THE PREVENTION OF INFECTION IN THE FAMILY AND

DISINFECTION IN TUBERCULOSIS.

EDWARD R. BALDWIN, M. D., Saranac Lake, N. Y.

Your president has kindly honored me with an invitation to address you on tuberculosis as related to the health officers' position, and the methods of prevention which may be deemed practical and important in the average family. I must speak chiefly from the standpoint of experience in a health resort, where I have served on the board of health and have had close contact with tuberculous individuals, but the conditions cannot be fairly paralleled in an average town where the patient is surrounded by his own family and usually nursed by them.

The most convincing of all dogmas based on external evidence has been that of the inheritance of tuberculosis. It was and is yet a distinct strain upon credulity to lay the burden of family tuberculosis upon the theory of infection. Even now the existence of any specific predisposition is questioned in some quarters and great stress is put upon infection during earliest infancy. However this may be we have some basic truths which give us a clear guide to methods of prevention. The first is that tuberculosis is always produced by a bacillus and that the human sputum is the most frequent source of the infection. Secondly, it is for the most part a housedisease, requiring prolonged and repeated exposure or close contact with the patient under especially predisposing conditions, for its successful implantation or development. Hence, we cannot fairly speak of contagion in connection with tuberculosis in the ordinary meaning of the term, else we must recognize a large degree of immunity to it as a normal condition of the human race.

Since, then, it is the inherited or acquired suceptibility that is needed to make the infection potent for harm, we should rightly ask, is it not of equal or greater importance to attack the problem of prevention from an entirely different standpoint than the baccillus? Indeed, we may as well give up the fight at the outset, unless we can have improved social conditions going hand in hand with strictly sanitary measures. It should be freely acknowledged that the present day diminution of tuberculosis has thus far been accomplished quite as much, if not more, by better food, housing, improved working conditions, the temperance movement, and all other physical and moral influences that distinguish our century. We must remember, however, that the removal of poverty, depravity, and ignorance is a slow process, whereas it is quite conceivable that some simple sanitary measures directed to the removal of the infective agent might produce a very great diminution in the disease. This we believe to be true of tuberculosis and it is a matter to which health officials can profitably give their attention. As has already been said, the sputum is the chief source of human tuberculosis, although we must not permit the impression to spread that no other source

need be considered. However few cases of tuberculosis are derived from infected milk, it is a convincing argument for the complete extermination of bovine tuberculosis, which will undoubtedly be accomplished in time by the aid of the tuberculin test.

When we come to apply the logic of our knowledge to the protection of the family where one of its members is afflicted with pulmonary tuberculosis we find one of the most difficult, and, at the same time, one of the most delicate problems which confront the health authorities, and much more, the attending physician. While theoretically it is possible to prevent the dissemination of the bacilli in the home it is practically impossible in nearly every case; but I believe that the most cleanly and intelligent people can so protect themselves that the small amount of inevitable infection can do no harm under ordinary circumstances of health.

We are not able to state how long an exposure or how much infection is necessary. in individual cases to become dangerous to that individual. Everything points to the fact that large numbers of tubercle bacilli are inhaled or swallowed by persons in normal health with impunity. On the other hand a combination of unfavorable conditions, either of health, environment, or habits, may make a very small number of virulent tubercle bacilli potent to do harm.

We naturally inquire when can a tuberculous patient first become a danger to his family, and the answer is from the time that he begins to expectorate tubercle bacilli; and the danger may undoubtedly be greater in some instances during the stage when the patient is yet able to move about in his home and has a strong expulsive cough than when he is bedridden and too weak to make violent efforts in expelling the sputum.

I should say that there are two stages in progressive tuberculosis when the patient may be regarded as more dangerous than at any other time. The first is, as already stated, when he begins to expectorate bacilli and when the diagnosis is yet unknown or denied by the patient or even-sad to say-by his physician. The second is during the last stage when he is too ill to observe care with his expectoration, which prior to this stage he may have been not only willing but anxious to do.

From the ignorant and vicious there seems to be little chance for protection short of forcible detention in an institution. With the more intelligent and naturally cleanly it is always possible to obtain coöperation and it is only necessary to show them where the danger lies, when they will gradually learn to use cuspidors and avoid promiscuous spitting. It requires undoubtedly a high grade of intelligence and conscience to be constantly on the guard when coughing, and to cover the mouth so as to avoid expelling small particles of sputum which undoubtedly constitute the danger in living rooms. In the majority of patients among the poor we may only hope by furnishing spit-cups and simple instructions to avoid the grosser danger from the sputum. It is conceivable that each state or township shall eventually provide freely, quantities of cheap paper cuspidors for the pocket and the room, which shall be burned daily. Quite as important to

my mind is the necessity for some substitute for the handkerchief. Women, as a rule, expectorate into handkerchiefs, and it cannot be denied that the children in the family of a tuberculous mother very frequently obtain their infection through this medium either directly or indirectly. The use of cheap gauze, or other cotton cloth, and Japanese paper, which can be frequently burned, lessens the danger immensely. When we reflect that the average handkerchief passes from the mouth of the mother to that of the child not infrequently, and is generally given an opportunity to become dry before it is washed, one does not fail to see that the handkerchief is often destined to be a fatal weapon when used by a diseased person.

