I6h HYGIENIC MEASURES IN RELATION TO INFECTIOUS DISEASES NUTTALL THE UNIVERSITY OF ILLINOIS LIBRARY ia is 2 eee EY east BBaRern at eae. Senet ay BAe ae rat 5 A Aw eee «2 Buell % Sane ee a ya Sh d ait 2. bei MGS! Fa isa he vostty bones aE oT ee | : GER SE 1 Aeeo Rs EF, =, rege eae zy, 4 ‘ er, Las: 2 be was ic 2, tA EF a HSI 6 et + ieee euauns ane ae ik ad ah Sir dP SD Li ARM a AS st PARE R) ‘eare Sle eT tae 251 ge DF KA SFR 2: ert ue Wi gee SS but ate eer Ont eet bungee 3 ee MEASURES | IN > RELATION TO NFE ECTIOUS a COMPRISING IN CONDENSED FORM INFORMATION AS TO THE CAUSE AND MODE OF SPREADING OF CERTAIN DISEASES, THE PREVENTIVE MEASURES THAT SHOULD BE RESORTED TO, ISOLA- TION, DISINFECTION, ETC. BY GEORGE H. F. NUTTALL, M.D., Pu.D. (GOTTINGEN) ASSOCIATE IN HYGIENE AND BACTERIOLOGY, JOHNS HOPKINS UNIVERSITY AND HOSPITAL; MEMBER OF THE ASSOCIATION OF AMERICAN PHYSICIANS j MEMBER OF THE AMERICAN PHYSIOLOGICAL SOCIETY ; FELLOW OF THE ROYAL MICROSCOPICAL SOCIETY, LONDON, ETC, | meany (iF €H: AAA VY 4891 a ats . ryt Ae aM is HMIVERSHT Y LPF Jt G. P. PUTNAM’S SONS NEW YORK LONDON 27 WEST TWENTY-THIRD STREET 24 BEDFORD STREET, STRAND The Rnicherbocher Press 1803 l Cc 1G: 8 i fe CuCuns Ce CGC i GIB ige fs € GG.G 6 ¢ c ¢ c Cie ee RK. « Pare Soe € ¢ te « c i c ti is fi < q te « Caviar x ¢ ¢ € ¢ c¢ ¢ c c Gc is C ¢&x ¢ Ge 6 (i ¢ € ( an [i c ¢ Ee eke LO) a) Wai: c CG Ic Gann GC ear ee ee c (ak C c&c € ¢ € € ¢ CopyrRiGuT, 1892 - BY GEORGE H. F. NUTTALL Electrotyped, Printed, and Bound by The Rnickerbocker Press, Tew Work G. P. Putnam’s Sons LL. Sel, ~ ta i AVS CONTENTS. PAGE UTES DEAR ah 0 AAU eae Pop LE a A lA RA 1x |S TRAE! WN ANGIE GS le Je ln is a hak ah Pt a I Observations of a general character on the sub- ject of disinfectants and methods of disinfection. What disinfectants, antiseptics, and deodorants SUE 2 UE ea ER es aa re Agents Used in Disinfection. I. Fire, dry heat, moist heat (steam and boil- ing water). Objects to which these modes of disinfection are applicable. Steam disinfectors, their construction, and how they are used....... 2. Chemical disinfectants. What is required in a disinfectant in order that it may be of prac- tical use. Certain precautions to be observed in Mi neeeiemical disiniectants.. 200.605 sic ee Carbolic acid, crude carbolic acid and sul- phuric acid mixture, corrosive sublimate, permanganate of potash and oxalic acid, milk of lime, chloride of lime, sulphur, il 575419 14 iv CONTENTS. PAGE 3. Disinfection by means of heat or chemical agents .in connection with the mechanical re- moval of the infectious agent from various ob- jects by means of glutinous brown bread, sponges, CLOTHS SCL DDETSHELG. Wu ute boa eel Cee earns 4. Measures in which false confidence is fre- quently placed: ventilation, sunning, airing, and 22 beating of infected clothes, etc. Commercial © MUsiniectantS ctCvek tc aes ean ete ee ce ee pages a PRACTICAL DIRECTIONS. Preliminary remarks. The term infectious disease defined. The extent to which disinfec- tion should be carried out varies in different CHSCOSES Ti hs teisiste ao on et eas gathered from the study of certain known dis- ease agents (pathogenic bacteria) and their behavior towards disinfectants. As these tables may fall into the hands "of persons not especially acquainted with the subject, it may not be out of place to make the following observations: By the term dis- enfectzon 2s meant the absolute destruction of tn- fectious materzal, and this is not accomplished by other agents than disinfectants, which must not be confounded with antiseptics and deo- dorants. A duzsenfectant kills the disease agent or putrefactive organism, and _ neces- sarily has some of the qualities of an antisep- tic and deodorant. (Many preparations sold as disinfectants are nothing of the kind, but may belong to the following classes.) Az antiseptic arrests putrefaction or fermentation, but does not kill the micro-organisms, whilst a deodorant is used to destroy bad odors from cesspools, stables, discharges, etc. We have IN RELATION TO INFECTIOUS DISEASES. 3 ——— in copperas (sulphate of iron) an excellent antiseptic and deodorant, which can unques- tionably be of great service ; for example, in epidemics, where a larger amount of decom- posing matter requires treatment than it is practicable to disinfect. It is of the greatest importance that these various agents should not be confounded. AGENtS USED IN DISINFECTION. We can disinfect by means of fire, dry heat,. moist heat (applied as steam or boiling water), or by various chemical agents,and, besides this, we can combine the action of disinfectants with the mechanical removal of infectious material, by means of brushes, sponges, cloths, etc. We will now consider the various agents above named. DISINFECTION BY MEANS OF FIRE. The simplest and most effectual means of destroying infectious material is by burning 4 HYGIENIC MEASURES it. This method of destruction being only applicable to worthless articles, has but a limited application as far as contaminated objects are concerned. On the other hand, sputa (especially tuberculous sputa on rags or paper, etc.), faeces (mixed with saw-dust), and wound dressings, etc., soiled with discharges, can be very readily and satisfactorily disposed of through the agency of fire. DISINFECTION BY MEANS OF DRY HEAT. Disinfection by means of dry heat has but a limited application. Articles to be disinfected must be exposed longer to the action of dry than to that of moist heat, and in consequence many animal and vegetable fabrics are injured. Dry heat penetrates so slowly that even after an exposure of three to four hours at 140° C. [284° F.] (Koch and Wolffhigel), compara- tively small bundles of clothing, etc., are not thoroughly penetrated by the heat. Vegeta- IN RELATION TO INFECTIOUS DISEASES. 5 tive forms of bacteria are killed by dry heat at a temperature of 100° C. (212° F.), usually inside of one hour and a half, whilst spores, as a rule, are only destroyed by a temperature of 140° C. (284° F.), maintained for three hours. If bedding, clothing, etc., are exposed to this latter temperature with any degree of fre- quency, for example, in hospitals, the fabrics are rendered much less durable. It has been shown that woollen fabrics change color after two hours at 105°C. [220° F. | (De Chaumont); that cotton and linen are affected after two hours at 125° C. [257° F.] (Vallin). It is diff- cult to control the temperature when dry heat is used, unless it be derived from compressed steam acting through iron pipes, etc. Vermin are destroyed completely after an exposure of but a few minutes to dry heat at a temper- ature of 105° C (220° F.), and in less than an hour at that temperature they are quite brittle and fall to pieces (Lake). Objects which 6 HYGIENIC MEASURES have been exposed to dry heat should be allowed to regain their hygrometric water (so as to insure against loss of substance) before being beaten or brushed (Vallin). Dry heat is useful in connection with steam disinfection, as will presently appear. DISINFECTION BY STEAM AND BOILING WATER. By means of steam at 100° C. (212° F.) and boiling water, we are able to thoroughly disinfect a number of articles which other- wise would be awkward to manage. We are dealing here with the most useful and relrable agent we know, as, on the one hand, it cannot be neutralized, as chemical disinfectants frequent- ly are, and, on the other, the most delicate fabrics can without injury besterilized by means of steam, provided certain precautions are taken. Disinfection by Steam. For this purpose a variety of steam disinfectors have been de- vised. The simplest, which might be of IN RELATION TO INFECTIOUS DISEASES. i service in an emergency, is suggested by Fligge ; that is, one made of a cask with one end perforated and the other knocked out, placed with the perforated end uppermost over a vessel of boiling water. The objects to be sterilized or disinfected can be placed ona kind of framework within the barrel, and the escape of steam from around the base of the latter prevented, to a large extent, by wrap- ping cloths aboutit. Such a home-made steam disinfector could be used several times, but, of course, would not be durable. The same in principle, but provided with a conical top to prevent the water of condensation from falling on the contained objects, are the ordinary steam sterilizers (made of iron or tinned copper) employed in our bacteriological labor- atories. An improvement on these, the 1 «“ Arnold steam sterilizer,’ is useful for the 1 This most excellent and inexpensive apparatus is manufactured by Wilmot Castle, & Co., Rochester, N, Y, It is made either of heavy 8 HYGIENIC MEASURES sterilization of small objects, bandages, instru- ments, etc. When, however, we come to con- sider what a variety of objects, small and large, it is necessary to disinfect in infectious dis- eases, we realize the necessity of larger steam sterilizers, and their equipment with a number of arrangements to increase their convenience. We will presently see what objects should and should not be disinfected by steam. Hospitals and public institutions for disinfec- tion should be provided with capacious steam disinfectors. A number of these have been suggested or patented, but they are all based on /the)same: principle > «hey best stoma 16 tubular, either circular or oval on cross-section, passing through a brick wall separating two rooms. The disinfector has two doors, one tin with copper bottom, or entirely. of copper; the former, of course, being considerably cheaper. The sterilizer can be heated over an ordinary stove, or by means of a gas, alcohol, or kerosene flame. The largest size is 1114 inches in diameter, and 12% inches in height. IN RELATION TO INFECTIOUS DISEASES. 