[Sidenote: Hospital Hygiene]
Some sage has remarked that men and women are doomed, from birth to
the grave, to combat three things—disease, dirt and the devil. With a
great many of the human race, the effort put forth to oppose either one
of the D’s is so weak that it could scarcely be called a combat. The
D’s are on hand, when the first breath is drawn, and the unfortunate
individual weakly yields to force of circumstances. If he does not
succumb to their influence early in life, he drags through an existence
somehow and calls it living. But in a hospital, if the health of the
workers is to be preserved, if the hopes of those who come as seekers
of health are not to be defeated, if life for any of its inmates is
to be considered safe, then nothing less than an unceasing war, a
hand-to-hand combat with the three D’s must be maintained.
[Sidenote: Prevention of Disease]
Preventive medicine and preventive nursing are each year assuming a
larger place in the study not only of those who deal with disease, but
of the public in general, and in no place is such knowledge of greater
importance than in a hospital. To Florence Nightingale we are under a
debt of gratitude for giving to the world some of its first and best
lessons on hospital sanitation. When she, with her corps of English
nurses, entered the huge hospital in Scutari in 1856 and began her
work among the six thousand wounded soldiers, the disorder and filth
and consequent suffering was appalling. She shocked the propriety of
some of the army officials beyond measure, but she saved lives. She
transformed the hospital, and the haughty officials who on her arrival
in astonishment had remarked: “Fancy! Some women have come to the
hospital! A Miss Nightingale, with a force of assistants. Was anything
ever more improper than women in such a place?” learned in less than a
week some lessons they were sadly in need of from that self-same woman.
Much of her teaching on hospital sanitation we have not yet outgrown,
in spite of all the progress we have made.
In the average home, under the best conditions, the skill of the
intelligent housewife is taxed to the utmost to prevent disease from
invading its precincts. How much the more vigilance is required in a
hospital with all its adverse influences to contend with? Many years
ago a medical officer of a health department in England, in speaking on
this subject, said:
“That which makes the healthiest house makes likewise the healthiest
hospital; the same fastidious and universal cleanliness, the same
never-ceasing vigilance against the thousand forms in which dirt may
disguise itself, in air, in soil and water, in walls and floors and
ceilings, in dress and bedding and furniture, in pots and pans and
pails, in sinks and drains and dust-bins; it is but the same principle
of management, but with immeasureably greater vigilance and skill; for
the establishment which has to be kept in such exquisite perfection
of cleanliness is an establishment which never rests from fouling
itself; nor are there any products of its foulness, not even the least
odorous of such products, which ought not to be regarded as poisons.
Above all this applies to the fouling of the air within hospital wards
by exhalations from the persons of the sick. In such exhalations are
embodied the most terrible powers of disease, the spreading flames,
as it were, of some infections and the explosive fuel of others; and
any air in which they are allowed to accumulate soon becomes a very
atmosphere of death.”
The subject of hospital sanitation is so large, so many-sided, that
to do it justice in the space allotted is impossible. It involves a
consideration of the site of the hospital and the plans, the separation
of the departments, the materials used in its construction, its
ventilating system, its plumbing and sewerage connection, its food and
water supplies, its facilities for isolation of infectious diseases,
for disinfection, for disposal of the waste and refuse from the various
departments, and its arrangement for living conditions for those
on whom the responsibility of carrying on the work of the hospital
involves.
[Sidenote: Sanitary Kitchens]
[Sidenote: Pure Food]
The days of hospital gangrene, of outbreaks of erysipelas, pyaemia
and puerperal fever in hospitals have passed, but we have still too
many cases of typhoid fever, diphtheria and other diseases developing
in hospitals and institutions of various kinds in this twentieth
century. The teachings of Pasteur and Lister that bacteria are the
cause of a large number of the ills that flesh is heir to, and that
these micro-organisms may be destroyed by the use of proper means—these
teachings have revolutionized some departments of hospital work. One
very important department that has not been entirely revolutionized is
the hospital kitchen. The number of sanitary kitchens is increasing, it
is true, but in many hospitals the kitchen is out of harmony with the
other departments. It is not unusual to find a beautiful and imposing
front entrance, to find marble and tile entering largely into the
construction of many parts of the building, to find a costly modern
equipment in many departments, and to find the kitchen of that same
institution, dark, too small, poorly equipped, poorly ventilated,
cheaply constructed throughout, and thoroughly unsanitary, a splendid
place for the development of germs—a place that is, if not a disgrace
to the institution, at least far from creditable. Who is to blame?
