By W. SCHEPPEGRELL, A. M., M. D.,

PRESIDENT WESTERN OPTHALMOLOGIC AND OTO-LARYNGOLOGIC ASSOCIATION, NEW ORLEANS, LA.

Hygiene is that branch of medical science which relates to the preservation and improvement of the health. As the prevention of disease is more important than its cure—in fact, superior to all methods for its cure—this is a subject which demands our most earnest attention. Hygiene is not limited to the preservation and improvement of the health of the individual, but includes that of whole communities. As, however, the health of a community depends upon the state of the health of the various families composing it, and this again of its members, the proper understanding of the hygienic laws by each individual is of the utmost importance.

For some reason, however, the subject of hygiene or the prevention of disease does not create the enthusiasm caused by methods advocated for its cure. A Koch, who publishes to the world a supposed means of curing tuberculosis, or a Behring, who introduces the serum therapy of diphtheria, arouses an interest which is limited only by the four corners of the world. The modest worker in sanitation, however, who explains the means of the development of these diseases, and the conditions and laws by means of which they may be prevented, is looked upon without interest and frequently with disfavor. But in spite of these conditions, the laws of hygiene are gradually becoming more farspread, and their influence is felt more with each advancing year.

The nose, throat, and ear are so intimately connected with the other parts of the body that their health depends to a large extent upon the condition of the system in general. The laws of hygiene and their application which refer to the body in general are also applicable to these parts, and whatever condition benefits the former will have a useful influence on the upper respiratory passages, and, inversely, any injurious effect will injure the health of these organs.

The physiology of this region is of much importance. Formerly the nose was considered principally in its relation to the organ of smell. This is a most important function, as it is a constant sentinel over the air we breathe and the food we eat. It is a curious circumstance that many of the functions that are referred to the organ of taste really belong to that of smell. In eating ice cream, for instance, the sense of taste simply informs us that it is sweet or otherwise, but the flavor is perceived only by the sense of smell. A proof of this is that where this function is destroyed, all ability in this direction disappears, and the patient thus affected will frequently complain that his sense of taste is defective, not realizing that it is the sense of smell which performs this act.

The nose, however, has a much more important function to perform—viz., in respiration. Strange to say, however, this has only recently been realized, and it is even yet not well understood. You have all observed that, when you had a severe "cold" which prevented nasal breathing, the next morning the mouth and throat were dry and parched and frequently inflamed, the voice sometimes hoarse, and there was a general feeling of depression. While the progress of the inflammatory process may be a factor in this, still the mechanical obstruction of the nose from any cause whatsoever will have a similar effect. In patients in whom, for various reasons, an artificial opening has been made in the trachea, the air of the room has to be heated to an almost intolerable point and saturated with moisture, or severe bronchial inflammation will soon develop in the patient, simply because the nose has not taken an active part in the act of respiration. These effects, therefore, clearly demonstrate that the nasal passages have an important function to perform in the breathing process. Summarized in a few words, it is simply to warm, moisten, and clean the air which we inhale.

The healthy nostrils are anatomically and physiologically so formed that when the current of air passes through them it will have been freed of its mechanical impurities, warmed to within a few degrees of the temperature of the body, and moistened to saturation. This has been experimentally demonstrated.

The opening of the passage of the ear into the throat has several objects, the most important being ventilation and the adjustment of the atmospheric equilibrium. This passage leads outward until it enters the cavity of the middle ear, which is closed by the drum on the outside, thus separating it from the external canal of the ear. We know that atmospheric pressure varies at different times and in different altitudes. It is much less, for instance, at the top of a mountain than at the seaside. The opening into the throat allows the air to enter, and adjusts the atmospheric pressure within the ear to these various external conditions. Those of you who have ascended Lookout Mountain by means of the incline cable car may have noticed the adjustment taking place by a peculiar click when different altitudes were reached.

So intimately are the nose, throat, and ear connected that it is unusual to find one affected to any considerable extent without the others being involved. While the rules of hygiene in general are applicable to the nose, throat, and ear, there are certain special conditions which deserve consideration. One of the most common causes of injurious effects to the nose, throat, and ear is the so-called "cold." The cold in this connection is, of course, understood to be simply the cause, the condition itself being a peculiar inflammation of the parts concerned. As cold is so frequently a cause of diseases of these parts, it would be well to consider under what circumstances it develops and the best mode of prevention.

I have often noticed that persons who suffer most frequently and severely from colds usually insist that they exercise the greatest care to avoid exposure. They have dressed in the warmest clothing, wrapped the neck in the heaviest mufflers, remained in the closest rooms, and avoided every draught, and yet they continually "take cold." The street urchin, on the other hand, with only two or three garments and without shoes, and who lives out of doors, suffers less frequently from this affection.

