There are germs, however, like typhoid fever and diphtheria, which do not produce any particular local disturbance with the growth of bacteria, but the whole body becomes sick, the circulation of the blood is affected, and a general disturbance ensues. This is due to the action of a poison, called a toxin, which is set free as a result of the growth of the bacteria in some one part of the body, which poison is then carried by the blood throughout the entire system, inducing fever and a general debility.

Just how these toxins are formed is not certain. They are not the bacteria themselves. This we know because the disease-producing bacteria can be grown in broth and the mixture can be strained through fine porcelain, fine enough to strain out the bacteria. Yet it has been found that the clear liquid passing the porcelain filter is capable of producing disease and is a deadly poison without the presence of any bacteria at all. During the incubation period of a disease, as, for example, in the three-week period when typhoid fever is developing, these poisons are being formed and are being scattered through the body, and it is during this time that the fight takes place between these poisonous forces and the defending forces always present in the human system. As already pointed out, these defensive forces are powerful or not, according as the general health of the individual is good or bad, and we see the familiar sight of persons said to be run down taking a disease, while those not so depleted of vitality are able to resist or remain immune.

So certain are scientific men of this power and of the fact that the power resides generally in the white corpuscles of the blood that, in the presence of a dangerous infection, a person's blood may be examined, and, if the white corpuscles are not present in sufficient quantity, proper means must be taken for developing this element in the blood, or else the person must take himself away from the infection, if the infection is to be avoided.

As a result of the conflict between the toxins and the defensive forces of the body, certain vital processes are set free in the blood and in the cells which seem to possess a highly specialized power of defense against any subsequent attack. Pasteur, in his researches on the subject of rabies, developed this power of resistance by inoculating into rabbits the rabies infection of a monkey. Monkey rabies is not a severe form and is scarcely felt by the ordinary rabbit, but if the infective material (usually part of the spinal cord) of the monkey-infected rabbit is transferred to a second rabbit, the disease becomes more severe; and if the disease is passed from animal to animal, it may be built up into as severe a form as desired, up to the maximum. Pasteur found that by inoculating an individual with a one-day rabbit, that is, with the weakest brand of infection killing a rabbit in one day, and the next day with a two-day rabbit, that the person could receive this two-day inoculation without discomfort or danger because of the greater antagonism acquired by the preceding inoculation. Continuing the inoculations for fourteen days and making the strength of the infection stronger each day, at the end of the period it was found that the fourteenth inoculation, strong enough to produce the disease and kill a fresh subject, had, on account of the preceding inoculations, produced ability to withstand or counteract the actual disease developing perhaps at the same time. Fortunately, in the case of this disease, the shortest period for its development is fifteen days, and often it is a month or more after the bite of the dog before the disease develops. By successive inoculation of increasing strength for fourteen days, the system will have acquired a habitude to the disease which prevents the normal effects.

Diphtheria is prevented in much the same way, except that in this case horses are used, their blood being strengthened to resist the disease by successive inoculations of the diphtheria poison. It is probable that all the bacterial diseases which exert their influence through the transmission of toxins in the blood may be counteracted by the production of an antitoxin when once the method of building up this antitoxin has been learned. At present, rabies, tetanus, diphtheria, and cerebrospinal meningitis are the four diseases for which antitoxin is made commercially and generally used. For a great many years, scientists have labored without success to find an antitoxin for consumption, and within the last year extensive experiments have been made in the American army on the use of antitoxin for typhoid fever.

Natural immunity.

It may be worth noting that not all resistance to specific diseases needs to be acquired in the roundabout way just described. The state of being free from disease is known as immunity, and the way of securing immunity just described is known as artificial immunity. This artificial immunity may also be obtained in the course of events by having the disease as a child, thereby generating the antitoxin in one's own body instead of in the body of some cow or horse or rabbit.

There is, however, a natural immunity which is due to long-continued environment or to protracted heredity. The negroes in the South have, by a lifelong proximity and struggle with the disease, acquired a practical freedom from typhoid fever, although it remains with the negro sufficiently to form a focus for the spread of the disease among others not equally immune. Creoles in yellow-fever districts have a natural immunity from the hookworm disease, although probably the class are responsible for its generous transmission to the poor whites with whom they associate. Racial immunity from certain diseases may be shown by statistical studies.

Chemical poisons.

Instead of the introduction of toxins into the body by the agency of bacteria, it is quite possible for chemical poisons, not formed originally by bacteria, to be set free in the body. Sulphate of copper, for instance, is essentially a mineral poison which acts on the human system in such a way as to produce death, and certain other mineral substances may be mentioned, such as phosphorus, arsenic, and mercury, which are well-known poisons. There are also many vegetable products, not bacterial, which are poisonous in their nature, that is, distributing to the blood and lymphatics certain substances in solution which act on the cells of the various organs of the body in such a way that the activity of those organs is stopped. Opium, cocaine, alcohol, and some of the coal-tar products used for headaches, as phenacetin, are deadly poisons when a limited dose is exceeded.

There are also certain poisons engendered in the body itself whose action is similar to that of chemical bodies and which can hardly be called bacterial. These poisons represent generally stages in the process of nutrition where for some reason the normal process is arrested and chemical bi-products are set free. Also, tissue which has been thrown off, in or by any organ, begins to decompose, thereby sending throughout the system the poisons of decomposition. Inflammation too generally results in the breaking down of the cells and the distribution of the resulting poisons. Of late years, much has been said of the poisonous property of the body waste not disposed of by excretion, and the theory of auto-intoxication, so-called, has received many adherents. The great scientist, Metchnikoff, has even gravely contended that it would be well for children to have their larger intestine removed entirely, because in that organ putrefaction occurs, the cause of the auto-intoxication he would try to prevent.

External causes.

The external causes responsible for disease are due to conditions of weather so severe as to be outside the possibility of self-protection. Excessive heat is responsible each year for deaths from sunstroke, and other conditions of weather are often the direct causes of disease, if not of death.

Accidents are the indirect cause of death, and there will always be a small proportion of the deaths occurring each year due to violence or accident. But, inasmuch as these deaths are clearly preventable, it is the duty of those interested in rural hygiene to study the reasons for accidental death, and, if the number of such accidents can be reduced, to strive for that reduction. As an example, it may be mentioned that each year a number of deaths in New York State, and probably in other states, occur from accidents at culverts and bridges, due to insufficient protection in the way of railings and fences. A method of reducing the deaths from accidents, therefore, would include a proper survey of all the roads of a vicinity to make sure that no danger exists in this regard. Other precautions against preventable accidents will readily suggest themselves.



CHAPTER XV

DISINFECTION

Inasmuch as more than 10 per cent of all deaths are due to bacterial or to various infectious diseases, it is of considerable interest to study the various means by which these germ diseases may be prevented. In this chapter it is proposed to discuss the different ways in which the active agents concerned in the spread of disease may be captured and put to death. It has already been pointed out that infectious diseases can be acquired only by the introduction of the specific germs into the human body, either through the mouth or lungs or through some skin abrasion. Further than this, it is quite as definitely known that the vitality of the germ after leaving a diseased person depends primarily upon its condition at the time of leaving the body and afterwards upon the environment which that germ finds outside of the affected person, while waiting for a chance to make its next human resting place.

It is evident, therefore, that if during the interval which elapses between the time when the germs leave a sick person and the time when they enter another person some method could be found by which these germs could be killed, the progress of the disease would be effectually stopped.

This, in the most general sense, is what is meant by disinfection. It is a determined effort to destroy the carriers of disease while temporarily absent from the human body which is their natural home. This process of killing bacteria, however, is not so simple a matter as it might at first seem. They are, unfortunately, such minute beings that they cannot be seen, so that the warfare is waged against an invisible enemy, not, however, to be despised on that account. The methods of warfare must be uncertain, since the exact location of the enemy cannot be known, and it is manifestly impossible to disinfect the universe. What is done is to fix upon the location or surroundings where the original patient was confined, and, assuming that the germs, if any, which have escaped ready for further infection are somewhere near, to poison the air and the wall and floor of the room in question so that happily the germs may be killed.

Disinfecting agents.

The various agents used to destroy those germs which are carriers of disease may be divided into two groups, namely, heat in its various forms, and chemicals. Literally, the word "disinfection" means "doing away with infection," so that to disinfect a room is to do away with the infection present in the room. It has, however, come to have a more general meaning than this and is commonly used instead of the word "destroy," so that a disinfecting solution is the same thing as a destroying solution, applied, of course, to bacteria.

It has already been explained that by far the majority of bacteria are useful if not essential to human life, and one of the difficulties in employing disinfecting or destroying solutions is that they put an end at the same time to both useless and useful bacteria. As an example, the fermentation processes in the human intestines are accompanied if not produced by certain kinds of bacteria, although on occasion these harmless or useful bacteria may develop into most obnoxious germs, producing unpleasant fermentation. It might be easy enough for a doctor to make a patient swallow some antiseptic solution, like carbolic acid or corrosive sublimate or nitrate of silver, for the purpose of getting rid of certain undesirable bacteria in the intestines, but it does not need a doctor to know that for a patient to swallow such active poisons as these would not merely kill the harmful bacteria and the good ones as well, but probably the patient himself.