9 opening into each room, the infected objects being introduced by the one and removed by the other. The walls of the tube are double, so that steam, superheated if necessary, can be admitted into the steam-jacket thus formed, and heat the objects within the tube without steam being admitted into the inner chamber. By this arrangement one can apply dry or moist heat to the objects inside. It is desira- ble to first apply the heat (dry) through the jacket until the objects inside reach the tem- perature of 100° C. (212° F.), as this prevents the steam, which is then let into the chamber, from condensing on the contained objects. This is very important. By means of properly arranged tenting, or thin metal plates arranged on the inside of the disinfector somewhat like shingles on a roof, but with large spaces be- tween them, any water which may condense at the top of the sterilizer is prevented from dripping on the objects, and runs down with- IO HYGIENIC MEASURES out injuring them to the floor of the chamber. The steam disinfector is covered on the out- side by woodwork and asbestos to prevent loss of heat. By means of such a steam disin- fector as this we are also able to utilize steam under pressure, both in the steam-jacket and inner chamber, thus increasing the rapidity of the process. To be properly conducted, two employees should have charge of the disin- fector, and two easily cleaned oil-painted carts should be used, the one for the transportation of the infected, the other for disinfected articles. Such carts can be painted of dif- ferent colors, so as to be easily recognized. It is best to have a separate building of small size devoted solely to this purpose, and consisting of two rooms, each with separate entrances, one for the handling of infected, the other for disinfected articles, and a third, if necessary, for an engine-room. The man in charge of the objects to be disinfected WV TRE EA TION TO INFECTIOUS DISEASES. II ——— should be provided with a skull-cap, overalls, and blouse of canvas or linen, and rubber boots, the same to be disinfected at short in- tervals. Before removing the outer clothes he has worn whilst handling infectious ob- jects he should wipe them off with a sponge moistened with carbolic acid solution, and after removing them disinfect the hands and face. Articles such as clothes, blankets, etc., should be hung up in the steam disinfector, not put in rolled up, and towels and mattresses (the latter ripped open in certain cases) so arranged as to leave space between the objects, so as not to prevent the heat or steam from penetrating. In some steam disinfectors, proper racks and wire baskets are provided in which to place the things to be disinfected. The length of time articles should be exposed to the action of steam. The time required for the disinfection of various articles by means of 12 HIYGIENIC MEASURES steam differs according to their bulk, the larger the object the longer it takes steam to pene- trate it. The time is calculated from the moment the air has been expelled’ from the chamber (this is most rapidly accomplished when the steam enters from above and drives the air out below), and an electric pyrometer or thermometer informs us that the tempera- ture has reached 100° C. (212° F.) or more, de- pending upon whether we use steam under pressure or not. If the objects are bulky, we place the thermometer within them, so as to know when the heat has penetrated. We can feel sure of small objects being disinfected in half an hour at 100° C. (212° F.), whilst more bulky objects should be exposed one to two hours. When a temperature of 110° to 120° C. (230° to 248° F.) (steam under pressure) is used, five to ten minutes will do for small ! Gruber’s experiments showed that the presence of air in a steam sterilizer prevents the effective action of steam, IN RELATION TO INFECTIOUS DISEASES. 13 objects, and fifteen to thirty minutes for large.’ < Disinfection by steam ts applicable to clothes, linen, blankets, towels, carpets, curtains, and a variety of delicate fabrics, mattresses and pillows (ripped open if bulky), letters, etc. Disinfection by steam ts not applicable to linen soiled by blood, pus or feces, as the stain be- comes fixed. Fliigge advises placing such objects (which should be contained in bags) twenty-four hours in a disinfectant solution (sublimate and salt), and then wash them off with a stream of water before sending them to be washed. Steam cannot be used, more- over, for the disinfection of objects made of leather or rubber, hair-brushes, combs, etc. These should be disinfected by washing or soaking in carbolic solution, and afterwards be well washed in soap and water. 1 Without doubt pathogenic organisms are often killed by shorter exposures than those here given, but it has been deemed advisable to err on the safe side. 14 HYGIENIC MEASURES Disinfection by botling. The articles to be cleansed‘ should be boiled or disinfected be- fore being sent to the laundry. Boiling for fifteen to thirty minutes will certainly kill all infectious agents. If the articles are dirty, or soiled by fatty or slimy matter, sputa, etc.; two per cent. of sal soda (commercial sodic carbo- nate) should be added to the water in which they are boiled. CHEMICAL DISINFECTION. Certain matters to be remembered in connec- tion therewith. It must be remembered thata definite quantity of disinfectant is needed, as it becomes exhaustedin action. In other words, the disinfectant must act in a certain concen- tration upon the infectious material, and must penetrate the latter. Depending upon each case, we must allow the disinfectant to act a 1 The ordinary treatment to which soiled linen and clothes are subjected in the laundry (one half hour’s boiling) would be quite sufficient for their disinfection were it not for the fact that the process of boiling is preceded by the processes of sorting, soaking, and rinsing in cold water (Fliigge). IN RELATION TO INFECTIOUS DISEASES, 15 longer or shorter time. The higher the tem- perature, the more markedly is the power of a disinfectant increased. The germicidal power of a disinfectant varies with each organism, depending in certain cases upon whether it ts present in the spore (resistant) or vegetative (less resistant) stage, and the activity of a dis- infectant varies also with the conditions under which the disease agent is encountered. In this way, dryness of the object to be disin- fected (for example, in the case of tuberculous sputa) will not allow the disinfectant to pene- trate, or steam to act as promptly. Again, much organic matter will neutralize the action of many disinfectants. | What ts destrable in disinfectants in prac- tice. A disinfectant, to be applicable in prac- tice, must not only stand the severe test of the laboratory, made with a view to its effective- ness under conditions similar to those nor- mally found, but also it must be inexpensive and not dangerous to handle. Further, it 16 HYGIENIC MEASURES should neither become easily altered in its chemical composition, have a bad, strong or lingering odor, nor injure articles to which it is applied. It is not essential that the disinfectant shall fulfil the severe test made on highly resistant bacterial spores if we can assure ourselves of the fact that the infec- tious agent is killed by a less powerful germi- cide. This matter can only be determined by exact experiments. With a view to their application in practice, only those disinfectants which answer the requirements above stated will be found in these tables. Carbolic actd has the advantage over cor- rosive sublimate in that it is not so readily decomposed, does not attack instruments, and has a characteristic, not disagreeable odor, which makes it safer for general use. It is used in the concentrations of three and five per cent. Crude carbolic acid, to whitch ts added an IN RELATION TO\INFECTIOUS DISEASES. 