Qall Record. ARRANGED UPON AN ORIGINAL AND CONVENIENT MONTHLY AND WEEKLY PLAN FOR THE DAILY RECORDING OF PROFESSIONAL VISITS. Frequent Rewriting of Names Unnecessary. This Visiting List is arranged upon a plan best adapted to the most convenient use of all physicians, and embraces a new feature in recording daily visits not found in any other list, consisting of stub or half leaves in the form of inserts, a glance at which will suflice to show that as the first week's record of visits is completed the next week's record may be made by simply turning over the stub-leaf, without the necessity of re- writing the patients' names. This is done until the month is completed, and the physician has kept his record just as complete in every detail of visit, charge, credit, etc., as he could have done had he used any of the old-style visiting lists, and has also saved himself three-fourths of the time and labor formerly required in transferring names every week. There are no intricate rulings; everything is easily and quickly under- stood ; not the least amount of time can be lost in comprehending the plan, for it is acquired at a glance. The Three Different Styles Made. The No. 1 Style of this List provides ample space for the daily record of seventy (70) different names each month for an entire year (two full pages, thirty-five [35] names to a page, being allowed to each month), so that its size is sufficient for an ordinary practice; but for physicians who prefer a List that will accommodate a larger practice we have made a No. 2 Style, which provides ample space for the daily record of one hundred and five different names (105) each month for an entire year (three full pages being allowed to each month), and for physicians who may prefer a Pocket Record Book of less thickness than either of these styles we have made a No. 3 Style, in which " The Blanks for the Recording of Visits In" have been made into removable sections. These sections are very thin, and are made up so as to answer in full the demand of the largest practice, each section providing ample space for the daily record of two hundred and ten (210) different names for one month; or one hundred and five (105) different names daily each month for two months ; or seventy (70) different names daily each month for three months; or thirty-five (35) different names daily each month for six months. Four sets of these sections go with each copy of No. 3 Style. Special Features Not Found in Any Other List. In this No. 3 Style the printed matter, and such matter as the blank forms for Addresses of Patients, Obstetric Record, Vaccination Record, Cash Account, Births and Deaths Records, etc., are fastened permanently in the back of the book, thus reducing its thickness. The addition of one of these removable sections does not increase the size quite an eighth of an inch. This brings the book into such a small com- pass that no one can object to it on account of its thickness, as its bulk 14 is very much less than that of any visiting list ever published. Every physician will at once understand that as soon as a section is full it can be taken out, filed away, and another inserted without the least incon- venience or trouble. This Visiting List contains a Calendar for the last six months of last year, all of this, and next year; Table of Signs to be used in Keeping Accounts; Dr. Ely's Obstetrical Table; Table of Cal- culating the Number of Doses in a given R, etc., etc.; for converting Apothecaries' Weights and Measures into Grammes ; Metrical Avoirdu- pois and Apothecaries'Weights; Number of Drops in a Fluidrachm ; Graduated Doses for Children; Graduated Table for Administering Laudanum ; Periods of Eruption of the Teeth ; The Average Frequency of the Pulse at Different Ages in Health'; Formula and Doses of Hypo- dermic Medication; Use of the Hypodermic Syringe; Formulae and Doses of Medicine for Inhalation; Formulae for Suppositories for the Rectum; The Use of the Thermometer in Disease; Poisons and their Antidotes; Treatment of Asphyxia; Anti-Emetic Remedies; Nasal Douches; Eye-Washes. Most Convenient Time- and Labor- Saving List Issued. It is evident to every one that this is, beyond question, the best and most convenient time-and labor-saving Physicians''Record Book ever published. Physicians of many years' standing and with large practices pronounce this the Best List they have ever seen. It is handsomely bound in fine, strong leather, with flap, including a pocket for loose memoranda, etc., and is furnished with a Dixon lead-pencil of excellent quality and finish. It is compact and convenient for carrying in the pocket. Size, 4 x 6| inches. IN THREE STYLES-NBT PRICES, POST-PAID. U. S. and Canada. Great Britain. France. No. i. Regular Size, for 70 patients daily each month for one year, $1.25 5s. 3. 7 fr. 75 No. z. Large Size, for 105 patients daily each month for one year, 1.50 6s. 6. 9 fr. 35 No. 3. In which "The Blanks for Recording Visits in'' are in re- movable sections, as described above, - - - • 1.75 7s. 3. 12 fr. 20 --EXTRACTS FROM REVIEWS. " While each page records only a week's visits, "Accounts can begin and end at any date, yet by an ingenious device of half leaves the names Each name can be entered for each day of every of the patients require to be written but once a month on the same line. To accomplish this, four month, and a glance at an opening of the book leaves, little more than one-third as wide as the shows the entire visits paid to any individual in a usual leaf of the book, follow each page. Oppo- month. It will be found a great convenience."- site is a full page for the recording of special Boston Medical and Surgical Journal. memoranda The usual accompaniments of this "Everything about it is easily and quickly class of books are made out with care and fitness." . understood."-Canadian Practitioner. American Lancet. " Of the many visiting lists before the profes- " This is a n<*vel list> and an unusually con- sion, each has some special feature to recommend venient ^."-Journalof the Amer.Med. Assoc. it. This list is very ingeniously arranged, as by a " This new candidate for the favor of physi- series of narrow leaves following a wider one, the cians possesses some unique and useful points, name of the patient is written but once during the The necessity of rewriting names every week is month, while the account can run for thirty-one obviated by a simple contrivance in the make-up days, space being arranged for a weekly debit of its pages, thus saving much valuable time, and credit summary and for special memoranda. besides reducing the bulk of the book."-Buffalo The usual pages for cash account, obstetrical Medical and Surgicad Journal. record, addresses, etc., are included. A large . .. , , , ' ' "This list is an entirely new departure, and amount of miscellaneous information is presented ■ . , , . ., , r. , , , „ , on a plan that renders posting rapid and easy. It in a condensed form. - Occidental Medical . . , , - . , , r , ,, is just what we have often wished for, and really Times. fills a long-felt want."-The Medical Waif. "It is a monthly instead of a weekly record, thus obviating the transferring of names oftener certainly contains the largest amount of than once a month. There is a Dr. and Cr. column practical knowledge for the medical practitioner following each week's record, enabling the doctor in the smallest possible volume, besides enabling to carry a patient's account for an indefinite time, the Poorest accountant to keep a correct record, or until he is discharged, with little trouble."- render a correct bill at a moment's notice.' - Indiana Medical Journal. Medical Chips. (F. 4. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 15 Hand-Book of Eclampsia; OK, Notes and Cases of Puerperal Convulsions. BY E. Michener, M.D., J. H. Stubbs, M.D., R. B. Ewing, M.D., B. Thompson, M.D., S. Stebbins, M.D. Price, in United States and Canada, Bound in Cloth, 16mo, Net, 75 Cents; in Great Britain, 3 Shillings; in France, 4 fr. 20. In our medical colleges the teachers of Obstetrics dwell upon the use of blood-letting (phlebotomy) in cases of puerperal convulsions, and to this method Dr. Michener and his fellows give their unqualified support-not to take a prescribed number of ounces, but to bleed for effect, and from a large orifice. This is plainly and admirably set forth in his book. To bleed requires a cutting instrument,-not necessarily a lancet,-for Dr. M. states how in one case a pocket-knife was used and the desired effect produced. Let the young physician gather courage from this little book, and let the more experienced give testi- mony to confirm its teaching. We have always thought that this treatment was I I "lost art" of blood-letting, and we must commend the indorsed, approved, and practiced by physicians generally ; ; ' modesty of their endeavor.-North Carolina Med. dour. and to such as doubt the efficacy of blood-letting we would 1 The cases were ably analysed, and this plea for vene- eommend this little volume.- Southern. Clinic. \ j section should receive the most attentive consideration from. The authors are seriously striving to restore the 11 obstetricians.-Medical and Surgical Reporter. TVST - A MANUAL OF INSTRUCTION FOR GIVING Swedish Movement*Massage Treanaeal. BY Prof. Hartvig Nissen, Director of the Swedish Health Institute, Washington, D.C. ; Late Instructor in Physical Culture and Gymnastics at the Johns Hopkins University, Baltimore, Md. ; Author of " Health by Exercise without Apparatus." ILLUSTRATED WITH 29 ORIGINAL WOOD-ENGRAVINGS. In One 12mo Volume of 128 Pages. Neatly Bound in Cloth. Price,, post-paid, in United States and Canada, Net, $1.00; in Great Britain, 4s. 3d.; in France, 6 fr. 20. This is the only publication in the English language treating this very important subject in a practical manner. Full instructions are given regarding the mode of applying The Swedish Movement and Massage Treatment in various diseases and conditions of the human system with the greatest degree of' effectiveness. Professor Nissen is the best authority in the United States upon this prac- tical phase of this subject, and his book is indispensable to every physician who wishes to- know how to use these valuable handmaids of medicine. This manual is valuable to the practitioner, as it the Swedish Movement and Massage we commend the contains a terse description of a subject but too little under- book.