Antiseptics.

There is another word often used in connection with bacteria, namely, "antiseptic," and the common significance of this word applies to a substance which interferes with or retards the growth of bacteria without actually destroying them. Doctors, for instance, use antiseptic instead of disinfecting solutions on wounds, not because they do not wish to kill the pus-forming bacteria, but because the antiseptic solution will prevent their growth and not be, as a disinfecting solution, harmful to the cells which he is trying to repair. It would be folly, for example, to inject a strong 50 per cent solution of carbolic acid into a wound on the arm produced by a saw, because all the energy of the vital forces at the seat of the wound are needed for repairs, and there is none to spare for so active a detergent as carbolic acid. An antiseptic, on the other hand, is mild enough so that it does not act on the tissue at all, but merely prevents any undesirable growth of bacteria.

Deodorizers.

There are substances used, perhaps not so much around country houses as around city houses and in water-closets, which are neither disinfectants nor antiseptic, but act as deodorizers only. Such a substance, for example, may be thrown into the kitchen sink, not at all for the purpose of killing bacteria, but for disguising the smell from the cesspool into which the sink-wastes discharge. It has no disinfecting properties and is good for nothing unless the material is so scented as to be agreeable on that score. One of the frauds perpetrated on the public is the preparation and sale of the various appliances designed and regulated to produce a perpetual smell and claimed on that account to be either disinfecting or antiseptic agents. The smell is worth nothing.

Patented disinfectants.

The poison of the disinfectant or antiseptic, whether it be in liquid or in gas form, is the essence of the material, and since the value of disinfectants is based on the crude raw materials which any one can buy, it is clearly unnecessary to buy expensive patented solutions for disinfectants when ordinary lime or carbolic acid are equally as good and can be had at much lower prices.

A disinfecting solution, to be successful in its action, must be reasonably proportioned in volume to the amount of material to be disinfected, whether this be a liquid or clothing or the air of a room. It is the height of absurdity, for instance, to pretend to disinfect the air of a large room by burning a tablespoonful of sulfur on a shovel in the center of a room without even taking the trouble to close the door. It is absurd to attempt to disinfect the bed linen in a single pailful of hot water, since even if the water was hot at the beginning, it would be so reduced in temperature by the first piece that went in that its efficacy would be lost for everything else. It is equally absurd that a liquid from a bottle, no matter how much advertised, can effectually disinfect a room, either by a gentle sprinkling of the liquid on the walls and floor or by a more thorough spraying of the air with an atomizer containing the liquid.

Disinfecting gases.

Two gases are available for use in disinfection, and these are valuable particularly in killing germs left in a room after a patient suffering from an infectious disease has been removed. The diseases referred to in the following chapters are all of this nature, and one of these two gases ought to be used in every case; otherwise the room may continue to harbor germs of the disease for months or years with the possibility of infecting a future tenant at a time when his vitality was such as to make him an easy prey. Nor must the contents of the room be overlooked.

The writer was recently told of a large family where one child had scarlet fever, recovering in September. The sick room was thoroughly disinfected, but the careful housewife, fearing damage to her blankets, had taken them to the attic before disinfection began. In the cold weather of February these blankets were brought down, and in six days the two children sleeping under them had contracted the disease.

Sulfur as a disinfectant.

When sulfur is burned, a gas is formed known as sulfurous acid, and until the last few years, it was the most common of all disinfecting agencies. The writer well remembers that when about to visit a city in South America infested with yellow fever, he was seriously advised to fill the inside of his shoes with sulfur as a precaution against the disease. He might as well have worn a red ribbon on his hat so far as any protection went, but it illustrates the confidence formerly shown in sulfur as a disinfectant.

It is now known that in the dry, powdered state, sulfur is of no value unless, perhaps, the germs be smothered with the sulfur flour. When burned, however, the gas given off has a certain disinfecting property, although this is limited. It has almost no power of penetrating into curtains, blankets, and upholstered furniture, although the penetration is decidedly increased if these objects are moistened either by steam or by water vapor. The proper amount of sulfur to be burned for any room is at the rate of 3 pounds per 1000 cubic feet of air space in the room. Thus, if a room be 12 feet by 15 feet and 8 feet high, containing 1440 cubic feet, it would be necessary to burn 144/100 of 3 pounds, or 4-1/3 pounds.

Before undertaking to disinfect a room with sulfur, it should be made thoroughly air-tight, and this must be done carefully, not merely by closing the larger and obvious openings, like doors and windows, but by pasting strips of paper over every crack which might allow air to escape. Thus the four edges of the window sash must be pasted up, and a strip must close the crack between the two sashes. All the doors but the one reserved for exit should be pasted up from the inside, and finally this last door pasted up on the outside. If the floor has settled away from the base-board, the cracks thus made must be pasted up. In short, the room must be made absolutely air-tight. The room should be left thus closed for at least twenty-four hours, and since there is some danger from fire, a proper provision should be made for the burning sulfur. This can be done by placing an old milk pan (a most convenient object in which to burn the sulfur) on a couple of bricks, which may be set inside a wash tub with perhaps three or four inches of water in the tub. The most convenient way of ignition is to moisten the sulfur with a little alcohol which can be readily set on fire.

Since clothes of every sort are more effectually acted upon when moist, they should be sprinkled with a hand atomizer just as the sulfur is lighted, and this should always be done in the case of any stuffed furniture or hangings. Anything that can be removed should be taken out and sterilized by steam, since live steam is the only disinfecting agent which will penetrate such things as mattresses, pillows, and rolled-up bundles of every sort, and with these last even steam is not certain. It is far safer to send a mattress to the cleaner to be steamed than to try to sterilize such bulky objects at home. It requires about twenty-four hours with the room tightly closed to generate enough gas so that the bacteria which may have found their way onto the walls or floor or ceiling or into the air of a room will be surely killed. After that time the room can be opened and then the usual household cleansing processes carried out as an additional safeguard. It is a wise measure in the case of infectious diseases, even after a room has been fumigated with sulfurous gas, to wipe off the woodwork and the walls, if their construction allows it, with a solution of carbolic acid, since in this way the germs which have accumulated on the woodwork will certainly be killed.

Formaldehyde disinfectant.

Formaldehyde is the other gas which is commonly used for disinfecting the air of a room. It is most readily produced by buying solidified formaldehyde and then decomposing it by the action of heat. Formaldehyde candles, as they are called, may be purchased at almost any drug store, and while special forms of generating stoves may be found in the open market, an ordinary heating apparatus of almost any sort will answer the purpose of decomposing the solid formaldehyde. About 20 ounces of the formalin should be used for each 1000 cubic feet of space. With this agent, however, as with sulfur, the penetrating power of the gas is not very great, and such things as mattresses and clothing should be sent to a steam sterilizer rather than be trusted solely to the power of the formaldehyde.

In using this gas, the same care about pasting up cracks and crevices in the room should be followed as already prescribed for the use of sulfur, and, as with sulfur, a reasonable precaution against fire should be taken by placing the apparatus in a tub of water or in a large pan of sand where accidents cannot happen. The room should be kept closed for at least twelve hours, and then should be thoroughly aired, and if the room is to be used again soon, the disagreeable odor may be removed by the free use of ammonia, either sprinkling it around in the room or by placing about saucers of ammonia.

Liquid disinfectants.

More common than gases and most readily suggested as disinfectants are certain liquids which have been proved both by laboratory experimentation and by actual experience to have the power of killing bacteria when brought into contact with them. Those liquids which have commended themselves particularly have additional advantages in not destroying fabrics, metals, or tissue with which they are brought in contact and in being purchasable at moderate prices.

There is little choice between a number of such liquids, and the number of modifications or combinations which are made and bottled and sold under some fancy name is legion. But the label, the name, and the additional price add nothing to the value of the basic chemical from which they are all compounded, and except for their convenience, they have little to recommend them.

Carbolic acid as disinfectant.

Carbolic acid is one of the most useful of these liquids, and in its various forms appears in almost all disinfectants. It may be obtained from the drug store in two forms, either as a crystal or as a concentrated solution.

A 2 per cent solution, that is, one pint of carbolic acid to six gallons of water, is the proper strength for all such uses as wiping off wooden surfaces, furniture, floors, etc. A stronger (5 per cent) solution is used when it is intended to destroy organic matter containing large quantities of germs. This is practically a saturated solution, so that if a bottle be partly filled with the crystals of carbolic acid and then completely filled with water, the water will absorb enough of the carbolic acid to make a 5 per cent solution, and the water may be poured on and off as long as the crystals remain. This 5 per cent solution is the proper strength to receive sputum from tuberculous patients, material ejected from the stomach in diphtheria, and fecal matter from typhoid and cholera patients. This strong solution should not be used on the living human body, since it is powerful enough to eat directly into the flesh, and being a violent poison, it should be kept out of the way of the household and carefully labeled to avoid accidents.