17 egual volume of concentrated sulphuric acid (Laplace, Fraenkel), the undissolved parts of oily consistency being removed by filtration, is most effective, more so than pure carbolic acid for the disinfection of excreta, etc. (N.B.—To be kept artificially cool when being mixed. ) Corrosive sublimate (solutions 1 to 500, I to 1,000, I to 2,000) is precipitated by albu- minous substances, and counteracted in pro- portion to the amount of the latter with which it comes in contact. The precipitated albu- minate of mercury is re-dissolved in an excess of albuminous fluid and acts as a germicide when not prevented from penetrating, which it is, however, in practice; for example, by the surface coagulation which takes place on masses of organic matter such as occur in feces and sputum. Sodium and potassium chloride added in the proportion of five to one to the sublimate in solution prevents the 2 18 HYGIENIC MEASURES coagulation above mentioned, as also the action of light from producing alterations in the sublimate. As an application to wounded surfaces, though very frequently employed, it cannot but be looked upon as practically useless and directly injurious: useless, as the concentration in which it ought to act is lessened by contact with albuminous substances; injurious, as it counteracts the natural germicidal power of the blood, and creates a greater tendency to wound-infection through the formation of a layer of necrotic cells wherever it comes in contact with living tissue, thus lessening the resistance of the part. (Welch.) Permanganate of potash combined with oxalic acid. Solutions of permanganate of potash and oxalic acid used warm, as described below in connection with surgical disinfection, have given the best results in hand disinfection (p. 97). IN RELATION TO INFECTIOUS DISEASES. 10 —— Milk of lime, applied as whitewash to walls. The value of this old method of purifying the walls of apartments after infectious diseases has been demonstrated by Jaeger’s experi- ments, where those organisms were chosen as tests which are most likely to be encountered in the disinfection of stables (including J. anthracis, the glanders bacillus and the Staphy- lococcus pyogenes aureus), the bacillus tuberculo- sis being the only one not affected inside of twenty-four hours byacoat of whitewash applied over the surface on which it had-been placed. Applied in the disinfection of excreta. In milk of lime we possess the most valuable agent for the disinfection of typhoid and cholera stools. This agent is prepared as follows: to unslacked lime, placed in a stone jar or wooden trough, as much water as it will absorb is carefully added. The slacked lime is stirred up with four parts of water to form the milk of lime, and this is mixed intimately with 20 HYGIENIC MEASURES ¥ the discharges until the mixture gives a strong alkaline reaction (tested by litmus paper). Owing to the varying age and frequent im- purity of lime, it is better to trust to the litmus test (Pfuhl) than to add a certain proportion of milk of lime to the discharges. It does not do to add unslacked lime to discharges, as the pieces of lime are only slowly affected, and in consequence the action of the lime is tardy and weak. We cannot afford the delay, and it should only be used when an opportunity for slacking lime is not immediately at hand. Chloride of lime to be effective must con- tain twenty-five per cent. of available chlorine. Its {cost 1s “Small isisxc oltineess to. tie gallon of water representing the standard solution recommended by Sternberg. Sulphur. Twenty grammes are to be burnt to the cubic metre of room space.’ The sulphur is moistened with alcohol before 1 Three pounds to one thousand cubic feet recommended by the Committee on Disinfectants, A. P. H. A., 1888. VV MeL ALION LO'NFECTIOUS ! DISEASES. ~ 21 ignition, and all the apertures leading out of the room closed. By the burning of sulphur, sulphurous acid is evolved (H,SO,), which attacks organic matter on account of its affinity for oxygen, combined with which it forms sulphuric acid (H,SO,), and to the latter is really due the greater part of the destructive effect. It has been experiment- ally shown (Wolff hiigel and Koch) that only the surface of exposed articles is affected, and that it is practically impossible to attain a proper degree of concentration. The burn- ing of sulphur in the presence of moisture is effectual, but fabrics are destroyed thereby, and metal surfaces attacked. Though sulphur, as generally employed, has not stood the test in relation to pathogenic bacteria, there is some evidence that it may affect other disease agents of a more susceptible nature. On account of the heat evolved by the burning sulphur, the vessel containing the latter should be placed in a basin or vessel containing water, 22 HYGIENIC MEASURES The fact that a disinfectant must act ina certain concentration and penetrate to be effective demonstrates the utter absurdity of ozone-lamps, or the dropping a little carbolic acid solution into privies, etc., as also the use of this agent when placed in dishes about the room, or when used to moisten suspended cloths,,or as a spray intended to purify the atmosphere. Regarded in this light, the burning of sulphur, as generally done, must frequently be useless. THE MECHANICAL REMOVAL OF THE DUST OR INFECTIOUS AGENT FROM WALLS, FURNI- TURE, ETC., BY “MEANS, OF °GLUTINOUS BROWN BREAD, BRUSHES, SPONGES, SCRAP- ERS, MOIST CLOTHS, ETC., IN CONJUNCTION WITH DISINFECTION BY MEANS OF HEAT OR CHEMICAL AGENTS. The dust which has settled on various objects in the sick-room is to be removed UNO EL LON LT OUNEFECTIOUS DISEASES. 23 daily by means of a cloth moistened with Branionide 1 (1) \to .1,000)",)- Dusting as). it is usually done in private houses simply scatters the dust from one place that it may settle in another. Sponges can also be used for the removal of dust if they are frequently wrung out in a disinfecting solution; it has been experimentally demonstrated. that sponges are most efficient for this purpose. The use of scrubbers, etc., see p. 47. Glutinous brown bread for the removal of the pathogenic organisms from the walls and surfaces of polished furniture, etc., was recom- mended by von Esmarch, in 1887. Experi- mentally it gave the best results—that is, it removed the organisms very well from various surfaces over which it was rubbed, the micro- organisms being enclosed in or sticking to the little pellets of bread that are formed in the process of rubbing. Bread has the advantage of not being dangerous to the persons 24 HYGIENIC MEASURES employed, etc., or injurious to papered or painted walls... The) directions -arenthat the walls be rubbed for at least the height of a man, and the crumbs which fall to the floor burnt. The success of this method depends on the conscientiousness of those engaged in the disinfection, and it has also other objec- tions. The bread is not inexpensive; it must not be too dry nor too moist; small particles adhere to the wall, and may subsequently fall to the floor, be trodden on, and be converted into dust, and the disease agent thus liberated again. Bread is certainly not applicable to walls where crevices and cracks occur, or to others than such as have a smooth surface. See further p. 47. MEASURES IN WHICH FALSE CONFIDENCE IS FREQUENTLY PLACED. Ventilation. It has for a long time been considered probable that the ventilation of ENE LLAILON (10) TNFECTIOUS: DISEASES. 