- Practice. stood in this country The book is got up very This attractive little book presents the subject in a very creditably.-N. K Med. Jour. practical shape, and makes it possible for every physician to The present volume is a modest account of the appli- understand at least how it is applied, if it does not give him cation of the Swedish Movement and Massage Treatment, dexterity in the art of its application. Fie can certainly in which the technique of the various procedures are clearly acquire dexterity by following the directions so plainly ad- stated as well as illustrated in a very excellent manner. vised in this book.-Chicago Med. Times. -North American Practitioner. It is so practical and clear in its demonstrations that This little manual seems to be written by an expert, if you wish a work of this nature you cannot do better than and to those who desire to know the details connected with peruse this one.-Medical Brief. 16 (F. 4. DAVIS. Medical Publisher, Philadelphia. Pa.. U.S.A.) JUST READY-THE LATEST AND BEST PHYSICIAN'S ACCOUNT- BOOK EVER PUBLISHED. THE PHYSICIAN'S All^Requisite Time. A rrn1inf.pnnV- a- Labor. Savins /-\ULUU.lil £)UUK. BEING A LEDGER AND ACCOUNT-BOOK FOR PHYSICIANS' USE, MEETING ALL THE REQUIREMENTS OF THE LAW AND COURTS. DESIGNED BY SEIBEBT, ZxC.ID., O£ Hasion, I=a.. Probably no class of people lose more money through carelessly kept accounts and overlooked or neglected bills than physicians. Often detained at the bedside of the sick until late at night, or deprived of even a modicum of rest, it is with great difficulty that he spares the time or puts himself in condition to give the same care to his own financial interests that a merchant, a lawyer, or even a farmer devotes. It is then plainly apparent that a system of bookkeeping and accounts that, without sacrificing accuracy, but, on the other hand, ensuring it, at the same time relieves the keeping of a physician's book of half their complexity and two-thirds the labor, is a convenience which will be eagerly welcomed by thousands of overworked physicians. Such a sys- tem has at last been devised, and we take pleasure in offering it to the profession in the form of The Physictan's All-Requisite Time- and Labor- Saving Account-Book. There is no exaggeration in stating that this Account-Book and Ledger reduces the labor of keeping your accounts more than one-half, and at the same time secures the greatest degree of accuracy. We may mention a few of the superior advantages of The Physician's All- Requisite Time- and Labor- Saving Account-Book, as follow:- First-Will meet all the requirements of I any similar book; the 300-page book the law and courts. contains space for 900 accounts, and the Second-Self-explanatory ; no cipher code. 600-page book contains space for 1800 Third-Its completeness without sacrificing accounts. anything. Ninth-There are no smaller spaces. Fourth-No posting; one entry only. Tenth-Compact without sacrificing com- Fifth-Universal; can be commenced at any pleteness; every account complete on time of year, and can be continued in- same page-a decided advantage atad definitely until every account is filled. recommendation. Sixth-Absolutely no waste of space. Eleventh-Uniform size of leaves. Seventh-One person must needs be sick Twelfth-The statement of the most com- every day of the year to fill his account, plicated account is at once before you or might be ten years about it and re- at any time of month or year-in other quire no more than the space for one words, the account itself as it stands is account in this ledger. ' its simplest statement. Eighth-Double the number and many times Thirteenth-No transferring of accounts, more than the number of accounts in balances, etc. To all physicians desiring a quick, accurate, and comprehensive method of keeping their accounts, we can safely say that no book as suitable as this one has ever been devised. NET PRICES, SHIPPING- EXPENSES PREPAID. No. 1. .300 Pages, for 900 Accounts per Year, Canada Great Size 10x12, Bound in X Russia, Raised In U. S. (duty paid). Britain. France. Back-Bands, Cloth Sides, . . . #5.00 #5.50 £0.18s. 30 fr. 30 No. 2. GOO Pages, for 1800 Accounts per Year, Size 10x12, Bound in X Russia, Raised Back-Bands, Cloth Sides, . . . 8.00 8.80 1.13s. 49 fr. 40 (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 17 PHYSICIANS' INTERPRETER I1X FOUR LANGUAGES. (ENGLISH, FRENCH, GERMAN, AND ITALIAN.) Specially Arranged for Diagnosis by M. von V. The object of this little work is to meet a need often keenly felt by the busy physician, namely, the need of some quick and reliable method of communicating intelligibly with patients of those nationalities and languages unfamiliar to the practitioner. The plan of the book is a sys- tematic arrangement of questions upon the various branches of Practical Medicine, and each question is so worded that the only answer required of the patient is merely Yes or No. The questions are all numbered, and a complete Index renders them always available for quick reference. The book is written by one who is well versed in English, French, Ger- man, and Italian, being an excellent teacher in all those languages, and who has also had considerable hospital experience. Bound in Full Russia Leather, for Carrying in the Pocket. (Size, 5x2| Inches.) 206 Pages. Price, post-paid, in United States and Canada, $1.00, net; Great Britain, 4s. 6d.; France, 6 fr. 20. To convey some idea of the scope of the questions contained in the Physicians' Interpreter, we append the Index :- NOS. NOS. General health i- 50 Falls and fainting spells 271-277 Special diet 31- 47 How patient's illness began, and when pa- Age of patient 52- 62 tient was first taken sick 278-279 Necessity of patients undergoing an opera- Names for various parts of the body 283-299 tion 63- 70 The liver 300-301 Office hours 7i- 77 The memory 304-305 Days of the week 78- 84 Bites, stings, pricks 314-316 Patient's history: hereditary affections in his Eruptions 317-318 family; his occupation; diseases from Previous treatment . 319 his childhood up 85-130 Symptoms of lead-poisoning 320-324 Months of the year 106-117 Hemorrhages 325-328 Seasons of the year..,,. 118-121 Burns and sprains 33°~33i Symptoms of typhoid fever ...131-158 The throat 332-335 Symptoms of Bright's disease 159-168 The ears 336-339 Symptoms of lung diseases 169-194 and 311-312 General directions concerning medicines, Vertigo 195-201 baths, bandaging, gargling, painting Theeyes 201-232 swelling, etc 340-373 Paralysis and rheumatism • 236-260 Numbers pages 202-204 Stomach complaints and chills 261-269 The work is well done, and calculated to be of great I be greatly obviated by use of this little work.- The Phy- service to those who wish to acquire familiarity with the I sician and Surgeon. phrases used in questioning patients. More than this, we The phrases are well selected, and one might practice believe it would be a great help in acquiring a vocabulary long without requiring more of these languages than this to be used in reading medical books, and that it would fur- little book furnishes.-Phila. Medical Times. nish an excellent basis for beginning a study of any one of How often the physician is called to attend those with the languages which it includes.-Medical and Surgical whom the English language is unfamiliar, and many phy- Reporter. sicians are thus deprived of the means, save through an Many other books of the same sort, with more ex- interpreter, of arriving at a correct knowledge on which to tensive vocabularies, have been published, but, from their base a diagnosis. An interpreter is not always at hand, size, and from their being usually devoted to equivalents but with this pocket interpreter in your hand you are able in English and one other language only, they have not had to ask all the questions necessary, and receive the answer the advantage which is pre-eminent in this-convenience. in such manner that you will be able to fully comprehend. It is handsomely printed, and bound in flexible red leather -The Medical Brief. in the form of a diary. It would scarcely make itself felt This little volume is one of the most ingenious aids in one's hip-pocket, and would insure its bearer against any to the physician w hich we have seen. We heartily com- ordinary conversational difficulty in dealing with foreign- mend the book to any one who, being without a knowledge speaking people, who are constantly coming into our city ■ of the foreign languages, is obliged to treat those who do hospitals.-New York Medical Journal. not know our own language.-St. Louis Courier of Medi- In our larger cities, and in the whole Northwest, the cine. physician is constantly meeting with immigrant patients. It will rapidly supersede, for the practical use of the to whom it is difficult for him to make himself understood, doctor who cannot take the time to learn another language, or to know what they say in return. This difficulty will all other suggestive works.-Chicago Medical Tirn^s. 18 (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) An Important Aid to Students in the Study of Anatomy. Three Charts of The Nervo-Vascular System. PAET I.-THE NEEVES. PAET II.-THE AETEEIES. PAET III.-THE VEINS. Arranged by W. HENRY PRICE, A.M., M.D., AND S. POTTS EAGLETON. ENDORSED BY LEADING ANATOMISTS. PRICE, IN THE UNITED STATES AND CANADA, 50 CENTS, NET, COMPLETE; GREAT BRITAIN, 2s. 6d. FRANCE, 3 fr. 60. " THE NERVO-VASCULAR SYSTEM OF CHARTS " far Excels Every Other System in their Completeness, Compactness, and Accuracy. Part I. The Nerves.