Disinfection of Houses—Value of
Fumigation—Formaldehyde—House-Cleaning—Burning and
Sterilizing—Boiling—Carpets, Rugs, and Mattings—Painting,
Papering, and Whitewashing—Temporary Removals—Vacant
Houses—Compulsory Cleaning.
=Disinfection of Houses.= One of the most important of the nurse’s
duties is her arrangement for the fumigation and cleaning of premises
that have been vacated by a consumptive. This takes place after death,
or upon the patient’s removal to an institution, to another house, or to
another room in the same house.
Since tubercle bacilli are not confined to the sputum, but are
discharged in great numbers during coughing attacks, and to a less
extent during sneezing, speaking, and so forth, a patient not confined
to one room, but who wanders freely about the house, scatters bacilli
everywhere. No matter how careful he may be about the sputum, the nature
of the disease makes it practically impossible to be equally careful
about the expired air. Moreover, these organisms do not die of
themselves, at the end of a few weeks. They are singularly tenacious and
persist for months, virulent and active. A case is recorded in which
they were found in a room six months after the patient’s removal, alive
and virulent enough to cause tuberculosis in guinea-pigs inoculated with
them. For this reason it takes drastic measures to rid a house of these
tenacious germs.
In indicating the rooms to be fumigated, it is necessary to include all
those that have been occupied by the patient within the past six months.
If he dies in his bedroom, it is not enough to do merely that one room.
It is equally necessary to fumigate the kitchen, in which he sat until
two months ago; the parlour, where he spent a few hours a day, and the
second bedroom, to which he was now and then removed. All are infected,
and all need the utmost care to free them from germs. The family must be
taught why these rooms are dangerous, and made to understand the
necessity for full and complete disinfection. It is better to err on the
side of too much, rather than of too little care.
In Baltimore, the actual fumigation is not done by the nurses, but by
the employees of the Fumigation Division of the Health Department. The
nurse indicates the rooms, instructs the family, and makes all the
preliminary arrangements, after which she reports the premises to the
fumigator, who disinfects them next day. It would be well if this
fumigation could be done by the nurses or by a special corps of nurses;
this would probably ensure more intelligent and conscientious work than
that which the average city employee bestows upon this important task.
As a matter of routine, every death from pulmonary tuberculosis is
reported to the Tuberculosis Division; the nurse in whose district this
death has occurred then inspects the house and arranges for the
fumigation. Four times out of five the patient is already known to us
and already under supervision, which makes the duty easier than if he
were unknown. In either case, however, the nurse visits the home and
arranges all the details.
In like manner, all patients who enter either hospital or sanatorium are
reported to the Health Department, the institutions furnishing their
names and addresses so that the fumigation may be attended to. When a
patient changes his address and moves to other quarters, the nurse is
the only one who knows of this change, hence it is her responsibility to
report these houses and see that they are fumigated. To arrange for all
these fumigations, whether after death or after removal, means that a
large amount of time is spent upon this work of trying to rid the
community of dangerous centres of infection.
=Value of Fumigation.= The actual value of fumigation is a debatable
point. Under the best conditions, its efficacy is not a hundred per
cent.—far from it—while under unfavourable conditions, when poorly done,
its efficacy is so low as to be almost nil. The house whose cracks have
been improperly stopped, and the old house, with open chimneys, loose
windows, and apertures which cannot be closed, are not made safe by this
process. Under such conditions, fumigation not only fails to remove the
danger, but it produces a false sense of security. Unless properly done,
it were better not to do it at all. We should prefer instead to depend
upon vigorous house-cleaning, the use of hot water, soap, and the
scrubbing brush, and the destruction of all infective material.
Moreover, even under the best conditions, formaldehyde has no powers of
penetration. Its action is purely superficial, and only useful for plane
surfaces, such as walls, ceilings, and so forth. The most dangerous
articles, such as clothing, carpets, bedding, and the like, are totally
unaffected by it. We ought to stop teaching that fumigation alone will
clear up these infected houses and make them safe for future habitation.
The public has been misled as to the value of this measure, and allowed
to place far more reliance upon it than has been justified by
experience. It is high time for enlightenment. The most that can be said
for fumigation is that undoubtedly it kills _some_ germs—so many that it
is worth while to continue the practice of it, but too few to afford
adequate protection. It must be supplemented by other and more radical
measures.
=Formaldehyde.= Formaldehyde in one of its preparations is the chemical
most generally used, and is more valuable than sulphur, which is now
discarded. In most cities, the Health Department attends to the
fumigation. In small towns or rural districts, where there is no
fumigating corps, formaldehyde is usually given upon application to the
local or State Board of Health. In some localities, especially in
country districts, there may be no appropriation for this disinfectant,
which the householder must then buy himself.[4]
Footnote 4:
There are many formaldehyde preparations on the market, simple and
easy to use, but these may be unobtainable. In this case, an effective
method is the combination of formaldehyde with potassium permanganate.