25 the sick-room diluted any infectious agent floating in the air, but nothing short of a good draught will accomplish this, according to the experiments of Stern, which, moreover, show that strong currents of air would have scarcely any effect in reducing the number of organisms once they have settled on the floor or objects in the room. Sunning, beating, and atring of infected articles. Sunlight has been shown, experi- mentally, to kill the resistant spores of the an- thrax bacillus, as also the bacillus tuberculosis, in a few hours. However, this agent would not do in practice, as it only acts on the im- mediate surface of infected objects. Beating and airing are not to be relied on for the removal of the infectious agent, as the latter adheres too closely to various fabrics, especially flannel, etc., tobe removed by any mechanical process (Stern); and even though a vacant lot may be chosen for beating and brushing of 26 HYGIENIC MEASURES. the”-infected: articles, ‘themintection may pe spread thereby, and those engaged in the beat- ing are greatly exposed. See further p. 36. Commercial disinfectants are, as a rule, un- reliable, having usually only the qualities of antiseptics or deodorants, besides being, as a rule, expensive. PRACTICAL DIRECTIONS PRELIMINARY REMARKS, ji infectious disease is one which is caused by the invasion and multiplication within the body of pathogenic organisms derived from various sources. In the following pages we shall consider only such infectious diseases as are due to patho- genic mzcro-organisms, and particularly those to which a system of disinfection should be applied. We shall describe as contagious such infectious diseases as are directly or indirectly communicable from one person to another. The extent to which disinfection should be carrted out varies in different infectious dis- eases, and it seems advisable from this point of view to classify those where disinfection is 27 28 HYGIENIC MEASURES. usually practised, even though it be provision- ally in accordance with our knowledge of how disease spreads, and the peculiarities of the specific infectious agent. The following table represents such a provisional classification, the diseases being grouped in three columns, ac- cording to the degree of infectiousness which characterizes them. Several diseases, about which insufficient knowledge exists, have been omitted from the table. At first sight tuberculosis may appear mis- placed, but by referring to page 87, where we speak of this disease and how it is spread, we see the necessity of careful and complete disinfection, especially in the houses of the poorer classes, where the habit of careless expectoration on carpets and floors is par- ticularly prevalent. The slow development of the disease, and the fact that a large number of persons are apparently immune, disguises greatly the degree of infectiousness which ‘sjavd pajooj “UL 9} JO suoTjIDeS ay} ‘peoo, usayM pue “UBUut ul A|[[BUOTSvIDO pus ‘doaoys puv 9]}}¥9]"ssooov ures ur sv ‘[e1gued st uolz/Aoy, YOryA *A[{OOAP-O9JUL 919M PooTq ure}}oy SuryzAuvfe ("C6 “d ‘snorosuep|-Ipur a0 ApoeIIpf-uod oF dv 10 Suture) puv suor froyjany 9a) suoljas9as | I9Y}19 ‘suUOT}OIONS F-UOd (7999 ‘auTAN ‘s99azJ)/-oofap Worf ‘snorsd *‘yuotyed oy} Jnoqe punon, wor r9oSuvq FsuryyAuv woyy zassur -uvp ywo,|sutyyA19A9 Wor I9Suecy ‘(91qv4 SITY} Surpso -a1d uorj90s 99s) sIsO[NI19qN J, VLU -woridag *‘s1opuryy “eiqoyd “Bulapao *Ar9judsA(] “IDADJ ‘eioyqydicy -OIpAT] queusieyy | ‘Baoyrtou0T *% ‘proyda J, “IDAOJ erodi9ng “eyeuUdyyy *snUuBya J, ‘stqptyddg *xelyjuy | ‘vroptoys) MOTTIA | *svpodtsAayy |-uexa aynoy *(uoTyepNooUTy Aq opqronpoadoas SL OSBdSIP SY} pue ‘asodstposd spunom ysnoyy *permnber |porambor TJS ssoq}qnop |-redde —uorso] uolso’y = |snotacid ON ‘juose snot *(souBiq *Aressaoau Sureq -OOJUL OY} Jol-wewW s nod N WhuoTseiqe 10 ynd ¥B ‘s}OaS *yyuLIp quoudopaaop {yy ‘z ut ‘soovzansf-ut ysno1y}.10 ‘sassvorvol pus pooj dy} oJ posmnb/popeaqe YIM Jowyfposvestp woay ATJo1p| oy. Ut -91 onsst}? snoj-uod ‘t ut) porzmbfpoarop AyTensn st ynq| ssop}qnop *9]V]S PIGVA -OUBINIGNS 9} /-94 SUOTJOINDS YSorFHSOLIYstp poyoyur ATpeq| powues , *sABM JO AJOLIVA B UL STENPLATput BuULSTeUttUB| Suryerjoued Ajoaryereduioo = fut re oy} ut yeoy Avut yuose snorfo} ssas0v ured souonbasuod ut pue jo sg jSpunoO A (YUM yoRyUOD fhuds5e¥ snorosjut oyy, j-ooyuroyy, Pare oy} ur jeoy uvo juss snoryoyur oy y, ‘aauoad ag “AHASAd As “HHAOAd LSI FHL NI SNOILOGANT » “SSHNSQOTLLOWANI UIAHL AO WANOAG AHL OL ONIGMOOOV SUSVASIA NIVLNAD AO NOLLVOIMAISSVIO ~ 29 30 HYGIENIC MEASURES. tuberculosis possesses, and, though susceptible individuals may be in the minority (we cannot say in advance who are and who are not sus- ceptible), it is our duty to protect them by every Means in our power. As far as practicable we should deal with the wnfecttous agents at their point of orzgin and under all circumstances act promptly. By pro- ceeding in this way we have the best chances of limiting the disease. In the acute exan- themata we prevent the diffusion of the infec- tious agent by means of applications of fatty substances to the skin, and by combining a disinfectant with the application we perhaps lessen its virulence. Gargles and washes of dilute disinfectants have the same effect. We should disinfect promptly, as we know in cer- tain cases that the infectious agent is capable of multiplying outside the body, and in conse- quence the longer we wait the greater may be the amount of infectious agent we have to IN RELATION, TO INFECTIOUS DISEASES, 31 deal with. If we wait too long insects may have an opportunity of gaining access to ves- sels containing excreta, etc., and act as car- riers, or through desiccation an opportunity is given the infectious agent to becomescattered about as dust. We know that moist surfaces will not permit the diffusion of infectious agents. Lastly, it is desirable always to use a chemical disinfectant in a sufficiently concen- trated form, or heat for a long enough period, to exclude all possibility of the disinfection not being complete. PRECAUTIONS TOP SE OBSERVED" BY PHYSICIANS AND THOSE, IN: ATTENDANCE ON 54 HYGIENIC MEASURES Under three headings will be found the following information : 1. How the infection spreads. How long the infectious material may remain virulent. Its resistance to heat, chemical disinfection, etc. The conditions which favor the develop- ment and maintenance of virulence of the infectious agent. 2. Measures which must be taken to prevent the spread of the disease, such as isolation, etc. 3. The disinfection which should be pursued. The information is sadly incomplete insome cases, owing to our ignorance of the nature of the specific agent which causes the disease, or its mode of attacking the body. 1.—Actinomycosis (“ Big-jaw”’ of Cattle). CAUSE: ACTINOMYCES OR “ RAY-FUNGUS.” Mode of Infection, ete. As the pus in this affection, and cultures of actinomy- ces derived therefrom, have been shown to be infectious by inoculations in animals, the pus should be treated as IN RELATION £0 INFECTIOUS DISEASES. 55 infectious matter. The specific agent probably enters the system with the food, from the fact that the site of infection is usually, both in man and animals, the mouth or passages leading therefrom. Preventive Measures and Disinfection. Pus or anything soiled therewith should be disinfected (page 38). 2.—Anthrax (Malignant Pustule). CAUSE : BACILLUS ANTHRACIS, F. P. Mode of Infection, ete. The disease, which is epidemic amongst cattle and sheep, is most frequently communicated to men engaged in scraping horns, skinning carcasses, or wool-sorting (wool-sorter’s disease), the hands, less frequently the face and neck, in short the exposed parts of the body, usually being the seat of inoculations through abrasions and cuts. The bacilli are present in the blood and cedematous fluid of man and animals when the disease is general. When the disease is local (“malignant pus- tule ’’) as is usually the case in man, the bacilli are present in the secretion from the pustules. The feces, and bloody urine of sheep and cattle may contaminate the surface 56 HYGIENIC MEASURES soil and vegetation of pastures. Insects feeding on excreta or cadavers of anthracic animals will spread the disease by bites inflicted on other animals or possibly man. All bandages which have been in con- tact with the pustules are dangerous. The disease may also occur through eating the smoked flesh of anthracic animals, where, owing to the bacilli having taken on the spore form, they may retain their virulence indefinitely. This form of the disease (internal anthrax) may also be brought about, as it has been experimentally, by the in- halation of spores. The fresh secretions, blood, etc., only contain the bacilli in the vegetative stage, when they are readily killed by carbolic acid or boiling water, though they withstand drying for several days. The bacilli in spilled blood, etc., form very resistant spores, which remain virulent for years in a dry state. They resist five per cent. carbolic acid as long as thirty-seven days,.and corrosive sublimate, 1 to 1,000, for twenty-four hours, Moist heat at 100° C, (212° F.) applied for four minutes kills the spores. Preventive Measures. Infectious skins should be destroyed and anthracic animals buried in deep pits, their bodies being covered with chloride of lime. Protective inoculations (Pasteur) WVERELALLON TO INFECTIOUS DISEASES. 57 have been applied with a view of limiting the disease in animals. Bandages, infected clothing, or dressings soiled by the discharges of malignant pustules should be very carefully handled and disinfected. Disinfection. ‘Soiled dressings, bandages, etc., should be burnt; other articles, when practicable, should be boiled or sterilized by steam for at least fifteen minutes. 