The prevention of grave throat diseases, such as diphtheria, necessarily forms a subject of much interest to the public in general and to mothers in particular. The causation of this disease has been much cleared up in later years, and we now know that the important factor is a bacillus—a small organism of the vegetable kingdom—which is the cause of this disease and a necessary material for its propagation. Bacteriologic investigations have shown that the so-called "membranous croup" is in by far the largest number of cases identical with diphtheria, and the same precautions which apply to the latter should therefore also be carried out in this disease.
As diphtheria is strictly an infectious disease, and one which must be directly or indirectly contracted from a similar case, there is no sanitary reason why this dreaded malady in the course of time should not be entirely eliminated from the earth. In view of the fact that diphtheria is so frequently present in our larger cities, this may appear at present a Utopian idea. It is not so many years ago, however, when smallpox was almost universal, and yet we now but rarely have it in our midst. Not only is this the case, but the health authorities are severely criticised when a number of these cases exist, as indicating that there has been a lack of watchfulness in carrying out certain well-known means of prevention.
While we have at the present time no means of inoculation that will permanently protect against infection from diphtheria, still it is not of such an infectious character as smallpox, as the cases are usually limited to children, and its spread may therefore be more easily prevented. Not only should children who have had diphtheria be prevented from returning to school until infection is no longer possible, but other children of the same household should also be kept at home. A few years ago a certain school in this city was rarely without a case of diphtheria among its pupils for many months. I am convinced that had the principal of the school or the parents insisted upon the other children of the infected household remaining at home, the spread in this direction would have been arrested and much suffering avoided.
When a patient has recovered from diphtheria, thorough disinfection is a most important measure. Unfortunately, however, many persons consider it a hardship if articles which can not be disinfected are destroyed, and many will even use every endeavor to prevent the representatives of the Board of Health from carrying out their regulations. In this way the germ of the disease remains on the premises, and under suitable conditions again finds another victim in the household. To illustrate this, I recall an instance some years ago in which I was called in consultation to see a most malignant case of diphtheria. The little patient fortunately recovered, and the premises were thoroughly disinfected, the parents being anxious to avoid any repetition of the dreaded malady. Five months later, however, a younger child became ill, and was found to have diphtheria. In view of the vigorous efforts which had been made to disinfect the house thoroughly, and of the fact that the child could not have contracted it elsewhere, not having left its home for several weeks, the cause at first appeared a mystery. Careful inquiry, however, soon elicited a fact which clearly explained the case. The first patient had used a mouth-organ just before its illness, and when this was abandoned, the toy was carelessly thrown on the top of a bookcase, the nature of the child's illness at the time not being known. The second child, just before its illness, had accidentally found this toy and used it frequently. This experience explains the necessity of disinfection in all its details, and also illustrates the tenacious character of the germ which produces this disease.
Our knowledge of the specific cause of scarlet fever is not as complete as that of diphtheria, but we have much useful information which is of importance from a hygienic standpoint. As in diphtheria, the specific poison is probably produced in the throat of the patient, and may therefore be spread by the dried secretion from the mouth and throat. The most common means of contagion, however, is the skin, which peels off in the later stage of the disease, infection being produced by the inhalation into the nostrils of some of the diseased particles.
A predisposing factor which applies alike to diphtheria and all other throat affections is the abnormal condition of the nose and throat. When these important parts are in an unhealthy condition, where mouth breathing exists and other conditions inimical to normal health, the patient is more predisposed to all forms of maladies of this region, and the attack when developed is more apt to be of a serious character. The more ordinary forms of sore throat, such as tonsilitis, are frequently due to defects in the sanitary conditions and surroundings of the home. While modern sanitary plumbing, when properly constructed, adds much to the convenience of the household, it is a certain menace to all its members if, through improper construction or defective ventilation, decomposing matter collects in the waste pipes and vitiates the atmosphere of the rooms. Many recurrent cases of tonsilitis are due to this cause. Even the ordinary stationary washstands may be a source of danger, especially in the bedroom, unless thoroughly ventilated and care exercised that the traps are not filled with decomposing matter. A physician of large experience in this city is so imbued with the danger of this form of plumbing that he condemns it in toto. When well constructed and well ventilated, however, they can not be the source of danger in the household.
Tuberculosis, which is responsible for so enormous a mortality, frequently also affects the throat as well as the lungs. Although it usually originates within the chest, it sometimes finds its primary origin in the throat, and in a large percentage of cases the throat affection forms a complication of tuberculosis of the lungs. In spite of the numerous remedies which have been advocated for the cure of this disease, it must be admitted that our chief reliance is in proper nourishment and climatic effects, and that hygiene is the sheet-anchor which will eventually rescue us from this terrible foe of the human race.
Recent investigations tend to prove more and more that tuberculosis is inherited in but rare cases; that inheritance is simply a predisposing factor, and that the real cause is infection. As an illustration of this, all have seen instances in which there had been apparently no cases in a family for ten or fifteen years, when from some cause one case develops, and this is soon followed by other cases in the same family. Whatever rôle heredity may play in these cases, this simply shows that the first case produced the infectious material which found a suitable soil in the other members of the family and developed a similar disease. The inheritance theory has been the source of much injury by causing members of the afflicted family to submit to the apparently inevitable instead of instituting measures for its prevention. The infectious product in tuberculosis is not the breath, as is so frequently believed by the laity, but simply the expectoration which comes from the diseased lungs or throat. When this is allowed to come in contact with clothing or other material in the room, it becomes dry and loads the atmosphere with a dust which contains the infectious bacillus, which may cause a similar disease in a person predisposed by heredity or sickness to this affection.
The germ of tuberculosis is the seed, and the predisposed person the soil, and it requires a combination of both to develop the disease. To illustrate the necessity of suitable conditions for the development of plants—for it is now almost universally admitted that the germ of tuberculosis is a micro-organism which belongs to the vegetable kingdom—I remember some years ago, while in North Europe, seeing in a hothouse a plant which is here commonly known as the "four o'clock." The gardener in charge of the conservatory considered it a remarkable plant, but difficult to propagate, and stated that it was absolutely impossible to raise it out of doors. In this part of the world, however, we know that this plant grows so easily that once established in a garden it is difficult to keep it within limits. In both of the cases we have the same seed, the difference being only in the soil and the conditions favorable for its development. The absence of either the seed or the soil will absolutely prevent tuberculosis, and if the laws of hygiene are properly carried out, both in destroying the seed and in preventing the formation of a suitable soil, favorable effects will soon be shown.
Hygiene in regard to patients demands simply that the infectious character of the expectoration be destroyed. The vessels for this purpose should contain some disinfecting solution, should be cleaned regularly, and handkerchiefs, towels, or other material with which the expectoration has come in contact should be sterilized by being placed for at least half an hour in boiling water. This is necessary not only for those in the same room with the patient, but also for the patient, as it is quite possible that a former expectoration may produce reinfection of the patient himself.