Carbolic acid has no value at all in the way of disinfecting the air, although fifty years ago surgeons were accustomed to use a spray of carbolic acid around the operating table before an operation in order to destroy any germs of the air lingering in the vicinity. It is equally futile to pour carbolic acid into sewers or to stand it around on the mantelpiece for the purpose of disinfecting a room. Nor are sheets wet in carbolic acid and hung over doorways and at the end of passages anything more than a remnant of medievalism.

Coal-tar products.

There are certain preparations made from coal-tar which, either alone or combined with carbolic acid, have very strong disinfecting properties and which are the bases of most of the patented disinfecting solutions now sold. They are commonly called cresols or creosols and a 4 per cent solution of any of the three ordinary forms will destroy bacteria in a few hours. They are commonly used for receiving organic excretions of sick persons in the same way as carbolic acid is used, and have about three times the power of carbolic acid to destroy bacteria.

They have one great advantage besides the strength mentioned, in that they are not materially affected or interfered with by the presence of albuminous material. Carbolic acid in the presence of albuminous material, like sputum, for instance, has the strength of the disinfectant partly used up in combining with this albuminous material so that the strength remaining for disinfection is weakened, and the result is not as satisfactory as it would otherwise be. The coal-tar products, on the other hand, are not so interfered with, and the solution acts in full strength upon the bacteria.

Mercury for disinfectant.

Corrosive sublimate, or bichloride of mercury, is one of the most active poisons known and is as effective in dealing with the microscopic organisms known as bacteria as it is in dealing with the larger animals for which it has been used for years past,—the destruction of bed-bugs.

For general cleaning purposes, such as scrubbing woodwork, floors, and walls, it should be used in strength of about 1 part to 3000 parts of water. This means that for 1 ounce of corrosive sublimate 3000 ounces of water or 25 gallons must be taken. This solution is very active in its effect on all metal, so that it must be kept in brassware or earthenware, and when mixed with the material which it is intended to disinfect, it must be kept from tin or iron. This solution is also affected by albuminous material, although this may be counteracted by the addition of salt. It is a good plan, therefore, to add to the solution salt at the rate of about 4 teaspoonfuls to each gallon of solution. On account of the very poisonous action of this solution great care must be taken to keep it away from children, and it has been suggested that it is desirable to add some coloring matter to the liquid, since without this it may be mistaken for clear water.

Lime for disinfecting.

Chloride of lime is one of the most useful as well as one of the cheapest disinfectants available. It costs about $25 a ton, although by the pound this wholesale price would not be obtained. It is effective in a 1 per cent solution, that is, 1 pound of chloride of lime to 100 pounds or 12 gallons of water. To be effective, the solution must be well stirred into the organic matter to be disinfected, since it is the chloride rather than the lime which is the disinfecting agent. Saucers or soup plates of chloride of lime standing around the room have no effect upon the germs in the air and on the floor and are of no more value than sulfur, or roses for that matter. Chloride of lime is commonly known as bleaching powder, and its effects on clothes or on any substance which can be eroded is well known. It is, therefore, not a suitable material for disinfecting towels, because the action is on the towel as well as on the bacteria, differing in this respect from mercury, which does not hurt the fiber of clothes.

Milk of lime is produced by slaking ordinary building lime until a fine white powder is obtained, about an equal quantity of water to the amount of lime to be slaked being necessary. When the powder has formed and steam has ceased to be given off, then about four gallons of water should be added to each gallon of the powder and the mixture well stirred. This will probably always leave some lime in the bottom of the vessel, since limewater is a saturated solution, and these proportions furnish more lime than is necessary. If not too thin, it is a good whitewash and is a most important agent when used as a whitewash in disinfecting walls and ceilings of such rooms as hospitals and cellars and other places where have been contagious diseases. Milk of lime is an admirable disinfectant in the sick room and generally in houses where infectious diseases have been. It may be poured down drains, into water-closets and privies, and used liberally in all places where bacteria may be supposed to thrive. It must come into intimate contact, however, with the bacteria, and merely sprinkling a little lime dry around the borders of a gutter or drain is of no value. The writer saw, not long ago, a chicken yard where the inspector of a health department had undertaken to secure disinfection by a generous sprinkling of white lime powder around the yard. Such a procedure, however, is not effective, but in a drain the dry powder might be of value because it would later become effective when washed in solution into the drain. Ordinarily, the dry powder is to be avoided.

Soap as an antiseptic.

No better antiseptic exists than ordinary soap, not altogether because of the properties of the soap, but because of the action of the soap combined with hot water. Washing soda, dissolved in water and used for boiling clothes which have become polluted, adds to the disinfecting power of the hot water the disinfecting properties of the soap, and the result is most effective. Ammonia has not the same value as the soda or potash soap, although it has the power of destroying bacteria in the course of a few hours.

It may not be out of place to emphasize the value of soap, not particularly in times of epidemic or contagious disease, but as a continual safeguard against infection. A large proportion of the contagious diseases are probably the result of infected fingers or hands coming in contact with the mouth and leaving there the germs of infection. One of the first things a surgeon learns, in order to avoid any possible infection of wounds or of openings which he makes for an operation, is to thoroughly wash his hands in order to remove therefrom all possible germs. He scrubs his hands, particularly his finger nails, with soap and water and then bathes them in a solution of bichloride of mercury before touching the patient in any place where infection might occur. The difficulty, even with this great care, of freeing their hands from bacteria has been found to be so great that, in late years, surgeons have preferred to use, during operations, thin rubber gloves which can be boiled before using and can be soaked in a stronger antiseptic than the hands could bear.

It is extraordinary, from the standpoint of self-infection, to see how men can be so careless as to sit down to dinner, after having worked in places where their hands have come in contact with all sorts of organic filth, without stopping to wash those hands even in cold water. It is certainly providential that disease germs are as uncommon as they are, for with the careless habits of most people in putting their hands to their mouths, the death-rate from infectious diseases would be much higher than it is except for the fact that most of the germs thus introduced into the mouth are not disease-producing.

Disinfecting by heat.

Better than any chemical agent known to be a destroyer of bacteria is heat in one form or another. This may be steam or hot water or dry heat. If a high enough temperature is maintained for a sufficient length of time, the action is absolutely destructive to all germs. Fire does, of course, destroy bacteria along with whatever material the bacteria are concealed in, but such a disinfectant is of little value for ordinary purposes, since the object of disinfection is to destroy bacteria without destroying the surface on which they are lodged. In some old buildings, where consumption or smallpox, for example, has become permanent, it may be that the surest way of killing all the bacteria is to burn up the house.

Dry heat.

Unfortunately, even a moderate heat cannot always be applied. One's hands, for example, can neither be heated in an oven to the necessary temperature for destroying bacteria in their pores, nor can they be immersed in boiling water or steam for a sufficient time to secure thorough disinfection. Therefore, with the body, chemical means for disinfection must be employed. Also when it is desired to disinfect a liquid, such as beef broth, in which the experimenter desires to grow some particular species to the exclusion of all others, dry heat is inapplicable because it would evaporate the liquid, nor is chemical disinfection possible because of its antiseptic effect on the bacteria to be cultivated. Moist heat, therefore, must be used. When dry heat is used, it is usually for the disinfection of glassware or earthenware or metallic objects, the quality of which will not be affected by the necessary temperature, namely, 150 degrees Centigrade, or about 300 degrees Fahrenheit. This temperature must be maintained for at least an hour, and it is not certain even then to penetrate in full power to the middle of blankets or comfortables. Except for glassware to be used in a laboratory, dry heat, such as would be obtained by a kitchen oven, is not to be recommended.

Boiling water.

Boiling water, on the other hand, is the most effective and penetrating disinfecting agent available. One has only to expose an object to boiling water for five minutes to absolutely kill all disease-bearing bacteria contained, and since bed linen, clothes, blankets, and such articles as are naturally used in a sick room have to be washed after a patient's recovery, it requires but very little additional trouble to subject the soiled articles to that temperature of the water which will secure disinfection at the same time. But the water must be boiling. The mere fact that it was once boiling water gives it, half an hour later, no disinfecting properties, and complete disinfection can be secured only by actually boiling the garments or articles for at least five minutes. The apparatus necessary therefore—and no better piece of disinfecting apparatus can be secured anywhere—is a good old-fashioned wash boiler. The action is more certain, that is, more penetrating, if a little washing soda is added to the water at the rate of a tablespoonful of soda to a gallon of water. This solution is admirable for washing dishes, spoons, knives, forks, and other eating utensils used by sick persons. It is always a mistake to wash dishes from the sick room in the same vessel with other dishes. They should not only be washed separately, but they should be washed in boiling water, and preferably in a soap solution as just described.