3.—Cholera. CAUSE : SPIRILLUM CHOLER ASIATICA, F. P. Mode of Infection, etc. The infection occurs through the fresh dejections, very exceptionally through the vomit, of cholera patients, conveyed more or less directly in water or food to the digestive tract of another individual. The water supply may be contaminated by discharges, through the wash- ing of soiled linen, or surface drainage. Insects may contaminate food. The food may be also contaminated through the soiled hands of attendants or sick persons. The spirilla will multiply readily if they gain access to milk, bouillon, meat, etc. If dried the spirilla soon lose their virulence, so that infection probably never occurs through the air becom- 58 HYGIENIC MEASURES. ing a vehicle forthe disease agent. Culture experiments show the spirilla to die in two or three hours if dried in a thin layer, whilst in thicker layers they may live for twenty-four hours. At a low temperature combined with incomplete drying the spirilla may remain alive for weeks or months. Freezing has no effect on the organ- isms. In water at 60° C, they are killed off in ten minutes. They are very sensitive to disinfectants, and die in putrefying fluids in about two weeks. One half per cent. carbolic acid kills them in a few minutes. Acquired immunity is of short duration—that is, it can only be relied on to protect individuals (with very few ex- ceptions) from a second attack during the one epidemic. Preventive Measures. What has been said for typhoid fever (page go) applies to cholera also. The necessity of keeping the sick- room well ventilated, so as to kill the spirilla by the simple process of drying, 1s apparent. Soiled linen should not be allowed to stay in cool, dark, and damp places, or be transported in a damp state, and should be disinfected and hung up in the sun to dry and air. The fact that washer-women are particularly prone to con- tract the disease is a direct indication that the handling of soiled linen, etc., is dangerous. IN RELATION TO INFECTIOUS DISEASES. 59 During epidemics the preventive measures referred to in the case of typhoid apply here also. Extra care should be taken about the cooking of the various foods. Disinfection. Proceed as in typhoid fever (page gz), 4.—Diphtheria. CAUSE ; ‘BACILLUS DIPHTHERIA. Or DP: Mode of Infection, ete. The infection is spread through the bacilli in the sputa, false membrane, and secretions of the various diseased mucous membranes. The bacilli are probably present at times in the stools. Physicians and nurses are partic- ularly exposed to the danger of the infection when swab- bing the throats of patients, through the coughing of mucus and flakes of membrane into their faces. Lesions of the mucous membranes where no susceptibility exists predispose to infection. The diphtheria of pigeons, calves, pigs (not determined in the case of the cat) is not to be feared as a source of human diphtheria, the diseases being due to different specific agents. As the bacilli resist drying they may be scattered about in the form of dust, In thin layers the bacilli 60 HYGIENIC MEASURES —_———« withstand drying for fourteen days, whilst in pieces of membrane, clothing, particularly when in dark, damp, and cool places, they may retain their virulence for four to seven months. A temperature of-58° ©. (736° #2 kills them in ten minutes. They apparently die in a few days in putrefying substances. The bacilli multiply at 18° C. (64° F.), and milk being an excellent medium for their growth, the milk of: dairies in a vicinity where the disease prevails may be a carrier of the infection and promote the development of the infectious organism. Preventive Measures. Complete isolation of the patient is necessary as long as the slightest trace of the membrane is present, and for some time after it disappears.. Children should be kept from attending school at. least four weeks after the disease has disappeared, Where the disease prevails, Loeffler maintains the importance of keeping the mouths, noses, and throats of healthy children clean, using for this purpose an aromatic or other wash, every three or four hours ; sublimate, 1 to 10,000 or 15,000; cyanide of mercury 1 to 10,000,; chloroform water, etc. For the patients he recommends a gargle every two to three hours of the nature recommended above, together with a stronger one used at longer intervals; namely, subli- IN RELATION TO INFECTIOUS DISEASES. O61 mate r to 1,000; three per cent. carbolic acid in thirty per cent. alcohol ; or equal parts turpentine and alcohol containing two percent. carbolic acid. These washes are intended to prevent the settlement and development of the bacilli on adjacent mucous membranes, and limit the growth of the membrane. Virulent bacilli could not be found after a few days when this treatment was fol- lowed, whereas they are to be found usually after three weeks when the ordinary treatment is pursued. Special precautions should.be taken when using poisonous solu- tions in the treatment of children. Disinfeetzon. See “ Practical Directions,” page 27. s.—Dysentery (Ameebic Dysentery). CAUSE : AMCEBA DYSENTERI. Mode of Infection, ete. The dejections of the patients contain the amcebe in such enormous quantities, and the latter bears such an unquestionable relation to the disease, that the stools should be treated as infectious material and the possible contamination of the water supply guarded against. 62 HVGIENIC MEASURES Preventive Measures. The precautions noted in the case of typhoid fever and cholera as regards the treatment and handling of stools, soiled linen, and the person of the patient, apply here also. Disinfection. Disinfection to be pursued as in typhoid fever (page Q2). 6.—Erysipelas. CAUSES STREP LOCOECECUS ERYSIPELATOS. Mode of Infection, ete. Occurs usually as epidemics in hospitals. It is rarely found as an epidemic otherwise. The disease is easily communicated from one person to another. The strep- tococcus erysipelatos, resisting dryness, can float in the air as dust and reach wounded or abraded surfaces in a variety of ways. It is killed by moist heat at 54° C. (129° F.) in ten minutes (Sternberg). Preventive Measures. Prompt isolation of cases of erysipelas in hospitals is necessary, and it the disease continues to appear in the wards empty the latter, thoroughly disinfect them and IN RELATION TO INFECTIOUS DISEASES. 63 all the furniture they contain. The clothing and bed- ding of the patients should be sterilized before their re- turn to the wards. Physicians and nurses should disin- fect themselves, their clothing, etc. Carelessness or some oversight will be found invariably connected with the spread of this disease. Disinfection. All dressings, bandages, etc., should be burnt, and other objects disinfected by boiling or chemical disin- fectants (see ‘“ Practical Directions ”’). 7.—Glanders or Farcy. CAUSE: BACILLUS MALLEI. 0. P. Mode of Infection, etc. The disease can be transmitted to man directly from diseased domestic animals [the horse, donkey (sheep, young dogs, and cats are also susceptible experimen- tally)] through the fresh secretions or excretions of the mucous membranes and skin, which may adhere to various articles about and produce the disease by in- oculation through a cut or an abraded surface of the skin or on the mucous membrane. The bacilli lose their virulence in a few days when dried, though they 64 HYGIENIC MEASURES have been found to resist putrefaction for twenty-four days. They are killed after ten minutes at 55° C. (131° F.). Three to five per cent. carbolic acid or scalding water readily renders them harmless. Preventive M. CASUTES.' Isolation of the patient is imperative. Horses suffer- ing from glanders should be killed and buried in a grave eight feet deep. To facilitate this, cutting off the legs of the animals is advisable. Chloride of lime should be thrown over the body before heaping on the earth. Bridles, bits, pails, and troughs should be disinfected. Disinfection. Where glanders has existed in a stable remove every- thing that is portable, burning as much as is practicable. Loose pieces of boarding, etc., especially the woodwork about the manger, should be destroyed in this way. Wash and clean out the stall thoroughly and then scrape it. Rinse it out with cold water, being sure at the same time to scrape out all cracks in the floor and woodwork with a sharp instrument, following this with the applica- 1 For particulars in relation to the treatment of diseased horses and stables, the writer is indebted to A. W. Clement, V. S., of Baltimore. IN RELATION TO: INFECTIOUS DISEASES, . 65 tion of scalding water wherever practicable, and fifty per cent. permanganate of potash solution. Finally, apply whitewash and scatter fresh chloride of lime on the floor. $.