-Gives in a clear form not only the Cranial and Spinal Nerves, showing the formation of the different Plexuses and their branches, but also the complete distribution of the Sympathetic Nerves, thereby making it the most complete and concise chart of the Nervous System ye^ published. Part II. The Arteries.-Gives a unique grouping of the Arterial System, showing the divisions and subdivisions of all the vessels, beginning from the heart and tracing their continuous distribution to the periphery, and showing at a glance the terminal branches of each artery. Part III. Th^ Veins.-Shows how the blood from the periphery of the body is gradually collected by the larger veins, and these coalescing forming still larger vessels, until they finally trace themselves into the Right Auricle of the heart. It is therefore readily seen that "The Nervo-Vascular System of Charts" offers the following superior advantages:- 1. It is the only arrangement which combines the Three Systems, and yet each is perfect and distinct in itself. 2. It is the only instance of the Cranial, Spinal, and Sympathetic Nervous Systems being represented on one chart. 3. From its neat size and clear type, and being printed only upon one side, it may be tacked up in any convenient place, and is always ready for freshening up the memory and reviewing for examination. 4. The nominal price for which these charts are sold places them within the reach of all. For the student of anatomy there can possibly be no veins of the human body, giving names, origins, distribu- more concise way of acquiring a knowledge of the nerves, tions, and functions, very convenient as memorizes and veins, and arteries of the human system. It presents at a reminders. A similar series, prepared by the late J. H. glance their trunks and branches in the great divisions of Armsby, of Albany, N.Y., and framed, long found a place the body. It will save a world of tedious reading, and will in the study of the writer, and on more than one occasion impress itself on the mind as no ordinary rode mecum, was the means of saving precious moments that must even, could. Its price is nominal and its value inestima- otherwise hav&been devoted to tumbling the pages of ana- ble. No student should be without it.-Pacific Record of tomical works.-Med. Age. Medicis and Surgery. These three charts will be of great assistance to We take pleasure in calling attention to these charts, medical students. They can be hung on the wall and read as they are so arranged that a study of them will serve to across any ordinary room. The price is only fifty cents for impress them more indellibly on your mind than can be the set.-Practice. They are a'S° Va'Uab'e for These charts have been carefully arranged, and will referenee.-Medtcal Bn^. prove to be very convenient for reiiy reference. They These are three admirably arranged charts for the are three in number, each constituting a part . use of students, to assist in memorizing their anatomical 18 ? h'gh recommendation that these charts have been »tudies.-JW«Zo Med. and Surg. Jour examined and approved by John B. Deaver M.D Demon- strator of Anatomy in the University of Pennsylvania.- This is a series of charts of the nerves, arteries, and Pacific Med. and Surg. Jour, and Western Lancet. (F. A. DAVIS, Medical Publisher Philadelphia, Pa., U.S.A.) 19 EVERY SANITARIAN SHOULD HAVE ROHE'S "TEXT-BOOK OF HYGIENE" AS A WORK OF REFERENCE. SECO1TD EIDITIO1T. IZLT EREZES. TEXT-BOOK OF HYGIENE: A COMPREHENSIVE TREATISE ON THE PRINCIPLES AND PRACTICE OF PREVENTIVE MEDICINE FROM AN AMERICAN STAND-POINT. By GEORGE H. ROHE, M.B., Professor of Obstetrics and Hygiene in the College of Physicians and Surgeons, Baltimore; Director of the Maryland Maternite ; Member of the American Public Health Association ; Foreign Associate of the Societe Franfaise d'Hygiene, of the Societe des Chevaliers-Sauveteurs des Alpes Maritimes, etc. Net Price, in the United States, S3.50; in Canada (duty paid), 182.75; in Great Britain, Ils. 3d.; France, 10 ir. 20. Second Edition-Thoroughly Revised and Largely Rewritten, with many Illustrations and Valuable Tables. Rohd's Hygiene is the Standard Text-Book in many Medical Colleges in the United States and Canada. It is a sound guide to the most modern and approved practice in Applied Hygiene. This New Edition will be issued early in the Spring of 1890, in one handsome Octavo volume of about 400 pages, bound in Extra Cloth. Read what competent critics have said of the first edition of Rohe's "Text-Book of Hygiene":- A storehouse of facts.-British Medical Journal. Nothing better for the teacher, practitioner, or student. Of invaluable assistance to the student.-Sanitary News. -Mississippi Valley Medical Monthly. This interesting and valuable book.-Pacific Medical Contains a mass of information of the utmost impor- and Surgical Journal. tance.-Independent Practitioner. Based upon sound principles and good practice.-Phila- Just the work needed by the medical student and the detphia Medical Times. busy, active, sanitary officer.-Southern Practitioner. Full of important matter, told in a very interesting This very useful work.-American Jour. Mal. Sciences. manner.-Science. Comprehensive in scope, well condensed, clear in style. In harmony with the most recent advances in pathology. and abundantly supplied with references.-Journal Ame.r- -Medical Times and Gazette, London. ican Medical Association. =^. JUST ISSUED PHYSICIANS' AND STUDENTS' READY-REFERENCE SERIES • ISTo. The Neuroses of the Genito-Urinary System irr tmk male, WITH STERILITY AM) IMPOTENCE. w BY DR. R. ULTZMANN, Professor of Genito-Urinary Diseases in the University of Vienna. TRANSLATED, WITH THE AUTHOR'S PERMISSION, BY GARDNER W. ALLEN, M.D., Surgeon in the Genito-Urinary Department Boston Dispensary. Illustrated. 12mo. Handsomely Bound in Dark-Blue Cloth. Net Price, in the United States and Canada, 91.00, Post-paid ; Great Britain, 4s. 6d. ; France, 6 fr. 20. This great work upon a subject which, notwithstanding the great strides that have been made in its investigation and the deep interest it possesses for all, is nevertheless still but imperfectly understood, has been translated in a most perfect manner, and pre- serves most fully the inherent excellence and fascinating style of its renowned and lamented author. Full and complete, yet terse and concise, it handles the subject with such a vigor of touch, such a clearness of detail and description, and such a directness to the result, that no medical man who once takes it up will be content to lay it down until its perusal is complete,-nor will one reading be enough. Professor Ultzmann was recognized as one of the greatest authorities in his chosen specialty, and it is a little singular that so few of his writings have been translated into English. Those who have been so fortunate as to benefit by his instruction at the Vienna Polyclinic can testify to the soundness of his pathological teachings and the success of his methods of treatment. He approached the subject from a somewhat different point of view from most surgeons, and this gives a peculiar value to the work. It is believed, moreover, that there is no convenient hand-book in English treating in a broad manner the Genito-urinary Neuroses. SYNOPSIS OF CONTENTS. First Part.-I. Chemical Changes in the Urine in Cases of Neuroses. II. The Neuroses of the Urinary and of the Sexual Organs, classi- fied as: 1, Sensory Neuroses ; 2, Motor Neuroses; 3, Secretory Neuroses. Second Part.- Sterility and Impotence. ■ The Treatment in all Cases is Described Clearly and Minutely. 20 (F. 4. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) Hay Fever ITS SUCCESSFUL TREATMENT BY SUPERFICIAL ORGANIC ALTERATION OF THE NASAL MUCOUS MEMBRANE. -BV- CHARLES E. SAJOUS, M.O., Lecturer on Rhinology and Laryngology in JetFerson Medical College: Vice-President of the American Laryngological Association: Officer of the Academy of France and of Public Instruction of Venezuela; Corresponding Member of the Royal Society of Belgium, of the Medical Society of Warsaw (Poland), and of the Society of Hygiene of France ; Member of the American Philosophical Society, etc., etc. WITH 13 ENGRAVINGS ON WOOD. 12mo. BOUND IN CLOTH. BEVELED EDGES. PBICJE, IN UNITED STATES AND CANADA, NET, $1.00; . GREAT BRITAIN, 4s. 3d.; FRANCE, 6 fr. 20. The object of this little work is to place in the hands of the general practitioner the means to treat successfully a disease which, until lately, was considered as incurable; its history, causes, pathology, and treat- ment are carefully described, and the latter is so arranged as to be practicable by any physician. Dr. Sajous' volume must command the attention of who are called upon to treat this troublesome disorder.- those called upon to treat this heretofore intractable com- The Buffalo Medical and Surgical Journal. plaint.-Medical and Surqical Reporter. __ . , , , , , x t , r, , , i ,, ' . * . , The symptoms, etiology, pathology, and treatment of tew have had the success in this disease which has ___ _ « „ . L. . mu . n , , , ., t.t. „ _ . Hay Fever are fully and ably discussed. The reader will so much baffled the average practitioner as Dr. Sajous, con- / x. .. . « , . , r x x- mi not regret the expenditure of the small purchase price of sequently his statements are almost authoritative. I he ... . ._ , , , . , . , , z, , . . . .xi • x j . • t , this work if he has cases of the kind to treat.-California * book must be read to be appreciated.-American Medical ,r , , . Medical Journal. Digest. • Dr. Sajous has admirably presented the subject, and, We are pleased with the author's, views, and heartily as this method of treatment is now generally recognized commend his book to the consideration of the profession, as efficient, we can recommend this book to all physicians -The Southern Clinic. PHYSICIANS' AND STUDENTS' READY REFERENCE SERIES. = 2sTo. OBSTETRIC SYNOPSIS. By JOHN S. STEWART, M.D., Demonstrator of Obstetrics and Chief Assistant in the Gynaecological Clinic of the Medico-Chirurgical College of Philadelphia. WITH AN INTRODUCTORY NOTE BY WILLIAM S. STEWART, A.M., M.D., Professor of Obstetrics and Gynaecology in the Medico-Chirurgical College of Philadelphia. 