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.