—Gonorrhea. CAUSE: MICROCOCCUS GONORRHE, O. P. Mode of Infection, etc. Through fresh secretions coming in contact with mucous membranes of the urethra or conjunctiva. The gonococcus is killed by an exposure to moist heat at 60° C. (140° F.) for ten minutes (Sternberg). Preventive Measures. Persons suffering from this disease should be careful that no other person touch clothes, towels, or handker- chiefs soiled by gonorrheeal secretions. They should also guard themselves against gonorrhceal ophthalmia by dis- infecting their hands, etc., when the latter have come in contact with the urethral discharge. Disinfection. Rags and scraps. of linen soiled by secretions should be burnt ; towels, etc., boiled or soaked in corrosive sub- limate solution (1: 1,000) to which five parts sodium chloride have been added. 5 66 HYGIENIC MEASURES 9.—Hydrophobia—Rabies. CAUSE : UNKNOWN. Mode of Infection. Through the bites of rabid animals and their fresh saliva (experimentally produced by inoculation with their brain and spinal cord). The virus loses its pathogenic qualities after an exposure to moist heat at 60° C. (140° ° F.) for ten minutes. (Sternberg.) Preventive Measures. Very effectual laws exist regarding this disease in Ger- many. No dogs are allowed on the streets during the prevalence of rabies without being muzzled and led. Unmuzzled dogs are promptly killed. 10.—Influenza. CAUSE : BACILLUS OF INFLUENZA, Mode of Infection, ete. Infection doubtless occurs from individual to in- dividual, and more or less indirectly. On account of the large number of organisms in the sputa, Leeffler suggests that these be treated as infectious material. IN RELATION TO INFECTIOUS DISEASES. 67 Preventive Measures. During epidemics of influenza those persons who are especially liable to succumb (old persons or those suffer- ing from heart disease, etc.) should absent themselves from public assemblages (where they expose themselves to a confined atmosphere contaminated by the presence of the infectious agent) and more or less completely isolate themselves. Disinfection. Sputa should be disinfected. 1z1.—Leprosy. CAUSE ;: BACILLUS LEPRA, O. P. Mode of Infection, etc. That leprosy is contagious is doubted by many. We consider it a reasonable supposition that the con- tagiousness of the disease is obscured by the fact that the majority of. individuals are resistant and that the disease develops very slowly. Where the disease has been ascribed to contagion usually the most intimate sexual relations with diseased individuals have existed. 68 HYGIENIC MEASURES Preventive Measures. Isolation of patients in leper hospitals in various parts of the world has reduced the amount of the disease. Inter-marriage of leprous individuals should not be permitted. Disinfection. Dressings should be burnt. 12.—Malaria. CAUSE : PLASMODIUM MALARIA, Mode of Lnfection, etc. This disease is not contagious. We do not know how invasion occurs. It is acquired most readily in low, marshy or badly drained regions, where abundant vegetable growth occurs, such conditions being found especially in tropical and sub-tropical regions. The dis- ease in temperate climates prevails most in autumn, especially after hot dry summers, and in the tropics dur- ing the rainy season. Facts are on record which point to the wind as a carrier of the poison. Preventive Measures. From the fact that infection seems to occur most frequently at night, persons should avoid exposure at that IN RELATION TO INFECTIOUS DISEASES. 69 time. It has been repeatedly shown that persons occupy- ing the upper stories of a house do not acquire the disease as do those living nearer the ground. ‘Trees planted in malarial districts have been considered to have a preven- tive influence. Where the disease prevails extensively Osler recommends the boiling of drinking water. In highly malarious districts ten grains of quinine should be taken daily ; smaller doses, three to five grains, will other- wise suffice, and Jones recommends the use of this remedy until ten days after exposure. - The severity of attacks is moderated when not prevented by the use of this remedy. 13.—Malignant C:dema. CAUSE : BACILLUS (DEMATIS MALIGNI., F. P. Mode of Infection, etc. The specific organism is frequently found in the surface soil, especially at times in garden-earth and in putrefying matter. The dust of apartments, hay-lofts, and that derived from rags, also the intestinal con- tents of animals, have been found to contain them. They are found at times together with the tetanus bacilli, pro- ducing infection under the same conditions. Pieces of muscle of an animal dead of the disease have been found to contain virulent bacilli after one year. 70 HYGIENIC MEASURES —— Preventive Measures and Disinfection. Proceed as in tetanus (p. 83). 14.—Measles. CAUSE : UNKNOWN. Mode of Infection. The infection is spread through the products of ‘the diseased skin and mucous membrane, especially the nasal secretions. ‘The infectious agent may remain virulent for six weeks, One attack does not always confer immunity. Preventive Measures and Disinfection. This disease is infectious in the first degree (see table, p- 29), and in consequence the precautions laid down under “ Practical Directions” apply here in a general way. 15.—Cerebro-Spinal Meningitis. CAUSE: THE DIPLOCOCCUS PNEUMONIZ HAS BEEN ISOLATED FROM THE CEREBRO-SPINAL FLUID. Mode of Infectzon, ete. Not directly contagious, probably not transmitted by clothing or excreta; occurs sporadically and as an epidemic (Osler). VO RELATION TO'\INFECTIOUS DISEASES. 71 Preventive Measures. Good ventilation and isolation are indicated, from the fact that crowding of individuals in barracks or tenement- houses offers favorable conditions for the development of epidemics of the disease. 16.—Mumps (Epidemic Parotitis). CAUSE : UNKNOWN. Mode of Infection, ete. A contagious, often epidemic, disease most frequently attacking children and adolescents. One attack immuni- fies. We lack definite knowledge as to the mode of . infection. Preventive Measures. Isolation. 17.—Pertussis (Whooping-Cough). CAUSE: UNKNOWN. Mode of Infection, ete. A contagious disease, the gravity of which is fre- quently not sufficiently appreciated by parents, A great deal of neglect exists in this respect, 72 HYGIENIC MEASURES Preventive Measures. Children suffering from this disease should be promptly isolated and prevented from attending schools. 18.—Pneumonia. CAUSE : DIPLOCOCCUS PNEUMONIA, Mode of Infection, ete. The contagiousness of this disease is unproven, though probable at times (epidemics in barracks, etc.). For the reason that only a limited number of individuals are susceptible, that the organisms vary greatly in virulence, and that a certain number of individuals (15 to 30 per cent.) have the specific organisms of pneumonia normally present in the mouth, in such cases the disease might well arise at any time under favorable conditions and it would not be preventable, but from the fact that the sputa of pheumonic patients contain large quantities of the pneumococcus they should be treated as infectious matter. The pneumococcus withstands drying and re- mains infectious for two or three months in diffuse light at room-temperature, and consequently could very well be inhaled as dust and reproduce the disease under proper conditions, | PV EAELATION TOUNFECTIOUS DISEASES.473 Preventive Measures. In the case of house epidemics, isolation and free ventilation are indicated, as also a thorough cleansing of apartments. , Disinfection. Disinfect sputa by boiling or burning. 19.—Puerperal Fever. CAUSE: VARIOUS PYOGENIC BACTERIA (STAPHYLOCOCCI AND STREPTOCOCCI). Mode of Infection, ete. Pathogenic micro-organisms are invariably present in this disease. Though auto-infection may occur, in the vast majority of cases the disease is spread through the agency of physicians, midwives, or nurses, especially is this so in epidemics, where the hands, instruments, etc., of those in attendance are not properly disinfected. The patho- genic organisms find a very good opportunity for their multiplication in the presence of the broken-down tissue and the wounds which occur in the genital tract during parturition. As the organisms which produce this dis- ease are capable of resisting desiccation they can be suspended in the form of dust, thus contaminating the 74 HYGIENIC MEASURES atmosphere of the room or ward. (Regarding the degree of resistance exhibited by the infectious agent see figures in connection with pyogenic bacteria, page 79.) Preventive Measures. The first duty of the physician should be to avoid attending cases of labor when fresh from the presence of erysipelas, puerperal fever, scarlatina, or other infectious diseases or septic material. Frequent ex- amination during labor should be avoided. In hos- pitals women before admission to the obstetrical wards should, if possible, be well bathed and clothed in fresh linen. The external genitalia and surrounding parts should be well washed with soap and water, followed by sublimate 1 to 2,000, with which the vagina should be carefully irrigated both before and after labor. Com- presses moistened with dilute disinfectants are also recommended as applications to the external genitalia during the progress of labor. Patients should be isolated promptly on the first ap- pearance of any suspicious symptoms, and a special nurse put in charge of the case. Physicians should take the precautions regarding the disinfection of instruments, hands, etc., which are noted on page 96. These ob- servations apply also to midwives and nurses, When IN RELATION TO INFECTIOUS DISEASES. 