42 ILLUSTRATIONS. 202 PAGES. 12mo. HANDSOMELY BOUND IN DARK-BLUE CLOTH. Price, Post-paid, in the United States and Canada, Net, $1.00; Great Britain, 4s. 3d.; France, 6 fr. 20. By students this work will be found particularly useful. It is based upon the teachings of such well-known authors as Playfair, Parvin, Lush, Galabin, and Cazeaux and Tarnier, and, besides containing much new and important matter of great value to both student and practi- tioner, embraces in an Appendix the Obstetrical Nomenclature sug- gested by Professor Simpson, of Edinburgh, and adopted by the Obstetric Section of the Ninth International Medical Congress held in Washington, D.C., September, 1887. It is well written, excellently illustrated, and fully up use of bold-faced type for headings, and italics for impor- to date in every respect. Here we find all the essentials of tant statements, gives the book a pleasing typographical Obstetrics in a nutshell, Anatomy, Embryology, Physi- appearance.-Medical Record. ology. Pregnancy, Labor, Puerperal State, and Obstetric This volume is done with a masterly hand. The Operations all being carefully and accurately described.- scheme is an excellent one. . . . The whole is freely Buffalo Medical and Surgical Journal. an(j most admirably illustrated with well-drawn, new It is clear and concise. The chapter on the develop- engravings, and the book is of a very convenient size. went of the ovum is especially satisfactory. The judicious St. Louis Medical and Surgical Journal. (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 21 DIPHTHERIA: Croup, Tracheotomy,^ Intubation. FROM THE FRENCH OF A. SANNE. TRANSLATED AND ENLARGED BY HENRY Z. GILL, M.D., LL.D. United States. Canada (duty paid). Great Britain. France. Net Price, Post-paid, Cloth, - *$4.00. $4.40. £ 0.18s. 24 fr. 60 " " Leather, - 5.00. 5.50. 1. Is. 30 fr. 30 The above work, recently issued, is a translation from the French of Sanna's great work on " Diphtheria," by H. Z. Gill, late Professor of Surgery in Cleveland, Ohio. Sanne's work is quoted, directly or indirectly, by every writer since its publication, as the highest authority, statistically, theoretically, and practically. The translator, having given special study to the subject for many years, has added .over fifty pages, in- cluding the Surgical Anatomy, Intubation, and the recent progress in the branches treated down to the present date; making it, beyond question, the most complete work extant on the subject of Diphtheria in the English language. Facing the title-page is found a very fine Colored Lithograph Plate of the parts con- cerned in Tracheotomy. Next follows an illustration of a cast of the entire Trachea, and bronchi to the third or fourth division, in one piece, taken from a photograph of a case in which the cast was expelled during life from a patient sixteen years old. This is the most complete cast of any one recorded. Over fifty other illustrations of the surgical anatomy of instruments, etc., add to the practical value of the work. Diphtheria having become such a prevalent, wide-spread, and fatal disease, no ge'neral practitioner can afford to be without this work. It will aid in preventive meas- ures, stimulate promptness in the application of, and efficiency in, treatment, and moderate the extravagant views which have been entertained regarding certain specifics in the disease Diphtheria. A full Index accompanies the enlarged volume, also a List of Authors, making altogether a very handsome illustrated volurrfe of over 680 pages. In this book we have a complete review and > Sanne's work is quoted, directly or indirectly, compendium of all worth preserving that has hitherto by many writers since its publication, as the highest been said or written concerning diphtheria and the authority, statistically, theoretically, and practi- kindred subjects treated of by our author, collated, cally. The translator, having given special study arranged, and commented on by both author and to the subject for many years, has added over fifty translator. The subject of intubation, so recently pages, including the surgical anatomy, intubation, revived in this country, receives a very careful and and the recent progress in the branches treated, impartial discussion at the hands of the translator, down to the present date; making it, beyond ques- and a most valuable chapter on the prophylaxis of tion, the most complete work extant on the subject diphtheria and croup closes the volume. of diphtheria in the English language. Diphtheria His notes are frequent and full, displaying deep having become such a prevalent, wide-spread, and knowledge of the subject-matter. Altogether the fatal disease, no general practitioner can afford to book is one that is valuable and timely, and one be without this work. It will aid in preventive that should be in the hands of every general practi- measures, stimulate promptness in application of, and tioner.-57. Louis Med. and Surgical Journal. efficiency in, treatment.-Southern Practitioner. OF HOW TO READ FACES. By MARY OLMSTED STANTON. Copiously Illustrated. Two Large Octavo Volumes. United States. Canada (duty paid). Great Britain. France. Price, per Volume, Cloth, $5.00 $5.50 £l.ls. 30 fr. 30 " " Sheep, 6.00 6.60 1.6s. 36 fr. 40 " " Half-Kussia, 7.00 7.70 1.9s. 43 fr. 30 $1.00 Discount for Cash. Sold only by Subscription, or sent direct on receipt of price, shipping expenses prepaid. The author, Mrs. Mary O. Stanton, has given over twenty years to the preparation of this work. Her style is easy, and, by her happy method of illustration of every point, the book reads like a novel, and memorizes itself. To physicians the diagnostic information conveyed is invaluable. To the general reader each page opens a new train of ideas. (This book has no reference whatever to Phrenology.) 22 (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) IMPORTANT ANNOUNCEMENT. A TREATISE Materia Medica, Pharmacology, Therapeutics. BY JOHN V. SHOEMAKER, A.M., M.D., Professor of Materia Medica, Pharmacology, and Therapeutics in the Medico-Chirurgical College of Phila- delphia, and Member American Medical Association, AND JOHN AULDE, M.D., Demonstrator of Clinical Medicine and of Physical Diagnosis in the Medico-Chirurgical College of Phila- delphia, and Member American Medical Association. IN TWO HANDSOME ROYAL OCTAVO VOLUMES. NET PRICES, per Volume, in United States: Cloth, $2.50; Sheep, $3.25. In Canada (duty paid) : Cloth, $2.75 ; Sheep, $3.55. In Great Britain: Cloth, Ils. 3d. ; Sheep, 14s. 6d. In France: Cloth, 16 fr. 20 ; Sheep, 20 fr. 20. THE Publisher takes pleasure in announcing that Volume I of this eagerly-looked-for work is Now Ready, and that the utmost diligence will be exercised in filling with the greatest rapidity, and in regular order of receipt, the numerous orders now awaiting its publication. The general plan of the work embraces three parts, each of which is practically inde- pendent of the other, as will be understood from the accompanying analysis, and of which Parts I and II are contained in the volume now announced ; this, however, is not the only advantage accruing from the preparation of the work in two volumes. Each volume will thus be much smaller and more convenient to handle, while some may wish to secure a particular portion of the work, and to them the cost is lessened. Several blank sheets of closely-ruled letter-paper are inserted at convenient places in the work, thus rendering it available for the student and physician to add valuable notes concerning new remedies and other important matters. Part I embraces three subdivisions, as follow:- First. A brief synopsis upon the subject of pharmacy, in which is given a clear and concise description of l^e operations and preparations taken into account by the physician when prescribing medicines, together witn some practical suggestions regarding the most desirable methods for securing efficiency and palatability. Second. A Classification of Medicines is presented under the head of " General Phar- macology and Therapeutics," with a view to indicate more especially the methods by which the economy is affected. Thus, there are Internal and External Remedies, and, besides, a class termed Chemical Agents, including Antidotes, Disinfectants, and Anti- septics, and an explanatory note is appended to each group, as in the case of Alteratives, Antipyretics, Antispasmodics, Purgatives, etc. Third. A Summary has been prepared upon Therapeutics, covering methods of Administration, Absorption and Elimination, Incompatibility, Prescription-writing, and Dietary for the Sick, this section of the work embracing nearly one hundred and fifty pages. Part II is devoted to "Remedies and Remedial Agents Not Properly Classed with Drugs," and includes elaborate articles upon the following topics: Electro-Therapy, Hydro-Therapy, Masso-Therapy, Heat and Cold, Oxygen, Mineral-Waters, and, in addi- tion thereto, other subjects, perhaps of less significance to the practitioner, such as Clima- tology, Hypnotism and Suggestion, Metallo-therapy, Transfusion, and Baunscheidtismus, have received a due share of attention. This section of the work embraces over two hun- dred pages, and will be found especially valuable to the student and recent gradate, as these articles are fully abreast of the times. Volume II, which is Part III of the work, is wholly taken up with the consideration of drugs, each remedy being studied from three points of view, viz., the Preparations, or Materia Medica; the Physiology and Toxicology, or Pharmacology, and, lastly, its Therapy. It will be Ready about May 1, 1890. The typography of the work will be found clean, sharp, and easily read without injury to the visual organs, and the bold-face type interspersed throughout the text makes the different subjects discussed quick of reference. The paper and binding will also be up to the standard, and nothing will be left undone to make the work first-class in every particular, (F. 4. DAVIS, Medical Publisher, Philadelphia, Pa., U.S A.) 23 - -JUST PUBLISHED. THE PHYSIOLOGY OF THE Domestic Animals. A TEXT-BOOK FOR VETERINARY AND MEDICAL STUDENTS AND PRACTITIONERS. -BY- ROBERT MEADE SMITH, A.M., M.D., Professor of Comparative Physiology in University of Pennsylvania; Fellow of the College of Physicians and Academy of the Natural Sciences, Philadelphia ; of the American Physiological Society ; of the American Society of Naturalists ; Associe Etranger de la Societe Fran^aise D' Hygiene, etc. . ..A' ■• . a? ' < ■ r W 4 A • f: 0 ' T Fig. 117.