Steam.

For some purposes, steam is better even than hot water; its effect on cotton and woolen garments is not so disastrous. A comfortable or blanket, for instance, may be subjected to steam without losing its elastic quality, and for small garments, an ordinary steamer, such as is used for puddings, answers admirably. Cities use steam sterilizers because of the greater convenience in furnishing steam to a large tank as compared with filling and emptying a tank with water and then providing sufficient heat to boil that water. The exposure to steam should last from half an hour to an hour, depending on whether the objects to be disinfected are small, open, and loose, or large, compact, and dense. Some articles, like bales of rugs, rolls of wool, and large bundles of cloth, cannot be sterilized at the center by ordinary steam, and while it is not likely that infection at the centers of such tightly rolled bundles has occurred if exposure took place while rolled up, yet it is certain that the disinfection does not reach these centers. In the case of such bundles as rugs from infected countries, where any single rug may become the medium of infection, it is requisite to thoroughly sterilize all parts of the bundle. For this purpose, it is necessary not merely to expose the articles to live steam, but to have the live steam under pressure so that it is forced into the inside of the packages by an excess of external pressure. This is probably not available in an ordinary house, where boiling must continue to be the method of disinfection.

Drying, light, and soil.

Before leaving this chapter, three agencies for disinfection may be pointed out, not perhaps to be depended on, but in order that the kindly provisions of nature may be appreciated. All germs removed from the body, which is their natural home, and exposed to the air are subject to drying and thus are killed. Unfortunately, this does not become true except after long periods of time, nor is it equally true with all germs, but it is certainly one of the methods by which the evil effects of disease germs may be lessened. The germ of consumption lasts as long as any germ, and yet this, when dried in the street, loses its vitality after about a week. Similarly, the typhoid fever germs, unless kept in a moist condition, dry up and die in a few days. With the drying, however, comes the danger that in the process they may be lifted by the wind and carried in the air to the mouths or nostrils of well persons, so that it is not wise to depend solely on this method of disinfection.

Sunlight is more positive than the wind, and the exposure to direct sunlight of a bottle filled with disease germs will kill them all in two or three hours. The surface layers of a pond never have as many bacteria in them as the lower layers, partly on account of the sedimentation, but largely because they are killed by the direct action of sunlight. The bacillus of consumption and bacillus of diphtheria are both killed in an hour or so by direct sunlight. This is one reason why living rooms should have sunny exposure and why, on the other hand, disease thrives in dark tenements.

The soil is the third natural method of disinfection, not because the soil itself destroys bacteria, but because in the soil are to be found millions of non-harmful germs and these germs are hostile to the disease-producing germs, so that they destroy their virulence. It is on this principle that the wastes from typhoid fever patients are buried in the garden, the presumption being that the bacteria there present will destroy the typhoid fever germs before they can escape and do any harm. While this action undoubtedly exists, it is not positive enough to depend upon, and disinfection by the use of chemicals should always be practiced.



CHAPTER XVI

TUBERCULOSIS AND PNEUMONIA

These two common widespread diseases affecting the lungs may be discussed together, although they are not closely related in origin or effects.

Tuberculosis.

That form of tuberculosis known as consumption is at present the most prevalent and the most dreaded of all infectious diseases. In 1908, in the Registration Area of the United States (about one half of the whole country), it caused 67,376 deaths. Deaths from other infectious diseases are shown in the following table, together with the population:—

TABLE XVIII. SHOWING DEATHS FROM VARIOUS INFECTIOUS DISEASES IN THE UNITED STATES, 1908

Population of Registration Area 45,028,767 Deaths in Registration Area 691,574 Deaths from tuberculosis 67,376 Deaths from pneumonia 61,259 Deaths from diarrhoea (chiefly of babies) 52,213 Deaths from cancer 33,465 Deaths from typhoid fever 11,375 Deaths from diphtheria and croup 10,052 Deaths from scarlet fever 5,577 Deaths from whooping cough 4,969 Deaths from measles 4,611 Deaths from smallpox 92 Deaths from hydrophobia 82 Deaths from leprosy 11 Deaths from bubonic plague 5 Deaths from yellow fever 2

Pneumonia is second in fatality, the two diseases of pneumonia and tuberculosis carrying off 128,635 persons, or about one fifth of all persons dying in the year. While these have both been great plagues to humanity from the very earliest days, it is only within the last ten years that their ravages have been appreciated and, especially with tuberculosis, their causes actively combated. There are two phases to be considered in discussing tuberculosis or consumption, namely, first, the method of prevention and second, the method of cure. It follows also that, since the cure of advanced cases is impossible and since every case which exists is a menace to the health of the community on account of the danger of the spread of the disease, the prevention is far more important than the cure.

Until the discovery by Robert Koch, in 1882, of the germ causing consumption, little could be done in the way of prevention, but since that time, only one quarter of a century ago, we have learned and applied the knowledge that, in the vast majority of cases, the disease is spread by the sputum of consumptive patients, which becomes dry, forms dust, and so is carried into the air to be breathed by persons not otherwise affected. It seems so simple a method, then, to prevent the spread of consumption. All that need be done is to take care of the expectorations of persons suffering with the disease. It is thoroughly believed by experts that if this were done carefully and faithfully, the disease would be stamped out within a few years, and the slogan of a certain sanitary organization is "Complete Control of Tuberculosis in 1915." Too much emphasis cannot be placed on the direct and simple method of infection, and while other factors enter, as will be shown later, a thorough recognition and control of tuberculosis sputum would practically stamp out the disease.

The following circular, issued by the Committee on the Prevention of Tuberculosis of the Charity Organization Society of New York City, indicates the procedures advised by them to prevent the spread of the disease and, as will be seen, the essence of the axioms there expressed are summed in the words "Don't spit!":—

DON'T GIVE CONSUMPTION TO OTHERS.

DON'T LET OTHERS GIVE IT TO YOU.

How to prevent Consumption.

The spit and the small particles coughed up and sneezed out by consumptives, and by many who do not know that they have consumption, are full of living germs too small to be seen. THESE GERMS ARE THE CAUSE OF CONSUMPTION.

DON'T SPIT on the sidewalks; it spreads disease, and it is against the law.

DON'T SPIT on the floors of your rooms or hallways.

DON'T SPIT on the floors of your shop.

WHEN YOU SPIT, spit in the gutters or into a spittoon.

Have your own spittoons half full of water, and clean them out at least once a day with hot water.

DON'T cough without holding your handkerchief or your hand over your mouth.

DON'T live in rooms where there is no fresh air.

DON'T work in rooms where there is no fresh air.

DON'T sleep in rooms where there is no fresh air.

Keep at least one window open in your bedroom day and night.

Fresh air helps to kill the consumption germ.

Fresh air helps to keep you strong and healthy.

DON'T eat with soiled hands; wash them first.

DON'T NEGLECT A COLD or a cough.

To be sure, the precept of "Don't spit," as applied in cities, has other reasons for enactment than to prevent tuberculosis. Spitting is a filthy habit, and its practice should be decried on the score of cleanliness whether on the streets or in any public place, so that the signs now seen in street cars and railroad trains, in halls and office buildings, are intended not altogether for consumptive patients, but also for those who need laws to force them to observe ordinary rules of cleanliness and decency. It is, however, the main step towards doing away with consumption, and the faithful observance of the injunction ought to be insisted upon quite as much in the individual home as in a city street or public building. Case after case has been cited of instances where one consumptive patient in a family has spread the disease through the household, and, at intervals of a year or so, one after another of the family has succumbed to the attacks of the consumptive germ, when by proper precautions and suitable care of the sputum of the first sick person, the other deaths might have been prevented.

Individual resistance to tuberculosis.

There is a remarkable difference in the ability of individuals to withstand the attacks of this disease, and it will be found always that the first to succumb are those whose vitality has been in some way depleted. The women of the family, who are generally confined to the house, who do not have their lungs reenforced by a continual influx of fresh air, who are tired and worn out with their household duties, give themselves an easy prey to the attacks of the bacteria, while the men and boys, who are more outdoors, who are vigorous and strong, throw off the attack and are not affected.

It is a significant fact that by examination, dead bodies, so far as was known, not afflicted with tuberculosis in life, have, to the extent of 60 per cent, been found to have evidences of consumption in their lungs; that is, the edges of the lungs have been found affected, although the vitality of the individual was such that the action of the germ had been stayed before any serious injury was done. Most of us, at one time or another, have had, unknowingly, mild cases of consumption. It would be strange, indeed, if we did not, in view of all the tuberculous infection flying around in the air. But most of us are able to successfully combat the disease, so that the germs are destroyed before they are able to affect the entire body.

The other part of prevention consists in building up and holding up the vitality of the individual to a point where the vital forces can successfully oppose the attacks of the germs. Probably the decrease in the number of cases of consumption in the last quarter of a century has been due quite as much to the improved sanitary conditions of living, whereby the germs have been unable to secure a foothold in the individual, as to any precautionary measures taken against the germ itself.