It will be a great step forward when health boards shall furnish physicians, of directly to the patient, free of charge, suitable cuspidors from time to time, and by actual inspection see that they are being utilized properly. Numerous devices have been originated of late years for the reception of the sputum. From my own experience I am opposed to any form of cuspidor which requires cleaning, except when a conscientious and intelligent person presides over the cleaning process. This service is rarely obtained even in institutions, therefore some of the paper cuspidors are to be recommended. A liberal expenditure in this direction and a sustained effort to have them used ought to pay well in lives for the community.

Next in importance for the protection of the family is what I choose to call the toilet of the sick room. You all know the stereotyped requirements for tuberculosis; namely, a large well-sunned and aired room with the least possible furnishing, preferably without a carpet so that moist cleaning is feasible. These conditions are rarely obtained among the poor, where the greatest danger exists, and it is obvious from all that has been said that the logical thing to do is to remove the patient to a sanatorium or hospital according to the stage and condition of the disease. But, as we must deal with these patients. at home we can try for the best obtainable conditions. The most important of all is to isolate the patient in a separate room where the sunlight or daylight is abundant. If this alone were accomplished and the children of the family not permitted to enter the room, I confidently assert a diminution in the number of cases would result.

In the more favorable types of the disease, and especially in those patients who have been treated in institutions and a more or less complete arrest of the disease accomplished, there is theoretically very slight danger when we reflect that in the majority of cases the expectoration is expelled most frequently in the morning before rising, and after going to bed. Hence, the patient's room should, for practical purposes, be the only infected place in the house. Much less danger exists in such a room than is popularly imagined if the mouth is covered during expulsive coughing and every advantage is given for light and air. A white coverlet which can be sunned and aired or frequently changed is an advantage for bedridden patients. Cloths which may be used to wipe away expectoration may be deposited in cheap paper bags. Drooping moustaches and beards should

be trimmed away. A still further refinement is the use of a mouth wash of borax and soda after the morning and evening cough. Disinfectants are of little value in my opinion, since they are seldom strong enough and tend to produce a false sense of security. Boiling-hot soapsuds are of great value and always available, and I am one of those who advocate using the simplest means to accomplish our end in sanitation, which for the great part has to do with poverty, ignorance, and inefficiency.

Many persons are greatly disturbed over the danger from kissing, or from the use of the same spoons and glasses which the afflicted member of the family may also use. While separate articles of this kind should be advocated, I venture the statement that there exists much less danger from these sources than is popularly supposed. Soap and water, the great civilizers, are here, also, our protection.

This leads naturally to the question of the disinfection of rooms and clothing of the tuberculous, and a consideration of the length of time during which the bacilli may retain vitality. We know, for example, that strong sunlight will sterilize dry sputum in from two hours to two days; on the other hand, deposited in dark corners, sputum may retain virulence from three to four months. A large number of bacilli die when thoroughly dried and exposed to the air without light, but more when even diffused daylight is present. It is consequently very unlikely from any investigation thus far made that the dust in very well-lighted rooms has much infective power. Cleansing and disinfecting with bichloride of mercury or carbolic acid is more certain to destroy the infection than fumigation, as frequently carried out. But formaline fumigation has now been made so simple and inexpensive that it should always precede cleansing. Sulphur or formaldehyde candles are altogether too uncertain. Formaline vaporized by the lime or permanganate of potash methods has simplified its use and made it more efficacious, though even under good conditions it may fail to disinfect, and thus do harm by a false feeling of security which frequently results in careless cleansing. With a mixture of 12 oz. formaline and 6 oz. of permanganate of potash to each 1,000 c. ft., placed in an old dish-pan on a few newspapers one should easily fumigate the average sleeping room with a minimum sacrifice of time and expense.

The method now in use in New York City, whereby for 1,000 c. c., 12 oz. of formaline is mixed with 4 oz. of concentrated H2So, and then 1 lb. of unslaked lime is added, is the one which we employ at our little hospital and is yet cheaper. Neutralization by ammonia vapor boiled in the room is quite an advantage if the room must be occupied at once.

It is impossible to enumerate all the methods of conveying tuberculous infection from one person to another. The popular fear has reached a point far too high and we have long been obliged to counteract the unreasoning attitude of unscientific persons who are to be considered intelligent on most subjects. We are questioned about the danger from books, money, telephone transmitters, and in fact anything which the poor leprous consumptive may touch, taste, or handle, and it should be our duty to explicitly state that