CHAPTER XI.
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.
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.
Sanitary Kitchens
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.
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.
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.
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.
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.
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.
GARBAGE CREMATORY
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.