CHAPTER XIII
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]]
[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]]
[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.