Precautions by the consumptive.

But the chief factor in the future restriction of the disease, as in the past, must be the disinfection of the germs immediately after they are thrown off from the consumptive patient, and it is well worth while to emphasize just what the consumptive should do or have done for him in order that he may not be responsible for the further spread of the disease. In the first place, when he spits, he must appreciate and act on the fact that the sputum is alive with consumptive germs, each one of which may possibly transmit the disease to whoever may come in contact with it. The patient must keep in mind continually that this sputum is poison, a deadly poison, and that it is his duty to see that every particle of it is disinfected or destroyed by one of the methods already indicated. He may expectorate into a vessel filled with a carbolic acid solution or he may expectorate into a vessel filled with water which may afterwards be boiled. He may use a cloth or paper, like a Japanese napkin, which may later be burned in the fire. But, above all things, he must not expectorate anywhere and everywhere, regardless of the consequences.

The consumptive patient must not cough without holding a handkerchief over his mouth, since small particles of sputum may become dislodged and distributed in this way.

The eating utensils used by a consumptive patient must not in any way be allowed to infect other people. The consumptive must have his own dishes reserved exclusively for him, and they must be, after each meal, carefully disinfected. With these precautions and with avoidance of such practices as kissing or otherwise directly infecting others, there is no reason why a consumptive patient should be in any way an object of dread or why he should not live with his family in as much comfort as he can obtain, in perfect safety to himself and to them.

Cure of consumption.

The chief factor in the cure of consumption is the time at which the attempt at cure is started. Consumption is not an incurable disease, as was once thought, and there is no reason for so considering it. There is no such thing as galloping or quick consumption as distinguished from slow or lingering consumption, since the consumptive germ is the same in all people. The same germ may act differently in different people, and if one's power of resistance, as happens with those accustomed to drinking liquor, is low, the action of the germ is rapid, although the disease is identical with the form in which death comes only after years and years. If taken in time, that is, before the germ has so infected the body as to be beyond all possible restraint, as large a proportion of consumptive patients may recover as of patients from typhoid fever or diphtheria or any other infectious disease, but the cure must be started early. For instance, at one of the sanitariums in the Adirondacks, out of 267 patients admitted, who had the disease in an incipient stage, complete recovery was had in 219 cases, the disease was arrested in the case of 42 others, and in only 6 was the treatment not effective. Where the disease had become advanced, however, it was found that out of 192 cases, only 32 apparently recovered and 140 were improved to some extent. These are the significant facts in an institution for incipient cases only, where advanced cases, such as are met with by the practicing physician, are not received.

Unfortunately, the ordinary physician does not always recognize the disease in its first stages, and a person may suffer for months with consumption, and even pass the time when the cure of the disease would be possible, without its being recognized. Such sick persons are treated for catarrh, for an obstinate cold and bronchitis, for grippe or malaria, whereas a proper diagnosis of the disease would be a recognition of the early stages of consumption and thus would prompt the patient to start at once on the necessary methods for cure. Nor is it possible to recognize the disease by any one definite indication. The cough which was once thought to be the deciding symptom is very often absent until the last stages of the disease. Expectoration of blood is similarly one of the last symptoms, exhibited only when too late for remedial measures. The presence of the tuberculosis bacillus or "T. B." in the sputum is also not generally found until the tissue of the lungs has become well advanced towards destruction, too late for remedy.

Experts in diagnosis attach great importance to family history, and have learned to expect the disease in persons when exposure to contagion is inevitable. They will recognize the disease from evidence not discernible to regular practitioners. For instance, if one member of a family is known to be affected, any chronic indisposition in another member, involving, perhaps, a daily rise in the temperature of the body, not sufficient to arouse alarm, but apparent in the listless behavior of the person, may be enough to suggest the beginning of the disease. An expert may detect the clogging up of the lung tissue by an examination of the lungs themselves, and probably this direct examination, with a record of the daily rise and fall of temperature, particularly if the suspected patient has a listless feeling and a gradual loss of weight, would be sufficient to suggest the ordinary remedies.

The three remedies, which are nature's own methods, are good food, fresh air, and rest. It is difficult to say which of these three items is the most important. Certainly no hope of building up the resistance of the patient against the inroads of the disease can be expected unless the patient is thoroughly nourished. One of the sad facts in connection with those unfortunates whose fight against tuberculosis is nearly over and who in desperation have fled to Arizona, hoping that the dry air might afford relief, is that the lack of nourishing food, inevitable in those deserts, hastens on the disease, so that the expected benefits from the dry air are entirely offset. Likewise, in tenement-house districts in cities, the fight against consumption is practically useless because of the impossibility of securing for those starved or underfed helpless ones the nourishing food necessary. In the country, this part of the treatment ought to be the simplest, and yet one fears that the habit of eating through nine months of the year only salted and dried foods has not furnished patients in the country with the kind of nourishment necessary. Experience indicates that eggs and milk should be the bulwark on which the patient must depend for food, and in the sanitariums of New York State it is not uncommon for patients to be stuffed with two dozen raw eggs every day in addition to other food.

The next important factor is rest, since the effect of tuberculosis is to break down lung tissue, and for the prevention of this it is necessary to give the forces of the body every aid in preventing this destruction. All exercise taken by a tuberculous patient means the withdrawing of that much blood from the lungs, where is the strategic point of the disease, to the part of the body being exercised, and one of the most striking features of sanitarium treatment is the absolute rest enjoined on the patients. Flat on their backs, day and night for months, without so much exercise as walking across the room, is the ordinary treatment, and the effect of disobedience is plainly seen in the rise in temperature or increase in fever which follows a violation of these rules. Even when the patients are allowed to sit up, they do not sit straight, but rest on couches or reclining chairs, so that their heads are down and their feet up, making the passage of the blood to the lungs easier. Even where the patient, determined to recover, is not able to place himself in the hands of a hospital physician, he can adopt this important method of arresting the disease by strictly avoiding exercise and exertion of every sort. The Massachusetts General Hospital in Boston has tuberculosis clinics, where patients who are not far enough advanced in the disease to require absolute rest are inspected daily, their condition noted, and advice given for the following twenty-four hours. One of the most common violations of the prescriptions given is overexertion, and yet the rest condition is essential for building up the diseased lung.

The third method of treatment involves fresh air, in order to improve the oxygenating character of the blood. If one remembers that the oxygen in the blood is the chief scavenger of the body and that the vitality of the red corpuscles and their abundance is an essential factor in curing the disease, it will be seen why fresh air is so important. The tendency to-day is to insist on fresh air and to lay less stress on the climate than was formerly done.

It was not uncommon a few years ago for a physician, recognizing consumption, to send his patient away, partly because he honestly believed the climate of Arizona or Colorado or the Sandwich Islands was better than that where the patient lived, and partly, without doubt, because he was glad to get rid of a disease which he knew it was not in his power to cure. To-day, unless the patient can go to a properly equipped and maintained sanitarium, physicians recognize that conditions may be as beneficial at home as elsewhere and, provided the three factors mentioned—good food, rest, and fresh air—can be obtained, the chances for recovery are better because of better care at home than elsewhere.

But fresh air is essential, and this means that the patient must spend twenty-four hours a day in the open. He must eat and sleep out of doors. He must not go into the house when it rains, nor when it snows, and even with the thermometer at zero he must still stay out, wrapping himself up, to be sure, so that his body is not cold, but breathing into his lungs the life-giving, vitalizing, oxygen-bearing air. The side porch of a house may be very easily transformed into a room with a cot bed and an easy chair, where the consumptive may stay continually, and while it is convenient to have a window or a door opening from the porch into a room where the patient may be dressed and bathed, this is not essential, although customary in sanitariums. If no side porch exists, it is possible to build such a porch, and the picture shows how such a construction may be added to even a small house in the city (Fig. 75). If this is out of the question, the windows of a room may be left open all the time, or the patient may lie on a bed, the head of which either extends through the window or is arranged to admit fresh air by a specially devised window tent.

Educational campaigns have been vigorously prosecuted for the past ten years, and gradually through the world is spreading a growing appreciation of the dangers of this disease. The effect of this increasing knowledge is reflected by a continually decreasing number of deaths in proportion to the population. The following diagram (Fig. 76) shows how this law is obeyed in New York State, the downward tendency of the line since 1890 being very plainly marked.



The results being so manifest, the prophecy of Dr. Biggs of New York, written in 1907, is certainly justified:—

"In no other direction can such large results be achieved so certainly and at such relatively small cost. The time is not far distant when those states and municipalities which have not adopted a comprehensive plan for dealing with tuberculosis will be regarded as almost criminally negligent in their administration of sanitary affairs and inexcusably blind to their own best economic interests."



Pneumonia.—The germ.