"Colds" have truly been called a product of modern civilization. The trouble was rare among the aborigines and is more common among the cultured than among the laboring classes. If we make a plant an exotic, we must keep it in the conservatory, and even here it is not free from danger. On the other hand, if we wish to harden it and make it proof against atmospheric and climatic changes, we must prepare it by judicious exposure for these conditions. The warm clothing which is thought to be a protection against cold is frequently the most fertile cause. It relaxes the body, moistens the skin, and the perspiration which is induced especially prepares the unresisting body for its attacks. This applies especially to warm covering around the neck, to which the air has periodic access. Except in unusually severe weather, the throat requires no more covering or protection than the face.

The method of having only two systems of underclothing, the heavy to be worn until it is quite warm, and vice versa, is also a source of danger. There should be three changes: one of the lightest texture for the warm weather of summer, a medium for spring and fall, and the pure wool for winter, which in this climate need not be very heavy. Waterproof shoes, rubbers, furs, etc., are not recommended for customary use, and should be worn only when absolutely indicated.

The best preventive of recurrent colds is the judicious use of the sponge or cold shower bath. The ordinary bath should usually be of a temperature not disagreeable to the body, but after the question of cleanliness has been attended to, an application, either by means of a sponge or shower, of ordinary cold water should be made. This should be of short duration, and friction with a coarse towel follow at once. When properly conducted, a reaction sets in so that there is no danger from this, and the toning effect of the method is of the utmost value in the prevention of colds. This applies, of course, only to persons in ordinarily good health. Even in these cases there are rare occasions in which this method is not advisable, and it may on general principles be stated that it should not be used by persons who do not react promptly. As stated, however, the application of cold water should be only momentary. The daily application of cold water to the throat and chest is also a useful practice for strengthening these parts.

In addition to these means there are certain injurious conditions that it would be well to avoid. One almost universally present in large cities is that of dust. The constant inhalation of the small particles of sand and of organic impurities of which dust is composed has an irritating effect on the delicate lining of the nose and throat, which may develop a chronic inflammation, resulting in injury to both the throat and ear. This evil, however, can be prevented by the artificial watering of our streets.

Excessive tobacco smoking produces injurious effects in the nose and throat. Of all forms of smoking, the cigarette is the most injurious, and allowing the smoke to pass through the nostrils the most dangerous. Occasionally ladies inhale the smoke of a closed room where the male members of the household are smoking, and this is injurious to a delicate throat.

Loud and excessive talking is sometimes a factor in throat diseases. The former is more apt to be exercised in transit in our steam or electric cars, and members of the theatrical profession realize this so well that they rarely use their voice while traveling. In excessive talking, in addition to the mechanical wear and tear of the throat, the respiration is usually spasmodic, a combination that is likely to lead to evil results. At puberty, when the voices of boys and girls are changing, the former sometimes almost an octave and the latter usually a note or two, special care should be taken of the voice, and singing or vocal exercises should be discontinued until the change has been finally established.

The effect of singing on the throat is of much interest, but it is one of such an extensive character that it can be only casually referred to here. The exercise required in singing improves the healthy throat in the same manner that exercise benefits the body in general. The diseased throat, however, may be injured by this practice, as no form of vocal culture can remedy a mechanical interference in its action. The method of singing is also of the utmost importance; an erroneous one may not only injure a promising voice, but may also have a bad effect on a normal throat. The subject of register requires careful consideration. The placing of the voice in the wrong register is fruitful of evil; the ambition of the singer to reach a few notes higher or lower than her range may also work severe injury to the throat.

The throat may be improved or strengthened by any of the forms of exercise, especially the out-of-door, which have been advised for the health in general. In addition to this, breathing exercises are of special value. These consist of taking deep inhalations through the nose, holding the breath for a few seconds and then gently expiring it, the body in the meanwhile being free from all restraint from tight clothing. The practice of this exercise for five minutes mornings and evenings will have a remarkable effect in developing the chest and throat.

In order to anticipate serious complications, children should be taught to allow their mothers to examine their throats freely and without resistance. I feel especially the importance of this subject, as I have frequently seen children almost sacrificed on account of the nervous dread of having their throats examined, or by their inability to control themselves. The method is exceedingly simple: the child is placed facing a bright window, and the handle of a spoon placed on the tongue and so depressed that the posterior part of the throat can be distinctly seen. At first this may be difficult, but the child soon becomes accustomed to the manipulation and the throat may then be examined without difficulty. Another advantage of this procedure is that the mother becomes familiar with the normal appearance of the throat, and can easily note any change due to disease.

In view of the important function of the nose in warming, cleaning, and moistening the inspired air, the greatest care should be taken to teach children to breathe through the nostrils. When only a portion of the air enters through the mouth, the irritation is not as marked as when all the air is inhaled in this manner, but it nevertheless develops a condition of chronic irritation which is easily recognized by one familiar with its appearance, and which may lead to important complications. In many cases, mouth breathing is not due to habit, but to some obstruction in the nostrils or throat. These cases form a proper subject for the consideration of the physician. After the removal of any existing obstruction, children will sometimes, from force of habit, continue to breathe through the mouth, but this can usually be overcome by attention and firmness on the part of the parents.