For a room containing 1000 cubic feet of air space (a room 10 feet
long, 10 feet wide, and 10 feet high), the amount needed is: Potassium
permanganate, oz. 111.; liquid formaldehyde, pint 1. Place the
formaldehyde in a large galvanized iron bucket (holding 8 to 10
quarts), and drop the permanganate into it. The room should be left
closed for six hours; a longer time is unnecessary, a shorter time
ineffectual. All cracks, of course, should have been previously
stopped.
Since fumigation is only a matter of six hours’ duration, it will cause
no great hardship or inconvenience to the family which for this short
period must be turned out of the house. Yet many people complain
bitterly over this trial, and raise every possible objection. They are
willing enough to have one room done, but refuse to allow more. The
nurse must explain that a six hours’ inconvenience is better than
risking health and life, and she should also explain that in insisting
upon fumigation the Health Department is neither arbitrary nor
vindictive. Fumigation is a rather costly affair, and this expense is
incurred, not to annoy but to protect the community. In winning over a
reluctant family she has a chance to do excellent educational work. It
is always better to secure their intelligent co-operation, even though
it take long and patient argument, than to end the discussion by
abruptly informing them that fumigation is compulsory, and will be done
whether desired or not.
=House-Cleaning.= Fumigation must always be followed by most searching
and thorough house-cleaning, which important task must be done by the
family itself. All floors should be scrubbed with hot water containing
lye or soda solution and all washable surfaces should be likewise
treated. This includes furniture, doors, door knobs, windows, stairs,
banister rails, and so forth. The necessity for this house-cleaning
cannot be too strongly emphasized.
=Burning and Sterilizing.= The most highly infective material is the
bedding, mattress, pillows, clothing, and so forth, which have been used
by the patient. Since these articles cannot be made safe by formaldehyde
fumigation, and since most of them cannot be washed and boiled, there
are but two methods of disposal. The most drastic and wasteful is to
burn them, yet this must always be advised unless we can offer the
alternative of sterilization under high pressure steam. To burn
infective material involves a loss which few people can afford, and they
are loth to make the sacrifice; most of these articles, while laden with
germs, are nevertheless serviceable and in good condition. To expect
that they will be burned, therefore, is to expect the impossible. If the
family consent to destroy certain articles, they reserve others, equally
unsafe for use. The only alternative is the municipal sterilizer, and
any community which expects to do effective preventive work must
establish this as a factor of first importance.
In Baltimore there is such a sterilizer, and the use of it is very
simple. When the nurse arranges about the fumigation, she selects at the
same time whatever articles are to be sterilized—pillows, mattresses,
blankets, clothing, and so forth. These are then called for by the men
from the Fumigation Division. They are placed in large canvas bags,
inventoried, labelled, and carried to the sterilizer. Here they are
steamed and dried, and returned a day or two later in good condition.
The householder signs a receipt to this effect.[5]
Footnote 5:
Certain articles are ruined by sterilization, and the nurse must be
careful not to include these, or there will be a suit for damages.
Leather and furs, can never be steamed. Straw mattresses are also
injured. Nor is it possible to sterilize carpets and matting, because
of their bulk. The sterilizer should be reserved exclusively for
material which lends itself readily to treatment of this kind. In
selecting what is suitable, the nurse should exclude old and filthy
articles, which should be burned.
Unfortunately, steam sterilizing plants are rare, and in most
communities the nurse will have to protect her patients in other ways.
As we have said before, the only alternative is burning, and this often
works great hardship on many families. With the very poor, the Federated
Charities may be called upon to supply new mattresses, etc., in place of
those that have been destroyed, and as a rule this response is prompt.
Yet there are many cases where the family is too poor to suffer this
loss, yet not poor enough to come within range of a charitable
association. These cases constitute a difficult problem—a problem that
is entirely solved only by the municipal sterilizer.
Except through sterilization, there is no way in which these articles
may be made safe. Carbolizing will not do this, neither will sunshine.
Valuable as sunshine is, it is difficult to secure prolonged exposure,
especially in tenement districts. It is possible, of course, to take a
mattress apart and wash and boil the ticking; feathers or hair may be
sent to an upholsterer, who has means of steaming them. Pillows may be
put into a large wash-boiler, and boiled for half an hour, after which
they may be washed—it will take a week or more before they become
thoroughly dry and usable. All these alternatives involve a great outlay
of time and energy, and we cannot but feel sceptical as to the
thoroughness with which this cleaning is likely to be done. A family
which objects to parting with dangerous articles, and prefers risk to
inconvenience or deprivation, is hardly likely to be scrupulous as to
details of this character.
In Baltimore, before the advent of the steam sterilizer, the amount of
material burned was never more than a third of the amount which should
have been burned. Still, under the circumstances, we were thankful to
have achieved this third. Since the establishment of the sterilizer, we
now succeed in getting over two thirds (70 per cent.) of the infective
material sterilized. This is a triumph for the nurse’s teaching, since
there is no law making sterilization compulsory.
=Boiling.= Everything which can be boiled will of course be made safe,
whether these articles be of wool, linen, china, rubber, etc. Even
blankets may be boiled, although the family will object to this on the
ground that it shrinks them. The nurse must explain that not to boil
them may have consequences even more disastrous. The nurse must never
permit her patients to make indiscriminate bonfires, and wantonly
destroy harmless articles, or those which may readily be made so. We
know one family which destroyed a whole set of dishes, not from painful
association, but from a misdirected desire to do the right thing. For
this reason, the nurse must look over all articles carefully, giving
thoughtful counsel as to the proper disposition of each.