Somebody surely is. Certainly when so much value is being placed on
the food supplies sent from the kitchen as weapons in the fight with
disease no hospital built in the twentieth century should have in it
a kitchen that is not in keeping with the rest of the building, that
will not bear critical inspection, that cannot be shown with as much
confidence and satisfaction as the operating room or the wards. And
not only in the situation, construction and equipment of the hospital
kitchen is this lack of progress evident, but in no part of the
hospital is the germ theory so little regarded in practical work. Pure
blood is regarded as one of the great essentials of health, and much
study has been devoted to that important part of the human system.
The most perfect apparatus for examining the blood is considered none
too good, but how often in the average hospital are tests applied to
the materials from which blood is made? Are all butchers and bakers
and grocers and dairymen so honorable that occasional analysis of the
products supplied is quite unnecessary? An examination of the ice
supply in a certain hospital, not many months ago, led to the discovery
of the ice as the cause of an epidemic of typhoid fever, that seriously
embarrassed the institution. A careful inquiry into such matters might
have prevented serious embarrassments in a number of other institutions
within recent years. Prevention is better than cure, and far cheaper.
It is always better to be sure than sorry, and now that scientific
research is popular, it ought to be possible for every hospital to
arrange for periodical examination of its food and water supplies.
[Sidenote: Filters and Water]
Filters are now regarded as essential in every hospital, but it is
quite possible for too much confidence to be placed in filters. The
filter that will run fast is likely to be the favorite, whether it
really filters or not. Elmer G. Horton, B. S., bacteriologist to the
Ohio State Board of Health, in speaking of the weaknesses of domestic
filters, says:
“If the rate of filtration is not moderately fast, the consumer will
not buy. The maker realizes this, and slights efficiency in order to
gain a more rapid flow. The filtering material is made coarser or more
porous, and, with the resistance decreased, the water passes through
more readily, and so do the bacteria.
“No filter will continuously yield a perfect effluent without being
often cleaned. Whatever a filter takes out of the water remains in the
filter until removed by cleansing; and if that cleansing be delayed
the filter will dispose of the accumulated filth by way of the passing
water. We must expect an unclean or foul filter to yield an effluent of
like character, although that effluent may appear clear.
“After all, the more harmful things in a water are not so much the
easily discernible ones—mud, floating vegetation, iron, odors, etc.,
but the invisible living micro-organisms, and especially those forms
capable of producing disease in man. It is true, and greatly to be
regretted, that clearness is the criterion by which the average citizen
measures the efficiency of his filter, but let it never be forgotten
that the clearness of a water is no guarantee of its purity. This
bottle of water which I pass around is clear enough, and no doubt
looks good enough to drink, but it actually contains not thousands but
millions of typhoid fever bacilli.
“A sample of filtered water from the filter in the dining room of a
large boarding-house was examined and found to contain five times as
many bacteria as the unfiltered water.
“Recently samples of filtered and unfiltered water were taken from a
filter in one of the offices of the State House. The 2,200 bacteria per
cc. of the untreated water had increased to 14,000 in passing through
their “germ-proof” filter. Organic matter collects in the filter
and serves as food, and there is developed a breeding nest for the
bacteria.”
Parkes in his manual of hygiene suggests this plan for the examination
of water: First, a physical examination of water; second, a
microscopical examination of suspended matters and sediment; third,
a quantitative examination of dissolved solids; fourth, a biological
examination.
[Sidenote: Air]
While it is important for every hospital to know something of the
quality of the food and water supplied to its inmates, it is of still
greater importance to know that in every department of the hospital
there is provision for the entrance of pure air and the exit of impure
air. We may live without food for days or weeks, but the breath of life
is the first great essential of existence. Deprived of it and death
results. Poison it and deterioration in health results. “Bountiful
nature has supplied an inexhaustible supply of this essential, and the
means for its purification. Only when man’s ingenuity or stupidity
thwarts her efforts, confines the air, prevents its free circulation,
does it retain the poison he has contributed to it.”