-Parotid and Submaxillary Fistulas in the Horse, after Colin. (Thanhoffer and Tormay.) K, Kt, rubber bulbs for collecting saliva; cs, cannula in the parotid duct. In One Handsome Royal Octavo Volume of over 950 Pages, Pro- fusely Illustrated with more than 400 Fine Wood- Engravings and many Colored Plates. United States. Canada (duty paid). Great Britain. France. NET PR/CES, CLOTH, $5.00 $5.50 £1. 30 fr. 30. " " SHEEP, 6.00 6.60 1.6. 36 fr. 20. THIS new and important work, the most thoroughly complete in the English language on this subject, has just been issued. In it the physiology of the domestic animals is treated in a most comprehensive manner, especial prominence being given to the sub- ject of foods and fodders, and the character of the diet for the herbivora under different conditions, with a full consideration of their digestive peculiarities. Without being over- burdened with details, it forms a complete text-book of physiology, adapted to the use of students and practitioners of both veterinary and human medicine. This work has already been adopted as the Text-Book on Physiology in the Veterinary Colleges of the United States, Great Britain, and Canada. 24 (F. A- DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) Abstracts from Reviews^^mith'S Physiology. The work throughout is well balanced. The work before us fills the hiatus of Broad, though not encyclopaedic, concise which complaint has so often been made, without sacrificing clearness, it combines and gives in the compass of less than a the essentials of a successful text-book. It thousand pages a very full and complete is eminently modern, and, although first in account of the functions of the body in both the field, is of such grade of excellence that carnivora and herbivora. The author has successors must reach a high standard be- judiciously made the nutritive functions the fore they become competitors.-Annals of strong point of the work, and has devoted Surgery. special attention to the subject of foods and Dr. Smith has conferred a great benefit digestion. In looking through the other upon the veterinary profession by his eon- sections of the work, it appears to us that a tribution to their use of a work of immense jus^ proportion ot space is assigned to each, value, and has provided the American vet- in view of their relative importance to the erinary student with the only means by practitioner. Thus, while the subject ot re- which he can become properly familiar witn production is dismissed in a tew pages, a the physiology of our domestic animals. chapter of considerable length is devoted Veterinary practitioners and graduates will to locomotion, and especially to the gaits ot read it with pleasure. Veterinary students the horse. London Lancet. will readily acquire needed knowledge from This is almost the only work of the kind its pages, and veterinary schools which in the English language, and it so fully would be well equipped for the work they covers every detail of general and special aim to perform cannot ignore it as their physiology that there is no room for any text-book in physiology.-American Veteri- rival. The excellence of typographical nary Review. work, and the wealth, beauty, and clear- Dr. Smith's presentment of his subject ness the illustrations, correspond with is as brief as the status of the science per- the thoroughness and clearness ot the mits, and to this much-desired conciseness treatise.-Albany Medical Annals. he has added an equally welcome clearness It is not often that the medical profes- ®f statement. • The illustrations in the work sion has the opportunity of reading a new are exceedingly good, and must prove a book upon a new subject, and doubtless valuable aid to the full understanding of English-speaking physicians will feel grate- the text.-Journal of Comparative Medicine ful to Professor Smith for his admirable and Surgery. and pioneer work in a branch of medical We have examined the work in a great science upon which a great amount of ignor- many particulars, and find the views so ance prevails. . . . The last portion of correct, where we have had the means of the work is devoted to the reproductive comparison of statements with those of some functions, and contains much valuable in- recognized authority, that we will be com- formation upon a portion ot animal physi- pelled hereafter to look to this work as the oIogy concerning which many are ignorant, text-book on physiology of animals. The The book is a valuable one in every way, book will prove of incalculable benefit to and will be consulted largely by veterinary , veterinarians wherever they may be found; and medical students and practitioners. and to the country physician, who is often | Buffalo Medical and Surgical Journal. called upon to attend to sick animals as The appearance of this work is most op- well as human beings, we would say, lose portune. It will be much appreciated, as no time in getting this work and let him tending to secure the thorough comprehen- familiarize himself with the facts it con- sion of function in the domesticated ani- tains.- Virginia Medical Monthly. mals, and, in consequence, their general Altogether, Professor Smith's " Physi- I well-being--a matter of world wide impor- ology of the Domestic Animals" is a happy i tance. With a thorough sense of gratifica- production, and will be hailed with delight \ tion we have perused its pages: throughout in both the human medical and veterinary 1 we find clear expression, clear reasoning, medical worlds. It should find its place , and that patient accumulation of facts so besides in all agricultural libraries.-Paul II valuable in a text-book for students. Paquin, M.D., V.8., in the Weekly Medical British Medical Journal. Review. I For notice this time, I take up the vol- It may be said that it supplies to the I ume on the "Physiology of the Domestic veterinary student the place in physiology । Animals," by Dr. R. Meade Smith, a volume that Chauveau's incomparable work-"The II of 938 pages, closely printed, and dealing Comparative Anatomy of the Domesticated I with its subject in a manner sufficiently ex- Animals"-occupies in anatomy. Higher 1 haustive to insure its place as a text-book praise than this it is not possible to bestow. for fifteen years at the very least, Its And since it is true that the same laws of learning is only equaled by its industry, physiology which are applicable to the vital and its industry by the consistency and process of the domestic animals are also ap- skill with which its varied parts are brought plicable to man, a perusal of this carefully together into harmonious, lucid, and in- written book will repay the medical student tellectual unity.-Dr. Benjamin Ward or practitioner.-Canadian Practitioner. Richardson, in the Jjondon Asclepiad. (F. A. DAVIS. Medical Publisher, Philadelphia, Pa., U.S.A.) 25 ---the International Rocket Medical Fopmularij, ARRANGED THERAPEUTICALLY. By G. SUMNER WITH ERSTl N E, M.S., M.D., Associate Editor of the "Annual of the Universal Medical Sciences;'' Visiting Physician of the Home for the Aged, Germantown, Philadelphia; I.ate House-Surgeon Charity Hospital, New York. More than 1800 Formulae from Several Hundred Well-Known Authorities. With an Appendix containing a Posological Table, the newer remedies included ; Important Incompati- bles ; Tables on Dentition and the Pulse ; Table of Drops in a Fluidrachm and Doses of Laudanum graduated for age ; Formula; and Doses of Hypodermic Medication, including the newer remedies; Uses of the Hypo- dermic Syringe; Formula; and Doses for Inhalations, Nasal Douches, Gargles, and Eye-washes ; Formula; for Suppositories; Use of the Thermometer in Disease; Poisons, Antidotes, and Treatment; Directions for Post-Mortem and Medico-Legal Examinations; Treatment of Asphyxia, Sun-stroke, etc.; Anti-emetic Remedies and Disinfectants; Obstetrical Table; Directions for Ligation of Arteries; Urinary Analysis; Table of Eruptive Fevers : Motor Points for Electrical Treatment, etc., etc. This work, the best and most complete of its kind, contains about 275 printed pages, besides extra blank leaves. Elegantly printed, with red lines, edges, and borders; with illustrations. Hound in leather, with side flap. It contains more than 1800 Formulae, exclusive of the large amount of other very valuable matter. Price, Post-paid, in the United States and Canada, $2.00, net; Great Britain, 8s. 6d.; France, 12 fr. 40. TFN WHY EVERY MEDICAL MAN SHOULD POSSESS A COPY OF I £/f THE INTERNATIONAL POCKET medical formulary. 1. Because it is a handy book of reference, replete with the choicest formulae (over 1800 in number) of more than six hundred of the most prominent classical writers and modern practitioners. S. Because the remedies given are not only those whose efficiency has stood the test of time, but also the newest and latest discoveries in pharmacy and medical science, as prescribed and used by the best- known American and foreign modern authorities. 3. Because it contains the latest, largest (66 formulae) and most complete collection of hypodermic formulae (including the latest new remedies) ever published, with doses and directions for their use in over fifty different diseases and diseased conditions. 4. Because its appendix is brimful of information, invaluable in office work, emergency cases, and the daily routine of practice. 