=Carpets, Rugs, and Mattings.= As the sterilizer cannot be used for
carpets, rugs, and mattings, there is nothing to do but advise that
these articles be burned. As a rule, this destruction is agreed to with
more readiness than in the case of pillows and mattresses.
=Painting, Papering, and Whitewashing.= Whenever possible, the rooms
used by a consumptive should be repapered, painted, or whitewashed as
the case may be. The more thorough and complete the measures taken to
eliminate tuberculosis, the greater the chances of success. It is a
costly disease, and costly measures, both as to money, energy, and time,
are required to get rid of it. Half-way methods are poor economy.
=Temporary Removals.= The foregoing directions apply mainly to those
cases in which the patient has either died, or has been permanently
removed elsewhere. If his return is not expected (as when an advanced
case enters the hospital), the amount of cleaning, burning, repapering,
etc., would naturally be as great as that required after death.
On the other hand, when his removal is but temporary and the patient
expects to return home after a few months, the amount of disinfection
would be considerably modified. When he enters a sanatorium, his house
must be fumigated and cleaned, so that for a few months at least the
family may be relieved of danger. Under such circumstances, it would not
be necessary to counsel the destruction of the mattress and bedding that
he is to use upon his return. Meanwhile, no other member of the family
should use these things, although in certain instances it is almost
impossible to prevent their doing so. For such cases the municipal
sterilizer is needed—indeed no community can make much headway against
tuberculosis until it provides a means of removing the danger without
causing loss to the individual.
=Vacant Houses.= When a family’s removal leaves a vacant house, there is
naturally no one left to do the cleaning. The Health Department will do
the fumigation, but the more essential house-cleaning remains undone.
These houses often stand idle for weeks or months before finding a new
tenant. Even if it were possible to discover the landlord or owners (a
task which in itself would require a staff of employees), it is doubtful
whether they would clean these houses themselves, or notify their new
tenants of the need for extra vigilance. Legislation compelling
house-cleaning would be difficult to put through. The landlord feels
relieved of all responsibility when once the fumigation is accomplished,
and that this fumigation is not a hundred per cent. effective is no
concern of his. He, together with the general public, has been misled as
to its true value. Nor is thorough cleaning, painting, and papering an
expense that he would willingly incur. The question of the fumigated but
not necessarily safe house is one that causes considerable anxiety. We
feel that the only way to deal with it, is that the nurse keep these
vacant houses on her visiting list, so to speak, and watch for the time
when they are re-let. This entails considerable loss of time, which she
can ill afford to spare from her patients, but the information she can
give the new tenant will have distinct preventive value. She must tell
the newcomer that he has moved into a house in which there has been
tuberculosis, and that only by the most exact and painstaking efforts
can it be made safe.
=Concessions.= In carrying out this important work, the nurse sometimes
becomes so enthusiastic that her common-sense gives way under the
strain. She wishes to carry her point, without fully realizing the
prejudices, ignorances, sometimes even the comfort, of the family she is
dealing with. After a death, she comes upon a household in a most upset,
distressed, and often irresponsible condition, and she must be very
gentle and patient in her relations with them. She must accomplish what
is necessary, without undue disturbance of their prejudices and
feelings. For example: Orthodox Jewish people observe a mourning period
of several days following death, during which time they wish to remain
undisturbed. Fumigation should be postponed until this time is past. A
few days’ delay will not injure the health of a family which has been
exposed to infection for months. By thus respecting their religious
customs, it will be possible to gain better co-operation as to cleaning
and so forth; co-operation which would have been jeopardized by riding
roughshod over their feelings and beliefs.
Sometimes people raise objections because they have nowhere to go for
the six hours required for fumigation, during which time they must leave
the house. If there is no kindly neighbour to take them in, the nurse
may arrange with a Settlement or other social agency, to give them
shelter. We have often asked for hospitality in this way, and have
always met a ready response. Sometimes, if a house is a large one, it is
possible to have it fumigated in sections, a few rooms being done one
day, a few the next.
=Compulsory Cleaning.= In most communities, fumigation is compulsory.
But there is no regulation whatever concerning the after-care of the
premises—the cleaning, sterilization, and destruction of infective
material. The relatively unimportant part is obligatory, while the
essential part is optional. And that this essential part is done, and
well done, depends almost entirely upon the teachings of the public
health nurse.
If, however, the family remains obdurate, refusing to clean and
disinfect, nothing can be done. Since it is now generally acknowledged
that fumigation falls far short of what it was once expected to do, we
need laws making adequate disinfection compulsory; until such laws are
enacted, we can only rely on the ability of the nurse to teach the
necessity for cleaning and disinfecting. How valuable is this teaching
may be gathered from these figures (_Report_, 1913, Tuberculosis
Division of the Baltimore Health Department): “After death: houses
cleaned, 80 per cent.; bedding, etc., either burned or sterilized, 70
per cent.” With adequate laws, the nurses would make even a better
showing.