A large part of the science of sanitation can be summed up in one
word: cleanliness; clean air, clean food, clean water, clean rooms,
clean beds and bed linen, clean occupants of the beds, and clean
appliances.
[Sidenote: Dirt]
Dirt has been defined as “matter out of place.” To have the ability to
recognize when matter becomes dirt, and get it into its proper place
and proper form, is to have the key to hospital sanitation. It means a
strict attention to what elsewhere might be considered small details.
It is said that under the microscope the dust of an ordinary house
resolves itself into soot, minute particles of cotton and wool fibres,
spores of bacteria, starch grains, pulverized straw, epithelial and
epidermic debris, and fragments of food. It consists to a great extent
of organic substance, capable of decomposition. When added to this we
have some of the constituents of dust common to a hospital, such as
shreds of linen or wool from soiled bedding, pieces of hair, dried
particles of pus, blood, and human tissue, crystals of urine, etc., the
consideration of how to get dust into its proper place and form, how to
deal with it, so that it is not a menace to both the healthy and sick
inmates, is no small or unimportant part of hospital management.
[Sidenote: Flies]
Flies—the common, innocent-looking house flies, that formerly were
regarded simply as annoyances to be endured, have been found to be
among the most active agents in the spread of disease. Now that the
germ theory is so well understood, it is not difficult to see how this
takes place. Victor Vaughan, a member of the Army Medical Commission
during the Spanish-American war, states as follows his observations
regarding the fly as an agent in spreading typhoid fever in the camps:
“They swarmed over fecal matter in the latrines. They visited and fed
on food prepared for soldiers in the mess tents. In some instances
when lime had been spread over the contents of latrines, flies, with
their feet white with lime, were seen walking over the food. Officers
whose mess tents were protected by means of screens suffered less
proportionately than those whose tents were not so protected.”
Dr. M. J. Rosenau, in his valuable book on “Disinfection and
Disinfectants,” expresses his opinion with no uncertain sound on the
fly question when he says: “In fact, as our knowledge of the subject
increases we find that domestic animals and vermin are playing a very
conspicuous role in the transmission of disease. So dangerous do we now
know that the fly and mosquito may be, that when the matter is more
generally understood, it should be a greater reproach to the housewife
to have these dangerous vermin in the household than to have bedbugs.”
Where dressings soiled with pus and excreta have constantly to be
handled, as in a hospital, the presence of flies is a real source of
danger that no careful housekeeper will ignore. To keep them out of
the building, and manage so that no substance about the exterior may
be left to attract them, means that a systematic inspection of the
premises must be made, to see that fruit peelings or scraps of food are
not thrown from the windows, that careful and prompt disposal of all
refuse is accomplished, that scrupulous cleanliness in and about the
institution is practiced, and that properly fitting screen windows and
doors are in place early in the season, and left till cold weather has
caused the fly to leave for parts unknown.
[Sidenote: Garbage]
The disposal of garbage and the waste accumulation from the wards
forms one of the most serious problems that confronts the hospital
housekeeper. There is but one safe method of disposal and that is by
cremation, prompt and swift and sure. The too common method of storing
garbage in large cans, and allowing it to vitiate the air with its
obnoxious odors, and attract to itself flies an other vermin, till the
city garbage collector gets around to remove it, is a practice that
ought to be abandoned as speedily as possible by every institution.
Much responsibility rests upon the superintendent in such matters. She
alone cannot effect desired improvements, but she realizes the need
as no member of the board can, and she ought to tactfully educate the
board and urge the necessity of proper appliances for this purpose.