In New York State in the year 1908, the largest number of deaths from any specific disease was due to consumption, the number of deaths in the rural population alone being 2906. The next largest number of deaths in the rural communities, and always a close second to consumption, was from pneumonia, the number being 2191; so that pneumonia justly ranks as highly important in the list of diseases which are at present most deadly in their effect on the human race and against which a vigorous fight should be made.

While pneumonia, like tuberculosis, is due to the action of a specific organism, the germ itself is not so generally infectious; that is, the germ has not the power of remaining vigorous when out of the human body in the same way as has the germ of consumption. Like tuberculosis, the germ is expectorated and remains virulent when dried into dust, but the germ is much more sensitive to temperature changes and does not live longer than two or three hours when dried and exposed to the sun. It is, very curiously, a normal resident in the mouths of at least one third of all healthy persons, and it is only necessary for the body of these persons to become weakened for the germ to be able to secure a foothold and produce the disease. Unlike tuberculosis, which attacks chiefly those in the vigor of life, from fifteen to forty-five years of age, pneumonia attacks generally the very young and the very old; those under five and those over forty-five, the time of life when the vital resistance is the least.

Weather not the cause of pneumonia.

One of the sources formerly believed to be largely responsible for pneumonia, that is, exposure to severe weather, is curiously negatived by the fact that children and old people are not those generally exposed to weather. Perhaps no fallacy in any disease has been more prevalent than that pneumonia is usually contracted by exposure to wet or to cold. It has, indeed, been noticed that the disease has been practically non-existent under conditions where it would be prevalent if exposure alone were the cause. For instance, in the Arctic zone, where the temperatures are very low and where no adequate provision against the rigors of a severe climate are possible, pneumonia is practically unknown. During Napoleon's retreat from Moscow, when thousands of soldiers died from physical exposure, from frost bite and starvation, where if exposure were the predisposing cause of pneumonia, it would have raged as an epidemic, it seldom appeared, proving this opinion.

Perhaps one reason why the disease has been supposed to result from exposure is the undoubted fact that it is chiefly prevalent in the winter and spring rather than in the summer. This argument is, however, modified by the fact that the majority of cases do not occur in January or February when the temperature is lowest, but in March, when the opening of spring is in sight. The reason for this is evident when we remember that the cause of the disease is a germ, generally present in the body and needing only a reduced vitality for its successful inroad on the human system. When, therefore, a person shuts himself up in an overheated house, without ventilation, takes insufficient exercise, and lives with an apparently determined effort to do everything possible to reduce his bodily vigor, then it is no wonder that the germ, almost in exultation, finds an opportunity for successful development.

Preventives in pneumonia.

Much as in tuberculosis, then, the best remedy and the best prevention for pneumonia is a careful attention to the needs of the body in order that it may preserve its normal vigor. Regular hours, sufficient sleep, and good food will, in most cases, keep the body in such a condition that pneumonia need not be dreaded, no matter what the exposure or what the temperature. Further than this, if the disease does once start and gain a foothold in the lungs, the best cure is, as with tuberculosis, a plentiful supply of oxygen or fresh air in order to remove the toxins formed by the disease and give the lung tissue an opportunity to recover.

Formerly medical men treated pneumonia by confining the patient in an overheated room in which steam was generated, with the idea that the lungs would be most helped by an atmosphere of moist heat. Now, a pneumonia patient is supplied with all the fresh air possible, the windows of the sick room, even in winter, being kept continually open, and every effort being made to give the patient fresh air even when every breath means a shooting pain, and apparently untold suffering. In some of the New York City hospitals, the ward for pneumonia patients is on the roof, and children and babies suffering with pneumonia are at once taken there, even with snow piled all around the tent in which they are kept. The nurses and physicians are obliged to don fur coats, and heavy blankets must be provided to keep the patients from freezing to death; but the pneumonia germ, under these conditions, is worsted almost as if by magic, and within a few hours after leaving the warm wards of the hospital the patients start on the road to recovery.

The remedy, then, for the 2000 cases of pneumonia which occur in New York State each year, is an improved regulation of the health conditions of the separate families throughout the state—a better hygienic regulation of the everyday life. Care must be taken to provide better ventilation in the houses, more fresh air in the sitting room and in the sleeping rooms, more outdoor life in the winter time, and more exercise by which the blood circulation will be kept active. Then more varied and more suitable food must be consumed, food which will be capable of absorption by the tissues and not clog the intestines and poison the system. More bathing, by which the pores of the skin can be relieved of the organic matter which otherwise clogs them and prevents their effective action in the removal of waste products, must be indulged in. With these three factors properly evaluated, with more fresh air, with better food, with ample bathing, pneumonia need not be dreaded, since then it would attack only those few whose constitutional vigor was impaired, and in the course of a generation or two the number of these would be so decidedly diminished that pneumonia would find no one susceptible.

Infection of pneumonia.

It must not be forgotten that a pneumonia patient is a source of infection quite as much as is a tuberculous patient, and the same precautions against infection should be followed. The nurse should be particularly careful not to infect herself. She should be careful to exercise enough self-control always to get daily exercise and fresh air and must, as a matter of self-protection, avoid overfatigue. The eating utensils, food refuse, and soiled clothing may all be infectious and must be sterilized by boiling as soon as removed from the sick room. The severe epidemics which have occurred from pneumonia have occurred in camps where sanitary conditions are grossly violated. Under such conditions pneumonia has become a most alarming epidemic, sometimes called the black death. In a single house, however, disinfection of the wastes of the patient and a proper care of the personal hygiene of the rest of the family will avoid the spread of the disease, and if the patient has sufficient vitality, sustained by good food and fresh air, he will recover without serious after affects.



CHAPTER XVII

TYPHOID FEVER

The two diseases already described, tuberculosis and pneumonia, are by far the most serious of all the infectious diseases, being responsible in New York State alone, in 1908, as already stated, for 5727 deaths. No other infectious disease even approximates the virulence and deadliness of these two, and while some of the constitutional disorders, such as Bright's disease, diarrhoea, and irregularity of the circulation, each result in from 2000 to 3000 deaths, the cause and prevention of these are so little understood as to baffle the hygienist. There are a number of contagious diseases which, while comparatively unimportant in the number of deaths, yet are of concern because the cause of the disease is so well known that the means of prevention is quite within our power. Of these, typhoid fever, in New York State in 1908, among the rural population alone resulted in 437 deaths, a rate of 18.7 per 100,000 population. The facts substantiate the assumption that for every person dying with typhoid fever there are ten cases of it, so it is a fair statement that in the rural part of New York State, in 1908, there were not far from 5000 persons afflicted with this disease.

Perhaps one of the reasons why so determined a fight against this particular disease, involving only 5000 cases of illness during the year, has been made, is on account of the length of the illness in each case and on account of the fact that the disease usually attacks those in the very prime of life, from 15 to 40 years. It is also to be economically considered by reason of the loss of time involved in an illness of nearly two months and the loss of money implied in the nursing, doctors, and medicine. The movement against the disease is most encouraging because the line of attack is well known, and there is, humanly speaking, no reason at all why the disease should not be stamped out.

Cause of the disease.

Typhoid fever is a modern disease, and only for the last fifty years has it been recognized in medicine. It is caused by bacteria, and its manifestations are the results of bacterial growth in the body, chiefly in the smaller intestine. Here the toxin produces a violent poison which results in an attack of fever, lasting about six weeks. Owing to the bacterial growth, serious failings, commonly known as perforations, may develop after a severe attack, in the membranes and linings of the intestine, and the resulting inflammation is not infrequently the immediate cause of death. It is a thoroughly established fact that the disease is caused by a special type of bacteria and that if the bacteria could be killed outside the body, no transmission of the disease could occur. It is also true that if the disease germs could be destroyed within the body the patient would recover immediately, provided the toxins had not been already distributed through the system.

There are, therefore, two possible methods of doing away with typhoid fever, one by eliminating all possibility of transmission outside of the body of the patient and the other by killing the germs while in the body of the patient. The latter plan is not feasible, since no antiseptic has been found which will kill the germs without killing the patient. It has been discovered that a drug called utropin will act on the germs when located in certain parts of the body, as in the kidneys; but this drug, although very effective in destroying germs in those organs, has no effect elsewhere. In general, we must eliminate the disease by preventing its transmission from the sick to the well.

The bacillus of typhoid.

Unfortunately, the typhoid fever germ is comparatively hardy and is not so easily killed by unfavorable environment as is the germ of pneumonia, for instance. It lives in water and in the soil, although probably it does not increase in numbers in either place. Nor will it live in the soil or in water indefinitely, and a great deal of study has been expended in trying to determine just how long typhoid fever germs will live under different conditions. It has been found, for example, that drying kills the typhoid bacillus in a few hours, although a few may survive for days. Experiments have also shown that it cannot leave a moist surface. It cannot, for instance, jump out of cesspools and drains and take to flight through the air, conveying the disease.