5. Because it is a reliable friend to consult when, in a perplexing or obstinate case, the usual line of treat- ment is of no avail. (A hint or a help from the best authorities, as to choice of remedies, correct dosage, and the eligible, elegant, and most .palatable mode of exhibition of the same.) 6. Because it is compact, elegantly printed and bound, well illustrated, and of convenient size and shape for the pocket. 7. Because the alphabetical arrangement of the diseases and a thumb-letter index render reference rapid and easy. 8. Because blank leaves, judiciously distributed throughout the book, afford a place to record and index favorite formula;. - । 9. Because, as a student, he needs it for study, collateral reading, and for recording the favorite prescriptions of his professors, in lecture and clinic; as a recent graduate, he needs it as a reference hand-book for daily use in prescribing (gargles, nasal douches, inhalations, eye-washes, suppositories, incompatibies, poisons, etc.) ; as an old practitioner, he needs it to refresh his memory on old remedies and combi- nations, and for information concerning newer remedies and more modern approved plans of treatment. 10. Because no live, progressive medical man can afford to be without it. It is sometimes important that such prescriptions as As long as " combinations " are sought such a book have been well established in their usefulness be preserved will be of value, especially to those who cannot spare, the for reference, and this little volume serves such a purpose time required to learn enough of incompatibilities before better than anv other we have seen.-Columbus Medical commencing practice to avoid writing incompatible and Journal * dangerous prescriptions. 1 he constant use of such a book Without doubt this book is the best one of its class by such prescribers would save the pharmacist much that we have ever seen The printing, binding. anxiety.--The Druggists' Circular. and general appearance of the volume are bevond praise.- In judicious selection, in accurate nomenclature, in University Medical Magazine. arrangement, and in style it leaves nothing to be desired. It may be possible to get more crystallized knowledge The editor and the publisher are to be congratulated on the in an equally small space, but it does not seem probable.- production of the very best book of its class.-I ittshurgh Medical Classics Medical Review. A very handy and valuable book of formula; for the One must see it to realize how much information am physician's pocket.-S. Louis Medical and Surg. Journal. I be got into a work of so little bulk.-( anada Medirai This little pocket-book contains an immense number Record. . . . of prescriptions taken from high authorities in this and ; To the young physician just starting out in prae tu< other countries.- Northwestern Lancet. | this little book will prove! an acceptable companion. This one is the most complete as well as the most ; Cl1""'- . ... . 3n,:. conveniently arranged of anv that have come under our The want of to-day is crystallized knowledge. 11 » attention. The diseases are enumerated in alphabetical neat little volume contains in1 the' order, and for each the latest and most approved remedies It is bound in morocco in 1™*?^form.with alphahetMa I from the ablest authorities are prescribed. The book is in- divisions of dlseases. so that it is Pos%bleJ? ^^2. dexed entirely through after the order of the first pages of to the remedy, whatever may be the disorder or wherever a ledger, the index letter being printed on morocco leather t the patient may be situated. . . . . 1 o the phys 1 and thereby made very durable. - Pacific Medical Journal. ; it is invaluable, and others should not be without it. We Itisabook desirable for the old practitioner and for ; heartily commend the work to our readeis.-Minnesota his younger brothers as well.-St. Joseph Medical Herald. 11 Medical Journal. 26 (F. A. DAVIS, Medical Publisher, Philadelphia. Pa.. U.S.A - - JUST ISSUED - PHYSICIANS' AND STUDENTS' READY-REFERENCE SERIES. '"■■■■■■ - *~" Synopsis of Human Anatomy: Being- a Complete Compend. of Anatomy, including the Anatomy of the Viscera, and Numerous Tables. BY JAMES K. YOUNG, M.D., Instructor in Orthopaedic Surgery and Assistant Demonstrator of Surgery, University of Pennsylvania; Attending Orthopaedic Surgeon, Out-Patient Department, University Hospital, etc. ILLUSTRATED WITH 76 WOOD-ENGRAVINGS. 390 PAGES. 12mo. HANDSOMELY BOUND IN DARK-BLUE CLOTH. Price, Post-paid, in the United States and Canada, $1.40, net; Great Britain, 6s. 6d.; France, 9 fr. 25. While the author has prepared this work especially for students, sufficient de- scriptive matter has been added to render it extremely valuable to the busy practitioner, particularly the sections on the Viscera, Special Senses, a and Surgical Anatomy. The work includes a complete account of Osteology, 2 Articulations and Ligaments, Muscles, Fasciae, Vascular f ^k"4- and Nervous Systems, Alimentary, Vocal, and Respiratory V and Genito-Urinary Apparatuses, the Organs of Special 3- Sense, and Surgical Anatomy. 12 In addition to a most carefully and accurately prepared text, wherever possible, the value of the work has .been n enhanced by tables to facilitate and minimize the labor of n£ students in acquiring a thorough knowledge of this impor- taut subject. The section on the teeth has also been |n|EJ^aiy especially prepared to meet the requirements of students of Dentistry. In its preparation. Gray's Anatomy [last edition], edited by Keen, being the anatomical work most used, has been taken as the standard. ▼ Anatomy is a theme that allows such concen- Excellent tables have been arranged, which tration better than most medical subjects, and, as tersely and clearly present important anatomical the accuracy of this little book is beyond question, facts, and the book will be found very convenient its value is assured. As a companion to the dis- for ready reference.-Columbus Medical Journal. secting-table, and a convenient reference for the The book is much more satisfactory than the practitioner, it has a definite field of usefulness.-- "remembrances" in vogue, and yet is not too cum- Pittsburgh Medical Review. ■ bersome to be carried around and read at odd . This is a very carefully prepared compend of moments-a property which the student will readily anatomy, and will be useful to students for college I appreciate-Weekly Medical Review. or hospital examination. There are some excellent If a synopsis of human anatomy may serve a tables in the work, particularly the one showing the purpose, and we believe it does, it is very important origin, course, distribution, and functions of the that the synopsis should be a good one. In this cranial nerves.-Medical Record. respect the above work may be recommended as a Dr. Young has compiled a very useful book. reliable guide. Dr. Young has shown excellent Weare not inclined to approve of compends as a judgment in his selection of illustrations, in the general rule, but it certainly serves a good purpose numerous tables, and in the classification of the to have the subject of anatomy presented in a com- various subjects.- Therapeutic Gazette. pact, reliable way, and in a book easily carried to Every unnecessary word has been excluded, out the dissecting-room. This the author has done. of regard to the very limited time at the medical The book is well printed, and the illustrations well student's disposal. It is also good as a reference selected. If a student can indulge in more than one book, as it presents the facts about which he wishes work on anatomy,-for, of course, he must have a to refresh his memory in the briefest manner general treatise on the subject,-he can hardly do consistent with clearness. - New York Medical better than to purchase this compend It will save Journal the larger work, and can always be with him during It is certainly concise and accurate, and should the hours of dissection.-Buffalo Medical and be in the hands of every student and practitioner.- Surgical Journal. || The Medical Brief. (F. A. DAVIS. Medical Publisher, Philadelphia, Pa., U.S.A.) Ji ANNUAL OF THE Universal Medical Sciences. 4 YEARLY REPORT OF THE PROGRESS OF THE GENERAL SANITARY SCIENCES THROUGHOUT THE WORLD. Edited by CHARLES E. SAJOUS, M. D., LBCTNHBK ON LARYNGOLOGY AND RHINOLOGY IN JEFFERSON MEDICAL COLLEGE, PHILADELPHIA, ETC.. AND SEVENTY ASSOCIATE EDITORS, Assisted by over TWO HUNDRED Corresponding Editors and Collaborators. In Fine, Royal Octavo Volumes of about 500 pages each, bound in Cloth and Hcdf-Rvssia, Magnificently Illustrated with Chromo-Lithographs, Engravings, Maps, Charts, and Diagrams. BEING 1st. To assist the busy practitioner in his efforts to keep abreast of the rapid strides of all the branches of his profession. 2d. To avoid for him the loss of time involved in searching for that which is new in the profuse and constantly increasing medical literature of our day. 2d. To enable him to obtain the greatest possible benefit of the limited time he is able to devote to reading, by furnishing him with new matter only. 4th. To keep him informed of the work done by all nations, including many other- wise seldom if ever heard from. 5th. To furnish him with a review of all the new matter contained in the periodicals to which he cannot (through their immense number) subscribe. 6th. To cull for the specialist all that is of a progressive nature in the general and special publications of all nations, and obtain for him special reports from countries in which such publications do not exist, and Lastly, to enable any physician to possess, at a moderate cost, a complete CONTEMPORARY HISTORY OF UNIVERSAL MEDICINE, edited by many of America's ablest teachers, and superior in every detail, of print, paper, binding, etc., etc., a befitting continuation of such great works as " Pepper's System of Medicine," 'Ashhurst's International Encyclopaedia of Surgery," " Buck's Reference Hand-Book of the Medical Sciences," etc., etc. EDITORIAL STAFF of the ANNUAL of the UNIVERSAL MEDICAL SCIENCES. ISSUE OF 1888. Chief Editor, DR. CHARLES E. SAJOUS, Philadelphia .ASSOCIATE ST2kFF. Volume I.