75 the disease prevails in hospital wards take the precautions observed in relation to erysipelas under like conditions, Disinfection. As in erysipelas—see above. 20.—Relapsing Fever (Febris Recurrens). CAUSE : SPIRILLUM OBERMEIERI. Mode of Infection, etc. A moderately contagious, at times epidemic, disease, portable (according to Murchison) by fomites. The disease has been reproduced by inoculations in man and monkeys made with the blood of individuals suffering from the disease. The life history of the specific agent is unknown. Neither age nor season have any particular influence. One attack does not protect either in the experimentally or naturally acquired disease, Over- crowding, such as occurs in tenement-houses, and lack of food (hence also called “ famine fever”’ or “ hunger pest,” etc.) promoce the spread of the disease. Preventive Measures. Good ventilation and food are directly indicated, as the absence of these promotes the spread of the disease. 76 HYGIENIC MEASURES The disease is not likely to spread from a single case placed in a well-ventilated apartment. Persons suffering from this disease in tenement-houses should be removed to hospitals, and the population of overcrowded tenements thinned (Osler, Flint, etc.). 21.—Rubella; Rotheln. CAUSE: UNKNOWN. Mode of Infection, ete. Spreads with great rapidity, and often extensive epi- demics occur ; readily communicated from one individual to another. (The occurrence of either measles or scar- latina in childhood does not afford protection against it.) (Osler.) Preventive Measures and Disinfection. See measles, page 70. 22.—Scarlatina. CAUSE: UNKNOWN. Mode of Infection, etc. Scarlatina is spread after the same manner as small- pox. The infectious agent may remain virulent for five IN RELATION TO INFECTIOUS DISEASES. 77 months, and possibly longer at times. Unless an attack has been mild, immunity is usually afforded for a number of years. The contagiousness probably begins with des- quamation. According to Henry, scarlatinal virus loses its virulence after being exposed to dry heat at 100° C, (212° F.) for one hour. Preventive Measures. The same precautions regarding isolation should be practised as in the case of smallpox. Desquamation lasts from ten to fifteen or twenty days, and may continue at times for weeks. Oiling the skin every day or second day, combined with soaking in hot baths during desqua- mation, and washing with carbolic soap, are recommended. The feet being very slow to desquamate, the process can be hastened by hot foot-baths with soda, combined with rubbing with pumice-stone. Socks and gloves smeared with ointment (carbolic or salicylic) should be used. Probably when desquamation has lasted four weeks and daily baths have been resorted to in the way above men- tioned, the person can be dismissed. Convalescent hos- pitals for the reception of scarlatinal patients are specially recommended. Disinfection. See smallpox, page 78. 78 HYGIENIC MEASURES 23.—Smallpox. CAUSE : UNKNOWN. Mode of Infection, ete. The infection is spread through the products of the diseased skin and mucous membrane (the sputa, nasal secretions, etc.). It is not known whether the contagion occurs prior to the desquamative stage. The disease agents are apparently given off in enormous quantities, and as they withstand drying they may tenaciously adhere to anything about the patient, thus infecting objects and persons around him. The light epidermal scales derived from the patient may float in the air as dust, and doubt- less are capable of producing the infection through inha- lation. With very few exceptions one attack immunifies for ife or for years. The infectious agent may remain virulent for two years, and in certain cases it has been shown to last even longer. This will vary according to the conditions under which the infectious agent is placed. Preventive Measures. Prompt isolation is imperative. Special hospitals, to which the patient should be promptly transferred, should be provided. No public conveyances should be used for the transportation of the sick to the hospital. IN RELATION TO INFECTIOUS DISEASES. ‘79 The patient should be kept scrupulously clean, the body linen, etc., being often changed. Disinfectant washes should be used for the discharges from the mouth, nose, and eyes. Lint moistened with dilute disinfectant solu- tions can be applied to the skin, and when crusts form, carbolized oil, glycerin, or vaseline should be used to keep the epidermal scales from being scattered as dust’ Isolation should be continued until the skin is perfectly normal (free from any trace of scabs). Drsinfection. The precautions and methods of disinfection and isolation laid down in broad lines under the head of ’ “Practical Directions ”’ apply here. -24.—Suppuration, Septicemia, and Pyxzmia. CAUSE: VARIOUS’ BACTERIA, THE MOST VIRULENT OF WHICH ARE THE PYOGENIC STREPTOCOCCI. THE FOLLOWING ORGANISMS MAY BE FOUND: STAPHYLO- COCCUS PYOGENES AUREUS, ALBUS, CITREUS, EPIDER- MIDIS ALBUS, STREPTOCOCCUS PYOGENES, MICRO- COCCUS TETRAGENUS, BACILLUS PYOCYANEUS, BACILLUS FTIDUS, ETC. Mode of L[nfection, etc. The infection may be spread through the fresh or dried secretions from infected wounds, which may adhere to all 80 HYGIENIC MEASURES kinds of objects about the patient—to instruments, hands of attendants, etc. Insects may act as carriers. Patho- genic bacteria are frequent on the body of healthy indi- viduals and in the skin (staphylococcus epidermidis albus). They vary greatly in virulence, and the susceptibility of the patient varies also. Fresh secretions containing strep- tococci are most virulent. Secretions of abscesses, furuncles, phlegmons, empyema, osteo-myelitis, pyzemia, and progressive gangrene should be treated as infectious material. The pathogenic cocci may remain alive in a dry or moist state for one year or longer. As they withstand drying, they may float in the air as dust and gain access to wounds in a variety of ways. According to Sternberg, staphylococcus pyogenes aureus, citreus, and albus, and the bacillus pyocyaneus are killed by an exposure to moist heat at a temperature of 62° C. (143° F.) for ten minutes. Preventive Measures. Modern surgical technique has demonstrated the value of antisepsis so fully that it seems superfluous to enter upon the subject here. The disinfection to be carried out in the operating-room will be found on page 96. All bandages and objects which have become contaminated should be disinfected promptly. Patients suffering from septiczemia or pyzemia should be isolated. IN RELATION TO INFECTIOUS DISEASES, 8t Disinfection. All wound dressings and bandages should be burnt, and other contaminated objects disinfected as noted in the text. 25.