Recently twenty letters were sent out to twenty various sized hospitals
inquiring as to the methods used in disposing of soiled dressings and
refuse from the wards. Answers were received from almost if not all,
and there was a general agreement that cremation was the only proper
method of disposal. However, in only three or four of the twenty had
any provision been made in the plans of the hospital for this very
important work. Some hospitals burnt them in the furnace, some in the
laundry stove in the basement, some covered them up and carried them to
the laundry stove in an outbuilding, some had them carted away to the
city dumping ground. From one Chicago hospital of whom inquiry was made
we had the following report: We have a water heater and garbage burner
which runs day and night, and into this burner we put all of our soiled
dressings and garbage of every description at any hour, day or night.
They are consumed without causing us any trouble whatever. We certainly
find it a great comfort not to have any garbage, not even a garbage
box or barrel on the premises. Our pails and baskets are brought down
to the boiler room twice daily, and there immediately emptied into the
burner. The pails are scalded and cleansed, so that we keep everything
sweet and clean.”
From a New England hospital we had the following report: “For four
years we have used a crematory for disposing of soiled dressings,
and have found it most satisfactory. It has gas burners and could be
placed in a bath room if it is large. With such a crematory on each
floor dressings can be burned immediately, and thus the objectionable
dressing or refuse pail be dispensed with. A careful nurse will turn
out the gas after the dressings are dry and ignited, and the expense of
the apparatus will thus be very slight.”
Through the courtesy of the Morse-Boulger Co., who have installed
crematories in a considerable number of large hospitals in the east and
in some smaller institutions as well, we are able to present a cut of a
crematory for a small hospital.
[Illustration: GARBAGE CREMATORY]
[Sidenote: Garbage Crematories]
The crematories are built in many sizes to conform to the location.
They provide a medium for the disposal on the premises with the utmost
rapidity and economy of every class of waste produced in a hospital.
They can be operated with any available fuel and all are provided with
perfectly efficient means of consuming the smoke and inflammable gases
thrown off by the burning material. These crematories can be placed
in the basement or cellar if necessary and connected directly with
the chimney or smoke pipes, from the heaters or steam boilers of a
building, or can be placed outside when deemed desirable.
In order to ascertain some facts concerning the working of these
crematories, letters of inquiry were also sent to a number of hospitals
in which the Morse-Boulger crematories are in use, and without
exception the reports were most favorable. The following from one of
the largest Philadelphia hospitals is characteristic of all the reports
received and goes to show that there is no risk of unsatisfactory
working in such an apparatus:
“It is true that we have a Morse-Boulger garbage destructor, and it
has been in service about four years. The capacity of the chamber is
about twenty barrels. In selecting the size we had in view the quantity
of garbage that we have to burn each twenty-four hours, so that the
chamber would hold all the garbage produced in twenty-four hours at
one charging, thus relieving the necessity of keeping the fire going
all the time. As it is now, the fire is started in our crematory about
4 o’clock in the afternoon, and by 10 o’clock at night the charge is
all burned out. This gives the apparatus time to cool off, so that the
night fireman can clean it out before he goes off duty and leave it
ready for re-charging in the morning.
“The destructor has worked very satisfactorily for us, and burns the
whole of our garbage with about 500 pounds of buckwheat coal per day,
which means an expense of from forty to seventy cents a day, owing to
the price one has to pay for the coal.
“I do not believe you can recommend too strongly the use of such an
apparatus for hospital purposes.”
Other and cheaper crematories for the use of the smaller hospitals are
in the market, they being efficient, so far as the capacity goes, and
the price being within the reach of practically every small hospital.
An illustration of one of the best of these cheaper crematories, made
by the Bramhall-Deane Co., is here shown.
Certainly every institution with new buildings or additions in course
of erection that has not yet made provision for the sanitary disposal
of garbage and refuse, should keep this matter in view as one of the
improvements to be arranged for as speedily as possible.
There is no royal road to safety in a hospital. There are hidden
dangers on every side. “Eternal vigilance is the price of safety.”
The most expensive and wisely constructed building and the best
modern equipment will not long remain in a sanitary condition unless
watchful care is exercised, and intelligence and energy applied to the
eradication of dirt, and conditions that favor the multiplication of
the enemies to life and health that are ever present.
In the regular daily cleaning of a hospital no “royal road” has been
discovered. There are on the market a great variety of washing powders,
scouring soaps and such things, but nothing has been discovered that
quite takes the place of human labor.