There is no possibility of contracting typhoid fever because a drain near the house is being cleaned out, since, so far as is known, the typhoid fever germ does not get into the air. The direct rays of the sun will kill typhoid fever germs within a few hours, although the value of this sort of disinfection is limited, because where typhoid fever germs are apt to accumulate, the turbidity of the water prevents the penetration of the sun's rays for more than a few inches.

It has been found that a high temperature kills typhoid fever germs, and even so moderate a temperature as 160 degrees Fahrenheit is sufficient to destroy them. This is the principle employed in pasteurizing milk, since it is assumed, justly, that by raising the temperature of the milk to 160 degrees Fahrenheit, for ten minutes, it will be possible to kill any typhoid fever germs present. Boiling, of course, since this involves a temperature of 212 degrees, will kill the germs, and it is for this reason that wherever a water is suspected of typhoid pollution, it should be boiled before being used for drinking. It has been found that in distilled water, that is, in water where no available food is to be had, the germs will live about a month, and that in water with organic matter present, but without other bacteria, this period may be extended two or three times. In water rich in organic matter, but where other antagonistic bacteria are also present, the typhoid germs are usually driven out or killed at the end of three or four days.

It is not unreasonable to expect that at least half of the germs discharged into a stream will live a week, and if the stream has a uniform current, so that the germs are continuously carried downstream, they will be found below the point of infection, a distance equal to that which the stream will flow in a week. This is important because it shows how unlikely it is that the germs once placed in water will die out or disappear without infecting those who subsequently drink the water. There is evidence that the typhoid germs, like all other germs for that matter, are likely to settle to the bottom of a lake or pond, and so a stream passing through a pond will lose a large part of the bacterial pollution with which it entered. This is not positive enough, however, to insure a good water-supply, since in the spring the heavy flow of the stream will wash this deposited material out through the pond, carrying the infectious matter downstream. In addition, the upheaval of the settled material from the bottom of the lake, which occurs twice a year on account of the variation in temperature at different depths, will bring the settled germs to the top.

It has been found also that just as a high temperature destroys the germs, so a low temperature has the same effect. Typhoid fever germs in ice are practically harmless after two weeks, and since in natural ice the impurities of the water are largely eliminated mechanically, so that frozen water is purer than the water itself, there is very little chance, even when ice is cut from a polluted pond, for typhoid germs to be found alive after being in an ice house for three or four months. In the ground, the life of the bacteria is longer, and while experiments do not agree very well as to the exact length of time that the germ may live there, there seems to be evidence that they may live several months, if not a year or more. Cases have come under the observation of the writer which seemed to show that certain well waters were polluted by germs which could only have been deposited in the near-by soil nearly a year before the time of the consequent outbreak.

Entirely to deprive the germs of life, therefore, it is necessary, inasmuch as they are so widely distributed, to act promptly and at once disinfect the fecal discharges from the patient rather than to wait until those discharges have been thrown into a stream or onto the ground and then attempt disinfection. There is probably no more important thing in stopping the spread of typhoid fever than to practice carefully disinfection in the sick room, using bichloride of mercury and chloride of lime, as already described in Chapter XV. Since, however, such disinfection is not always practiced and since care must be taken to avoid the introduction of the germs into the system, it is well to know how, assuming that they have not been killed in the sick room, they make their way from that place to a healthy individual.

Methods of transmission of typhoid.

There are three main avenues used by the germ, namely, water, milk, and flies, and of these three, the first is by far the most important and includes probably 80 per cent of all the cases. The reason for this is twofold. First, that water is so universally used, and second, that it is so easily and generally polluted. There are many historic examples which show definitely that water once polluted by typhoid germs is able to spread the disease far and wide.

The epidemic in Ithaca, New York, is a good example and ranks as one of the most serious that this country has ever known. The water-supply of the city is taken from a small stream, Six Mile Creek, which is a surface water with a drainage area of about 46 square miles. The stream is polluted to a large extent. About 2000 persons live on the watershed, and there are many houses practically on the bank of the stream which runs for a large part of its course at the bottom of a valley with steep side slopes. At the time of the epidemic, 1903, a dam was being built on the stream about half a mile above the waterworks intake, and while no proof of the fact could be found, it was generally supposed that some of the Italians working on the dam were affected with typhoid fever and had polluted the water. However, there were on the banks of the stream, farther up, no less than seventeen privies, and it was known that there were at least six cases of typhoid fever during the season just previous to the epidemic. During the month of December, 1902, a heavy rain occurred, so that any pollution on the banks would naturally have been washed down into the stream. On the 11th of January, the epidemic broke out through the town and by the middle of February there were some 600 cases reported in a population of 15,000. The number of deaths from this epidemic was 114, and there is reason to suppose that the number of cases was double the number reported by the physicians. After the water from the creek was shut off and after the citizens had been persuaded to boil all water used, the epidemic stopped and the installation of a filtration plant has prevented any recurrence of the epidemic.

In 1880, a severe epidemic occurred in Lowell, Massachusetts, and was traced to an infection of the river from which the city's water-supply was taken. This was definitely shown to have come from a small tributary of the Merrimac River, and the particular infection responsible for the epidemic was traced to a small suburb named North Chelmsford, where one case of typhoid fever occurred in a factory, the privy of which was located directly on the bank of the small tributary.

In 1900, an epidemic of typhoid occurred at Newport, Rhode Island, through the pollution of a well, and about 80 persons were affected, most of whom lived within a radius of 300 feet of the well and all of whom used the well water. The well was a shallow one with dry stone sides and a plank cover, and surrounding the well were about 20 privies, the nearest one only 25 feet away. The water in the well was 2 feet below the surface of the ground. It was found that a month before the epidemic broke out, there had been cases of typhoid fever in houses adjacent to the well, and that discharges from the typhoid patients found access to the privy vault which was only 25 feet from the well. It was practically certain that the well was infected by the leechings of these privies, particularly from the one only 25 feet away.



Another example of the way in which underground waters, such as springs, may become contaminated is described by Whipple as occurring at Mount Savage, Maryland, in 1904. Through this village ran a small stream known as Jennings Run, which was grossly contaminated with fecal matter. In July, 1904, a woman who had nursed a typhoid patient in another town came home to Mount Savage, ill with the disease. She lived in a cottage on the hillside above the stream, and the drainage of the cottage was conveyed through an iron pipe onto the ground just above the stream. Figure 77 (after Whipple) shows the relative positions of the cottage and stream. Heavy rains occurred during the first week in July which probably washed the infectious matter from the ground into the ditch and then through the ground into a spring just below down the slope. A week afterwards twenty workmen who had been drinking water from the spring came down with the fever and new cases occurred daily for a week or two.

An interesting epidemic occurred in Massachusetts, caused by a farmer's boots carrying infectious matter from recently manured fields onto the well cover, whence it was washed into the well by repeated pumping.

The moral of these incidents is very plain, namely, that where any possibility of the infection of drinking water occurs, that water ought either to be avoided or else to be thoroughly sterilized before using. This applies particularly to the old-fashioned well,—the kind with loose board covers and chain pumps.

Construction of wells in reference to typhoid.

Two points already mentioned are essential if well water is to be kept pure. One is to line the well with a water-tight masonry lining, and the other point is to have the cover of the well made with a thoroughly water-tight coating. This does not always give full protection, since in some cases polluting matter may pass through even ten feet of soil. This would be particularly true if the well was in a fissured or seamed rock, and very recently the writer found a well dug in a laminated granite, where a near-by sewer, leaking at the joints, contaminated the water of the well, although the well was cased with an iron casing twenty-five feet deep. The sewage escaped into a crack in the rock and followed the crack down vertically and horizontally into the well. Limestone is even more dangerous if any pollution exists in the vicinity. In cases where a well goes down to a horizontal layer of limestone and where a privy vault is dug to the same rock, it is found that pollution will follow the surface of the rock horizontally a long distance, and this condition of things always makes a well water suspicious. In sand or fine gravel, on the other hand, the danger of contamination is almost negligible; on Long Island, for example, the cesspools and well are both dug ten or fifteen feet deep and only fifty feet apart without any trace of contamination being detected.

Milk infection by typhoid.

Milk is responsible for perhaps 5 per cent of the cases of infection. Although the infection is always foreign to the milk itself,—that is, enters the milk only after the milk is drawn from the cow,—milk frequently becomes infected because infected water has been added to it or because the cans have been washed in infected water, or because some persons in contact with a typhoid patient have had their hands infected and then handled the milk or the milk utensils. There are a number of epidemics which have been clearly traced to milk polluted in one of these ways. In Somerville, Massachusetts, for example, in 1892, 32 cases occurred, 30 of which were on the route of a single milkman. It was found that the milkman had two sons, one of whom had typhoid fever just before the outbreak. This son washed the milk cans and mixed the milk in a milk house in the city, and the inference was that in some way this man infected the milk, probably in one of the mixing cans.