-Obstetrics, Gynaecology, Pediatrics, Anatomy, Physiology, Pathology, Histology, and Embryology. Frof. Wm. L. Richardson, Boston. Prof. William Goodell and Dr. W. C. Prof. H. Newell Martin and Dr. W. H. Prof. Theophilus Parvin, Philada. Goodell. Philadelphia. Howell, Baltimore. Prof. Louis Starr, Philadelphia. Prof. E. C. Dudley, Chicago. Dr. Chas. 8. Minot. Boston. Prof. J. Lewis Smith. New York City. Prof. W H. Parish. Philadelphia. Dr. E. O. Shakespeare. Philadelphia. Prof. Paul F. Munde and Dr. E. H. Prof. William S. Forbes. Philadelphia. Dr. W. X. Sudduth, Philadelphia. Grandin, New York City. Volume II.-Diseases of the Respiratory, Circulatory, Digestive, and Nervous Systems: Fevers, Exanthemata, etc., etc. Prof. A. L. Loomis, New York City. Prof. E. C. Seguin, New York City. Prof. Jas. Tyson, Philadelphia. Prof. Jas. T. Whittaker. Cincinnati. Prof. E. C. Spitzka, New York City. Prof. N. 8. Davis, Chicago. Brof. W. H. Thomson, New York City. Prof.Chas.K. Millsand Dr. J. H.Lloyd, j Prof. John Guiteras. Charleston, S. C. Prof. W. W. Johnston, Washington. Philadelphia. Dr. Jas. C. Wilson. Philadelphia. Prof Jos. Deidy, Philadelphia. Prof. Francis Delafield, N. Y. City. Volume III.--General Surgery, Venereal Diseases, Anaesthetics, Surgical Dressings, Dietetics, etc., etc. Prof. D. Hayes Agnew, Philadelphia. Prof. F. R. Sturgis, New York City. Prof. T. G. Morton and Dr. Wm. Hunt, Prof. Hunter McGuire, Richmond. Prof. N. Senn, Milwaukee. Philadelphia. Prof. Lewis A. Stimson, New York. Prof. J. E. Garretson, Philadelphia. Dr. Morris Longstreth, Philadelphia. Prof. P. 8. Conner, Cincinnati. Prof. Christopher Johnston, Baltimore. Dr. Chas. Wirgman, Philadelphia. Prof. J. Ewing Mears, Philadelphia. Dr. Chas. B. Kelsey, New York City. Dr. C. C. Davidson. Philadelphia. I*rof. E. L. Keyes, New York City. | Volume IV.-Ophthalmology, Otology, Laryngology, Rhinology, Dermatology, Dentistry, Hygiene, Disposal of the Dead, etc., etc. Prof. William Thomson, Philadelphia. I Prof. C. N. Peirce, Philadelphia. Dr. Chas. S. Turnbull, Philadelphia. Prof. J. Solis Cohen, Philadelphia. ' Prof. John B. Hamilton, Washington. Dr. Edw. C. Kirk, Philadelphia. Prof. D. Bryson Delavan, New York. Prof. H. M. Lyman, Chicago. Dr. John G. Lee, Philadelphia. Prof. A. Van Harlingen, Philadelphia. Prof. S. H. Guilford, Philadelphia. Dr. Chas. E. Saijous, Philadelphia. 28 hist of Collaborators to Dental Department. Prof. Janies Truman. Philadelphia. Prof. E. H. Angle, Minneapolis. Minn. Dr. J. D. Patterson, Kansas City, Mo. Prof. J. A. Marshall, Chicago, Ill. Prof. J. E. Cravens, Indianapolis, Ind. Dr. J. B. Hodgkin, Washington, D. C. Prof. A. W. Harlan, Chicago, Ill. Prof. K. Stubblefield, Nashville, Tenn. Dr. R. R. Andrews, Cambridge, Mass. Prof. G. V. Black, Chicago, Ill. Prof. W. C. Barrett, Buffalo, N. Y. Dr. Albion M. Dudley, Salem, Mass. Prof. C. H. Stowell, Ann Arbor, Mich. Prof. A. H. Thompson, Topeka, Kan. Dr. Geo. S. Allen, New York City. Prof. L. C. Ingersoll, Keokuk, Iowa. Dr. James W. White, Philadelphia. Dr. G. S. Dean, San Francisco, Cal. Prof. F. J. S. Gorgas. Baltimore. Md. Dr. L. Ashley Faught, Philadelphia. Dr. M. H. Fletcher, Cincinnati. Ohio. Prof. H. A. Smith, Cincinnati, Ohio. Dr. Robert S. Ivy, Philadelphia. Dr. A. Morsman, Omaha, Neb. Prof. C. P. Pengra, Boston, Mass. Dr. W. Storer How, Philadelphia. Dr. G. W. Melotte. Ithaca, N. Y. Volume V.-General and Experimental Therapeutics, Medical Chemistry, Medical Jurisprudence, Demography, Climatology, etc., etc. Prof. William Pepper, Philadelphia. । Prof. George H. Rohe, Baltimore. Dr. W. P. Manton, Detroit, Minh. Prof. F. W. Draper, Boston. Dr. Albert L. Gihon, U. S. N. Dr. Hobart A. Hare, Philadelphia. Prof. J. W. Holland, Philadelphia. Dr. R. J. Dunglison, Philadelphia. Dr. C. 8. Witherstine, Philadelphia. Prof. A. L. Ranney, New York City. THE STBSCEIFTIOlT (Including the "SATELLITE" for one year). United States. Canada (duty paid). Great Britain. Fra.ee. Cloth, 5 Vols., Royal Octavo, - - #15.00 #16.50 £3.6s. 93 fr. 95 Half-Rusaia, 5 Vols., Royal Octavo, - 20.00 22.00 4.6s. 124 fr. 35 EXTRACTS FROM REVIEWS. We venture to say that all who saw the Annual as it appeared in 1888 were on the lookout for its reappearance this (1889) year; but there are many whose knowledge of this magnificent undertaking will date with this present issue, and to those a mere examina- tion of the work will suffice to show that it fills a legitimate place in the evolution of knowledge, for it does what no single individual is capable of doing. These volumes make readily available to the busy practitioner the best fruits of medical progress for the year, selected by able editors from the current literature of the world; such a work cannot be overlooked by anyone who would keep abreast of the times. With so much that is worthy of notice incorporated in one work, and each depart- ment written up with a minuteness and thoroughness appreciated particularly by the specialist, it would avail nothing to cite particular instances of progi^ss. Let it be suffi- cient to say, however, that while formerly there was a possible excuse for not having the latest information on matters pertaining to the medical sciences, there can no longer be such an excuse while the Annual is published.-Journal of the American Medical Association. We have before us the second issue of this Annual, and it is not speaking too strongly when we say that the series of five volumes of which it consists forms a most important and valuable addition to medical literature. Great discretion and knowledge of the subjects treated of are required at the hands of those who have taken charge of the various sections, and the manner in which the gentlemen who were chosen to fill the important posts of sub-editors have acquitted themselves fully justifies the choice made. We know of no branch of the profession to which this Annual could fail to be useful. Dr. Sajous deserves the thanks of the whole profession for his successful attempt to facilitate the advance of medical literature and practice.-London Lancet. • This very valuable yearly report of the progress of medicine and its collateral sciences throughout the world is a work of very great magnitude and high importance. It is edited by Dr. C. E. Sajous, assisted, it is stated, by seventy associate editors, whose names are given, making up a learned and most weighty list. Their joint labors have combined to produce a series of volumes in which the current progress throughout the world, in respect to all the branches of medical science, is very adequately represented. The general arrangements of the book are ingenious and complete, having regard to thoroughness and to facility of bibliographical reference.-British Medical Journal. ANNUAL, 1890. The editor and publishers of the Annual of the Universal Medical Sciences take this opportunity to thank its numerous friends and patrons for the liberal support accorded it in the past, and to announce its publication, as usual, in 1890. Recording, as it does, the progress of the world in medicine and surgery, its motto continues to be, as in the past, " Improvement," and its friends may rest assured that no effort will be spared, not only to maintain, but to surpass, the high standard of excellence already attained. The Subscription Price will be the same as last year's issue and the issue of 1888. (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 29 ISSUE OE IBS© OF The Annual of the Universal Medical Sciences. In Five Royal Octavo Volumes of over 500 pages each, bound in Cloth and Malf-ltussia, Magnificently' Illustrated with Cliromo-JLithographs, Engravings, Maps, Charts, and Diagrams. THE SUBSCRIPTION PRICE (including the "Satellite" for one year). United States. Canada (duty paid). Great Britain. France. Cloth, 5 Vols., Royal Octavo, - - $15.00 $16.50 £3.6s. 93 ft. 95 Half-Russia, 5 Vols., Royal Octavo, - 20.00 22.00 4.6s. 124 fr. 35 This work is bound in above styles only, and sold by subscription. Published in Connection with the Annual and for Subscribers Only. THE SATELLITE -OF THE- ANNUAL OF THE UNIVERSAL MEDICAL SCIENCES. \ Monthly Review of the most important articles upon the practical branchesof medicine appearing in the medical press at large, edited by the Chief Editor ot the Annual and an able stall'. Editorial Staff of the Annual of the Universal Medical Sciences, issue of 1889. Chief Editor, Dr. CHAS. E. SAJOUS, Philadelphia. ASSOCIATE STAFF. Volume I.-Diseases of the Lungs, Diseases of the Heart, Diseases of the Gastro- Hepatic System, Diseases of the Intestines, Intestinal Entozoa, Diseases of ihe Kidneys and Bladder, Fevers, Fevers in Children, Diphtheria, Rheu- matism and Gout, Diabetes, Volume Index. Prof. Jas. T. Whittaker, Cincinnati. Dr. Jas. C. Wilson, Philadelphia. Prof. A. L. Izioinis, New York City. Prof. Louis Starr, Philadelphia. Prof. E. T Bruen, Philadelphia. Prof. J. Lewis Smith, New York. Prof. W. W. Johnston, Washington. Prof. N. S. Davis, Chicago. Dr. L. Emmett Holt, New York. Prof. Jas. Tyson, Philadelphia. Prof. Jos. Leidy, Philadelphia. Volume II.-Diseases of the Brain and Cord, Peripheral Nervous System, Mental Diseases, Inebriety, Diseases of the Uterus, Diseases of the Ovaries, Diseases of the External Genitals in Women, Diseases of Pregnancy, Obstetrics, Dis- eases of the Newborn, Dietetics of Infancy, Growth, Volume Index. Prof. E. C. Seguin, New York City. i Prof. W. H. Parish, Philadelphia. Prof. Henry Hun, Albany. Prof. Theophilus Parvin, Philadelphia. Dr. E. N. Brush, Philadelphia. Prof. Wm. L. Richardson, Boston. Dr. W. R. Birdsall, New York. Dr. A. F. Currier, New York. Prof. Paul F. Munde. New York City. Prof. Louis Starr, Philadelphia Prof. Wm. Goodell, Philadelphia. Dr. Chas. S. Minot, Boston. Dr. W. C. Goodell, Philadelphia. Volume III.