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.

Another method of contracting tuberculosis is by means of animals, such as cows, used for food and milking, which are known to be subject to this disease. It has been shown in some localities that one cow out of every twenty-five was affected with tubercular disease. This suggests the importance of having competent veterinarians to examine not only the meat which is sold, but also the cows used for milking purposes. Where there is the slightest doubt as to the nature of the meat or milk, the former should be thoroughly cooked and the latter sterilized before using.

In this connection it would be well to refer to the subject of spitting in street cars and in public places. While this nuisance is the subject of danger to every one in the street cars, especially in winter, when the windows are closed and a large amount of impurities is inhaled, it is more particularly so to ladies, whose skirts, in spite of every care, are soiled by the filthy expectoration, thus making them subject not only to the inhalation in the car, but also to carrying the infectious material to their homes.

The danger of this condition is not merely speculative. It has been bacteriologically demonstrated that the organisms of various contagious diseases thus find a lodging place in our cars and public places, and experiments on animals, in which the inoculation has developed diseases, have shown that these organisms retain their vitality in these places and may propagate disease under favorable conditions.

A factor in the spread of diseases of the throat and mouth that should not be overlooked is kissing. Unfortunately, this matter has usually been treated with much levity, and where a sanitarian is bold enough to condemn the habit he is frequently made the subject of all forms of ridicule in the public press.

The tender lining of the lips, mouth, and throat, and its large blood supply, make it peculiarly susceptible to contagion, and I have no doubt that the habit of kissing is responsible for many cases of infection. Last year I noticed a lady coming from a house from which a diphtheria flag was flying, who walked to the corner to take the street car, when a nurse with a small child approached. The lady without hesitation stooped down and kissed the little child. As it is well known that a healthy person may transmit a disease without incurring the disease himself, this lady voluntarily risked the danger of inflicting this disease upon the innocent child. It is not an uncommon thing for nurses to kiss the children under their charge, and here in New Orleans even the colored nurses sometimes practice this habit, occasionally with the permission of the parents. In fact, a fashionable lady on one occasion told me, when I remonstrated with her about this, that she feared to hurt the feelings of the old nurse, who had been a valuable servant in the family for many years.

How often this habit is productive of evil results is of course only speculation. I recall, however, an instance in which two small children of one family developed a specific disease which originated in the mouth and affected the whole system. Examination proved this to have been caused by a nurse, a white woman, who had been in the habit of kissing the children. If women will voluntarily incur risks by using kissing as a form of salutation in all stages of acquaintanceship, I would at least request that the innocent children be spared the possible consequences.

The subject of the hygiene of the ear is so intimately connected with conditions influencing the nose and throat, which have already been explained, that but few words are needed to cover this part of my subject. In general, the best care of the ear is to leave it alone. Ear scoops are injurious; the ear should be cleaned simply on the outside, and nothing, as a rule, should be inserted into the external canal. I have seen many cases of abscess and the most severe inflammation due to endeavors to clean the ear with the omnipresent hairpin and other objects used for this purpose. The use of cotton in the ear in general is to be condemned. It produces an artificial condition in the outer canal of the ear which reduces its physical resistance and makes it more liable to injury from exposure. The ear is sometimes injured by the entrance of cold water. This happens occasionally during ordinary bathing, but more frequently in outdoor bathing and in swimming. In surf bathing, where the water is thrown up with considerable force, it is much more liable to enter the external orifice of the ear, and severe inflammation may originate from this cause.

Salt water has been claimed to be more injurious than fresh, but my personal experience leads me to believe that it is more a question of temperature than of the quality of the water. Some years ago a large reservoir was built by an educational institute near this city, the water, which was quite cold even in summer, being supplied by an artesian well. The tank was used for bathing purposes, but earache soon became so frequent among the boys that the use of the reservoir for this purpose had to be entirely abandoned. In ordinary bathing, the entrance of water into the ear can easily be avoided. In swimming or surf bathing it is advisable to use a pledget of lamb's wool to close the opening of the ears. Ordinary cotton soon becomes saturated and is of no use in this connection, but the wool, which is slightly oily, forms an excellent protection in these cases.

The "running ear" is a diseased condition which should not be tampered with by the inexperienced, but which should not be neglected. The old idea that the child will outgrow it, or that it is a secretion of the head which if interfered with would prove dangerous, has been fruitful of many cases of deafness and even more serious complications.

Another condition to which I would call your attention is the incipient development of deafness in children. Where the capacity of hearing is quickly lowered from the normal to fifty per cent, it is so striking that the patient is much distressed and even confused. But when this change takes place insidiously from day to day, it is frequently not observed by either the patient or those around him until it has greatly advanced. Children thus affected hear only with difficulty and by straining certain small muscles of the ear, which soon become fatigued, and the child becomes listless and inattentive. I have seen numerous cases in which children have been severely punished for inattention, when this was due to defective hearing. Watchfulness and early attention in these cases will frequently prevent the more serious forms of deafness.