In Stamford, Connecticut, in 1895, an epidemic occurred which caused 386 cases and 22 deaths. Ninety-five per cent of all the cases occurred among those who took milk from one dealer, and it was probable that in this case the infection came from using a badly polluted water to wash the cans. In Montclair, in 1902, a small epidemic involving 28 cases occurred, where the health officers decided, after having found out that the cases were all among those customers taking milk in pint bottles, that the infection came from a house on the route, where typhoid fever had occurred. It appeared that this family infected the bottles left at their house, and since the milkman failed to sterilize the bottles before re-filling them, the infection was passed on to others also taking milk in pint bottles.

Infection by flies.

Flies also transmit typhoid fever chiefly because they are essentially such unclean insects. They are born in filth and they delight in living in filth, and if privies and cesspools and manure piles and garbage piles could be shut out from flies, the fly pestilence would be at an end. The feet of the flies are suction tubes, and when a fly lights on any object, it causes more or less of that material to stick to his feet, and then when he flies elsewhere, he may leave the particles on the object on which he alights. This has been proved by allowing a fly, caught in the house of a typhoid fever patient, to walk over a gelatine plate, leaving on the plate not merely his tracks, but the germs which his feet had carried. When the plate was exposed in an incubator, it was found that, within two or three days, millions of bacteria had grown from the number deposited by the one fly.

It is believed that the number of cases of typhoid which occurred in our Spanish-American War, at the military camps, and which were so disastrous, were due largely to flies. Among the 107,973 soldiers quartered in military camps at that time, there were 20,738 cases of typhoid fever, and the number of those which were fatal constituted 86 per cent of all the deaths from disease during this campaign. It was shown by the commission appointed to investigate the matter that the spread of the disease was not due to water or to food, but in most cases to the direct transmission of the germs through the agency of flies. In the Japanese and Russian war, where in the Japanese army of over a million men only 299 deaths from typhoid occurred, strict measures were taken to do away with all the breeding places of flies, and Major Seaman, who writes most interestingly on the success of the Japanese in avoiding typhoid, describes the ways in which the Japanese soldiers made flycatchers of themselves and waged war against flies quite as actively as against the Russians.

Other sources of typhoid fever.

There are other sources of the disease; for instance, there have been a number of small epidemics undoubtedly caused by infected oysters. One of the unpleasant habits of the oystermen is to bring in oysters from the ocean and leave them for a few days in shallow water where they may plump up or fatten, and they have found by experience that this fattening occurs more rapidly in dirty water. If the oysters are fattened in sewage-polluted water, the typhoid germs get inside the shell in the oyster liquor and are thus transmitted to those persons who eat the oysters raw.

Some kinds of food may transmit the disease: lettuce and celery, for instance, if washed in contaminated water or handled by persons with unclean hands or perhaps fertilized with manure containing typhoid germs. Finally, it is possible to acquire the disease by direct contact—not that the germs of typhoid are in the air in the room where a typhoid fever patient is lying, but rather that the nurse in some way soils her hands and then infects herself by putting her fingers in her mouth, or handles dishes or food afterwards used by other people, and so infects those others. It is not uncommon, for example, to see food partly consumed by a sick person given to children, or it may be that a child in the sick room is fed dainties prepared for the use of the patient. The result of such division of food is very apt to be a division of the sickness to the injury of the child.

Treatment of typhoid fever.

So far as present knowledge extends, the disease is one best treated by being let alone, with some moderate modification. When germs have been swallowed and when the vitality of the individual is such that the disease is contracted (happily, as has already been said, only about 10 per cent of those into whom the germ effects an entrance are inoculated), the first stage in the disease is a multiplication of the germs. This constitutes what is known as the incubation period, and lasts about ten days. During this time, the individual feels uneasy, has more or less headache and backache, and loses mental energy. The typhoid bacillus during this time spreads into almost every organ and tissue of the body, and towards the end of the period, when the resisting forces of the body have been proved unable to counteract the attack and the fever is well developed, the condition of the patient is deplorable. The bacteria are everywhere throughout the system, although they are especially active in the small intestines. This inflammation may produce ulceration and the blood vessels may be attacked, so that hemorrhages or even peritonitis may occur. A slight rash appears on the body, and a peculiar appearance of the tongue is to be found in severe cases. In from two to four weeks, the battle has been decided, and if the resisting forces prevail, the fever stops, and the patient begins to get well. This means probably, not that the bacilli are all dead, but that the patient has developed in his blood a sufficient antidote to the poison, so that the effects of the latter are no longer noticeable. The period of recovery, if the patient does recover, is most tedious, since the condition of the alimentary canal is such that great care must be exercised lest serious disorders there occur, and, although the patient is excessively hungry and really in great need of nourishing food, no greater folly can be committed than in allowing his desire for food to lead to indiscretion.

Injudicious exposure or fatigue will also cause a relapse, and while recovery is usually a simple matter, it is only so when under the eye of a judicious and careful nurse. The only treatment required is plenty of water for drinking, to make up for the enormous loss by perspiration from the skin, which helps to wash out the poisons from the body. Then baths, where such methods of treatment can be used, as in hospitals, are also used both to lower the skin temperature and to add water to the surface. Sponge baths in water or alcohol are valuable and in some cases tub baths with the temperature as low as 40 degrees are used. Then a proper diet to keep up the strength of the patient, liquids always, and usually milk, forms the only other treatment possible. No drug is of any avail, and uninterrupted watchful care is the only way of combating the disease.

In concluding this chapter, it may be mentioned that certain army officers interested in medical work have discovered what they believe to be an antitoxin for typhoid fever, and they have inoculated hundreds of soldiers as a preventative. The results are not yet conclusive, but there seems to be great promise. It is hoped that the time may come soon when people will be so educated that there will be no opportunity of the germs escaping from the sick room, and that food and drink will be so cared for that there will be no possibility of infection. The writer feels that it is in these last two methods of prevention rather than in the use of antitoxin that the hope of the future lies.



CHAPTER XVIII

CHILDREN'S DISEASES

There are four diseases, scarlet fever, measles, whooping cough, and chicken pox, which are recognized as belonging preeminently to the period of childhood and which are supposed to be the result of bacterial contagion, although, curiously, the specific bacteria concerned in any one of these four diseases has not been detected. They may be rationally grouped together for two reasons. First, because of their attacking, in the majority of cases, children under the age of fifteen years, and second, because the first stages of these diseases are very similar, so that the recognition of them is not easy except for the practiced physician. It must not be thought, however, that because these are diseases of childhood and because a majority of children have them at one time or another, without great suffering and without serious after effects, they are on that account to be despised. Scarlet fever, for instance, is to-day probably the most dreaded of children's diseases, not because so many children die of it,—although the death-rate is large, about 20 per cent of the cases finally succumbing,—but because of the large number of complications and consequences which are directly due to this disease. Measles, also, though not to the same extent, is frequently followed by serious after results. In the United States, about 13,000 children die every year of measles and about half as many die of scarlet fever. It is a significant fact that the death-rate is much higher among younger children, so that if, by carefully keeping children from the possibility of infection, the disease can be postponed until they are well along in years, the danger of fatal termination is much reduced.

The following table, for instance, shows the number of deaths from measles and scarlet fever at different ages, and it is very evident from this table that if the former disease is contracted by a child under five years old, the danger of death is four times as great as if it were postponed until the child were ten years old:—

TABLE XIX. TABLE SHOWING DEATHS AND PERCENTAGES FROM MEASLES AND SCARLET FEVER FOR DIFFERENT AGES IN UNITED STATES REGISTRATION AREA FOR 1907

========================================================================= MEASLES SCARLET FEVER - Per cent of Per cent of Age Period Number of Total Age Period Number of Total Deaths Deaths Deaths Deaths - All ages 4302 100 All ages 4309 100 Under 1 yr. 1058 24 Under 1 yr. 175 4 1-2 yr. 1315 31 1-2 yr. 474 11 2-3 yr. 626 14 2-3 yr. 639 15 3-4 yr. 343 8 3-4 yr. 640 15 4-5 yr. 189 4 4-5 yr. 511 12 5-9 yr. 350 8 5-9 yr. 1213 30 10-14 yr 89 2 10-14 yr. 315 8 Under 5 yr. 3531 82 Under 5 yr. 2439 58 Under 15 yr. 3970 92 Under 15 yr. 3967 92 Over 5 yr. 771 18 Over 5 yr. 1870 42 Over 15 yr. 332 8 Over 15 yr. 342 8 =======================================================

The table shows also that the dangerous age period for scarlet fever is later than for measles. It indicates that while 82 per cent of all deaths from measles are of children under five years of age, only 58 per cent of the deaths from scarlet fever are in that period; but that the number of deaths of the latter between five and nine years is so great that the percentage of deaths under fifteen is the same in both cases. The moral is plain, namely, that a child should be carefully protected from infection by measles until he is five years old and from scarlet fever until fifteen, if the danger to the child's life is to be reduced to a minimum.