-Surgery of Brain, Surgery of Abdomen, Genito-Urinaiy Surgery, Dis- eases of Rectum and Anus, Amputation and Resection and Plastic Surgery, Surgical Diseases of Circulation, Fracture and Dislocation, Military Surgery, Tumors, Orthopeedic Surgery, Oral Surgery, Surgical Tuberculosis, etc., Sur gical Diseases, Results of Railway Injuries. Anaesthetics, Surgical Dressings, Volume Index. Prof. N. Senn, Milwaukee. Prof. D. Hayes Agnew, Philadelphia. Prof. E. L. Keyes, New York City. Dr. Morris Longstreth, Philadelphia. Prof. J. Ewing Mears, Philadelphia. Dr. Thos. G. Morton, Philadelphia. Dr. Chas. B. Kelsey, New York City. Prof. J. E. Garretson, Philadelphia. Prof. P. S. Conner, Cincinnati. Prof. J. W. White, Philadelphia. Dr. John H. Packard, Philadelphia Prof. C. Johnston, Baltimore. Prof. Lewis A. Stimson, New York City. Prof. E. C. Seguin, New York City. Dr. J. M. Barton, Philadelphia. Volume IV.-Skin Diseases, Ophthalmology, Otology, Rhinology, Diseases of Pharynx, etc., Intubation, Diseases of Larynx and Oesophagus, Diseases of Thyroid Gland, Legal Medicine, Examination for Insurance, Diseases of the Blood, Urinalysis, Volume Index. Prof. A. Van Harlingen, Philadelphia. I Dr. Chas. E. Sajous, Philadelphia. Dr. Chas. A. Oliver and Dr. Geo. M. Prof. D. Bryson Delavan, New York. Gould, Philadelphia. Prof. R. Fletcher Ingals, Chicago. Dr. Charles S. Turnbull, Philadelphia. Prof. F. W. Draper. Boston. Prof. J. Solis Cohen, Philadelphia. Prof. Jas. Tyson, Philadelphia. Prof. John Guiteras, Charleston, S. C. Volume V.-General Therapeutics, Experimental Therapeutics, Poisons, Electric Therapeutics, Climatology, Dermography, Technology, Bacteriology, Embry- ology, Physiology, Anatomy, General Index. Dr. J. P. Crozer Griffith, Philadelphia. Dr. C. Sumner Witherstine, Philadelphia. Dr. Hobart A. Hare, Philadelphia. Prof. J. W. Holland, Philadelphia. Prof Geo. H. Rohe, Baltimore. Prof. A L. Ranney. New York. Prof. John B. Hamilton, Washington. Dr. Albert H. Gihon, IJ. S. N. Dr. Harold C. Ernst, Boston. Dr. W. P. Manton, Detroit. Prof. H. Newell Martin, Baltimore. Dr. W. X. Sudduth, Philadelphia. Dr. R. J. Dunglison, Philadelphia. Prof. Wm. T. Forbes, Philadelphia. 30 (F. A. DAVIS, Medical Publisher, Philadelphia. Pa., U.S.A.) THE LATEST BOOK OF REFERENCE ON NERVOUS DISEASES. Lectures on Nervous Diseases, FROM THE STAND-POINT OF CEREBRAL AND SPINAL LOCALIZATION, AND THE LATER METHODS EMPLOYED IN THE DIAGNOSIS AND TREATMENT OF THESE AFFECTIONS. By AMBROSE L. RANNEY, A.M., M.D., Pr Lessor of the Anatomy and Physiology of the Nervous System in the New York Post-Graduate Medical School and Hospital ; Professor of Nervous and Mental Diseases in the Medical Department of the University of Vermont, etc. ; Author of "The Applied Anatomy of the Nervous System,'' " Practical Medical Anatomy," etc., etc. FROFVSELT ILIVSTBATET) With Original Diagrams and Sketches in Color by the Author, carefully selected Wood- Engravings, and Reproduced Photographs of Typical Cases. ONE HANDSOME ROYAL OCTAVO VOLUME OF 780 PAGES. United States. Canada (duty paid). Great Britain. France. CLOTH, - - - .185.50 186.05 £1.38. 34 fr. 70 SHEEP, - - - 6.50 7.15 1.6s. 40 fr. 45 HALF-RUSSIA, - - 7.00 7.70 1.9s. 43 fr. 30 SOLD OKLY BY SUBSCRIPTION. It is now generally conceded that the nervous system controls all of the physical functions to a greater or less extent, and also that most of the symptoms encountered at the bedside can be explained and interpreted from the stand-point of nervous physiology. The unprecedented sale of this work during the short period which has elapsed since its publication has already compelled the publishers to print a second edition, which is already nearly exhausted. We are glad to note that Dr. Ranney has pub- appeared in medical literature, is presented in com- Itshed in csok form his admirable lectures on nervous pact form, and thus made easily accessible. In our diseases. His book contains over seven hundred opinion. Dr. Ranney's book ought to meet with a large pages, and is profusely illustrated with origi- cordial reception at the hands of the medical pro- nal diagrams and sketches in colors, and with many fession, for, even though the author's views may be carefully selected wood-cuts and reproduced photo- sometimes open to question, it cannot be disputed ■graphs of typical cases. A large amount of valua- that his work bears evidence of scientific method and ble information, not a little of which has but recently honest opinion.-American Journal of Insanity. LECTURES ON THE Diseases of the Nose and Throat. DELIVERED AT THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA, By CHARLES E. SAdOUS, M.D., Lecturer on Khinology anti Laryngology in Jefferson Medical College; Vice-President of the American Laryngological Association; Officer of the Academy of France and of Public Instruction of Venezuela: Corresponding Member of the Royal Society of Belgium, of the Medical Society of Warsaw (Poland), and of the Society of Hygiene of France ; Member of the American Philosophical Society, etc., etc. ILLUSTRATED WITH 1OO CHROMO-LITHOGRAPHS, FROM OIL PAINTINGS BY THE AUTHOR, AND 93 ENGRAVINGS ON WOOD. ONE HANDSOME ROYAL OCTAVO VOLUME. SOLD ONLY BY SUBSCRIPTION. United States. Canada (duty paid). Great Britain. France. Oloth, Royal Octavo, - - - 184.00 184.40 £0.18s. 24 fr. 60 Half-Russia, Royal Octavo, - 5.00 5.50 1. Is. 30 fr. 30 Since the publisher brought this valuable work before the profession, it has become : 1st, the text-book of a large number of colleges; 2d, the reference-book of the U. S. Army, Navy, and the Marine Service; and, 3d, an important and valued addition to the libraries of over 7000 physicians. This book has not only the inherent merit of presenting a clear expose of the subject, but it is written with a view to enable the general practitioner to treat his cases himself. To facilitate diagnosis, colored plates are introduced, showing the appearance of the differ- ent parts in the diseased state as they appear in nature by artificial light. No error can thus be made, as each affection of the nose and throat has its representative in the 100 chromo-lithographs presented. In the matter of treatment, the indications are so complete that even the slightest procedures, folding of cotton for the forceps, the use of the probe, etc., are clearly explained. • It is intended to furnish the general practitioner II they would appear to him were they seen in the not only with ;■ guide for the treatment of diseases of || living subject. As a guide to the treatment of the the nose and throat, but also to place before him a nose and throat, we can cordially recommend this representation of the normal and diseased parts as work.-Boston Medicalaud Surgical Journal. (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 31 The Medical Bulletin MONTHLY-ONE DOLLAR A YEAR. Bright, Original, and Readable. Articles by the best practical writers procurable. EVERY article as brief as is consist- '"THERAPEUTIC NOTES by the leaders ent with the preservation of its * of the medical profession thbough- scientific value. out the world. THESE, and many other unique features. help to keep The Medical Bulletin in its present position as The LEADING LOW PRICE MEDICAL MONTHLY of the WORLD. subscribe; now ! TERMS, $1.00 A YEAR IN ADVANCE In United States, Canada, and Mexico. FOREIGN SUBSCRIPTION TERMS, POSTAGE PAID: England, 5 Shillings. France, 6 Francs. Germany, 5 Marks. Australia, 5 Shillings. Japan, 1 Yen. Holland, 3 Florins. F. A. bAVlS, Publisher, Philadelphia, Pa., (J.5.A. BRANCH OFFICES: 45 East 12th St., New York City, U.S.A. 1 Kimball House, Atlanta, Ga., U.S.A. 24 Lakeside Building, 220 S. Clark St., 427 Sutter St., San Francisco, Cal., U.S.A. Cor. Adams, Chicago, Ill., U.S.A. 139-143 Oxford St., London, W., England. FOREIGN AGENCIES: PARIS-Le Soudier. VIENNA-Josef Safar, VIII Schlosselgasse, 24. TOKIO, JAPAN-Z. P. Marnya & Co. -^IN PRESS. SECOND EDITION. = Ointments and Oleates in Diseases of the Skin. -BY- JOHN U. SHOEMAKER, AM, M.D., Professor of Materia Medica, Pharmacology, Therapeutics, and Clinical Medicine, and Clinical Professor of Diseases of the Skin in the Medico-Chirurgical College of Philadelphia, etc. 16mo. NEATLY BOUND IN CLOTH. PRICE, IN UNITED STATES AND CANADA, NET, SI.00, POST-PAID ; GREAT BRITAIN, 4s. 3d.; FRANCE, 6 fr. 20. The accompanying Table of Contents will give a general idea of the work: CONTENTS. PartI.-History and Origin. Part II.-Process of Manufacture. Part HI.-Physiological Action of the Oleates. Part IV.-Therapeutic Effect of the Olbates. Part V.-Ointments : Local Medication of Skin Diseases.-Antiquity of Ointments.-Different Indi- cations for Ointments, Powders, Lotions, etc.-Information about Ointments: Scanty, Scattered, and Insufficient.-Fats and Oils: Animal and Vegetable.-Their Chemical Composition.-Comparative Permeability of Oils into Skin ; of Animal, of Vegetable. Incorporation of Medicinal Substances into Fats: (i) Mode of Preparation, (a) Vegetable Powders and Extracts, (3) Alkaloids, (4) Mineral Sub- stances, (5) Petroleum Fats ; Chemical Composition; Uses and Disadvantages.-List of Officinal Oint- ments.- Indications.-Substances often Prescribed Extemporaneously in Ointment Form.-Indications. A FULL INDEX RENDERS THE BOOK CONVENIENT FOR QUICK REFERENCE. CRITICISMS OF FIRST EDITION. The profession in both countries is deeply in- To those of our readers who wish to learn the debted to Dr. Shoemaker for his excellent work in therapeutic effects of a class of preparations which this department of medicine.- William Whitla, are destined to grow in favor as their merits be M.D. (Q.U.I.). come more generally known, we commend this It is the most complete exposition of their action book.-Journal of Cutaneous and Venereal which has yet appeared. They are very valuable Diseases. accessions to the materia medica, and should be No physician pretending to treat skin diseases familiar to every practitioner.-Medical and Sur- should be without a copy of this very instructive gieal Reporter. little book.-Canada Medical Record. 32 (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.)