—Syphilis. CAUSE : UNKNOWN. Mode of Infection, ete. Through various secretions coming in contact with abraded mucous membranes or skin. It is not known how long the infectious agent may remain virulent, but it is generally stated that the secretions must be fresh. As a rule acquired by coitus. Fournier and Ricord consider that about 25 per cent. of all cases of syphilis occurring in females, lessso in males, are innocently or non-venere- ally acquired, and this in a variety of ways, as shown by reported cases (Bulkley). It does not seem out of place to mention some of these: (1) transmission in domestic life from articles used by syphilitic subjects, such as spoons, knives, forks, cups, glasses, tobacco-pipes, cigars ; wearing apparel, such as shirts, drawers, bathing-suits, and handkerchiefs ; from bedding and toilet articles, such as sponges, combs, tooth-brushes, syringes, pins, etc. ; (2) personal transmission, most frequently by kissing, also oc- 82 HYGIENIC MEASURES - casionally by biting and scratching ; (3) in infants, besides being directly transmissible to the nurse or the infant, milk- bottles, sugar-teats, spoons, cups, etc., have been known to convey the disease ; (4) transmission may also occur in attendance on the sick ; either the physician or midwife may acquire the disease in the practice of their professions by contact with specific sores on various parts of the body, or the reverse,—that is, they may convey the disease directly or indirectly by instruments (many cases recorded in relation to the use of the Eustachian sound), specula, etc. Vaccination, tattooing, and ritual circumcision, as well as the removal of foreign bodies from the eye with the tongue, have been the means of communicating the disease. To repeat, all the modes of transmission already mentioned have been known to occur in well authenticated cases, Preventive Measures. Strict medical supervision of prostitution materially reduces the amount of syphilis, as has been strikingly demonstrated in barrack-towns. Sentimental ideas should not blind but open the eyes of the public to the necessity of regulations which will protect a large number of inno- cent persons who fall victims to the disease through the agency of those that have transgressed. IN RELATION TO INFECTIOUS DISEASES. 83 ——— Regarding marriage in relation to this disease, the cc“ physician “should insist upon the necessity of two full years elapsing between the date of infection and the con- tracting of marriage. This, it should be borne in mind, is the earliest possible limit, and there should be at least a year of complete immunity from all manifestations of the disease ”’ (Osler). What has been said in the preceding column will plainly enough suggest other precautions, which consci- entious individuals will at any rate attempt to observe. Disinfection. Burning, boiling, or chemical disinfection of any objects or dressings which have come in contact with in- fectious secretions. 26.—Tetanus (Lock-Jaw). CAUSE: BACILLUS) TETANI, Fo P. Mode of Infection, ete. The spores of the tetanus bacillus are very generally distributed in the surface soil, and have been isolated also from the dust of streets and apartments, and from putrefying fluids and feces. Soils from certain localities are particularly virulent. The wound secretions 84 HYGIENIC MEASURES from a tetanic man or animal, and everything that has come in contact therewith, are dangerous if the virus is introduced subcutaneously. Wooden splinters or earth getting especially into deep lacerated wounds are most _frequently carriers of the infectious agent, which, more- over, has apparently to enter the body in a certain Gienin to produce the disease. The bacilli, both in culture and in dried secretions, as- sume the spore stage, in which they withstand drying for along time. In some cases they have been found virulent after six months, and even after more than two years, The spores withstand dry heat at 150° C. (302° F.) for ten minutes, but are all killed off inside of eight minutes by moist heat at 100° C, (212° F.). Preventive Measures. Guard against the handling of bandages, etc., soiled by wound secretions, Tetanus in new-born children is usually due to infection through the navel and should be guarded against by antiseptic dressings of the latter, etc. Anything that may have become contaminated by wound secretions of a tetanic subject, including bedding, etc., should be carefully handled and disinfected. The necessity of prompt washing of wounds where dirt has entered as well as the removal of splinters, etc., and the UN RELATION “TO INFECTIOUS DISEASES. 85 non-use of dirty rags, cobwebs, etc., on cuts should be brought home to the public. Disinfection. Dressings, etc., should be treated as in anthrax (p. 57). 27.—Trichiniasis. CAUSE: TRICHINA SPIRALIS. Mode of Infection, etc. Infection occurs in man through the ingestion of im- properly cooked pork containing encapsuled embryos. The capsules are dissolved in the alimentary canal and the trichinz liberated. In about three days after ingestion the embryo reaches maturity, and in about a week produces hundreds of fully developed embryos, which pass through the intestines and reach the muscles, become encapsulated therein, and their development ceases. Through the process of calcification, which lasts four to five months in man, and at times years in the hog, the opaque, oat-shaped cysts become visible to the eye. Trichinz have been known to develop after lying twenty-four years encapsuled in the system. Trichinz occur in swine, rats, mice, and cats, and the disease is easily reproduced experimentally in rabbits and guinea- 86 HYGIENIC MEASURES pigs. In Northern Germany, where raw ham and sausage are much eaten, the disease occurs most frequently. Epidemics arising from the use of infected meat supplied from a common source have been frequently observed. From the fact that calcification of the capsules occurs very slowly in the hog the presence of trichinz is overlooked. The flesh of hogs may contain an enormous number of embryos and the animals appear well nourished and healthy. Preventive Measures. Microscopical examination of samples of different muscles (abdominal muscles, diaphragm, intercostal mus- cles, muscles of the larynx and tongue) taken from each animal slaughtered should be required by law, as is the case in Germany. Thorough cooking of the meat contain- ing trichinee renders the same harmless. In large joints the centre may be insufficiently cooked and the disease be pro- duced by the trichine therein. It should be remembered that salting and smoking give no assurance of protection. According to Heller, the parasite is killed by an exposure t0.687; Caer es 2) If it has been discovered within twenty-four to thirty- six hours that the infected meat has been eaten purgatives of rhubarb and senna should be given, or an occasional VEOH AON LOL NIACLIOUS DISEASES, 87 dose of calomel. Diarrhoea in the first days of infection is a favorable symptom (Osler, etc.). 28.— Tuberculosis. CAUSE : BACILLUS TUBERCULOSIS. O. P. Mode of Lnfection, etc. The infection chiefly spread by the bacilli contained in the dried sputa of tuberculous individuals, which become pulverized and are inhaled. On account of the prevalence of the disease the bacilli are very generally distributed in the form of dust which can adhere to anything about the patient. Children playing about on carpets that have been contaminated with the sputa of tuberculous persons may inhale the bacilli in the dust. Bacilli have been found in the dust of ill-kept hospital wards, and may be scattered about on the street in the sputa. As many as four billion bacilli may be expecto- rated by a patient in twenty-four hours (Nuttall). Infec- tion may occur through milk or meat of tuberculous animals. Salted meat may infect, as the bacilli are not affected by the process of salting. Direct inoculation may occur through sputa on clothes, etc., if they gain access to cuts in the hands, etc., in the process of washing. Tubercle bacilli can retain their virulence for five months 88 HYGIENIC MEASURES in dried sputum, and in sputum which has undergone putrefaction they may remain virulent for forty-three days. Preventive Measures. Isolation not being practicable, every other means of limiting the spread of the disease should be resorted to. Impress the patient with the importance of care on his part as a duty to others. The sputa, being the chief agent in spreading the disease, must be looked to. Kissing is to be avoided as a direct means of infection. If the sputa be small in quantity the patient can expectorate on pieces of toilet paper, which should be burnt promptly. The use of handkerchiefs for expectoration is to be con- demned, as the sputa readily dry therein, and through friction in the pocket the infectious matter is converted into dust and scattered about. Sputum cups containing five per cent. carbolic solution (dangerous when the patient is delirious, as the contents may be swallowed), properly closed by a lid to prevent drying, as also the entrance of flies, should otherwise be used. The use of ordinary spittoons is to be avoided. Healthy persons should never be permitted to sleep in the same bed with a tuberculous individual. All handkerchiefs, linen clothes, etc., contaminated with sputa should be rendered sterile before being washed or handled, ‘Tuberculous CVPR ELALION LOVIN PLC TIOCUS DISLA SES, 89 ‘patients should be provided with special eating utensils, which should be boiled after using. This should not be forgotten in hospitals where tuberculous patients are allowed to eat their meals together with others. Tuberculous individuals should not be engaged about dairies. ‘Tuberculous cattle should be slaughtered, and the possible spread of the disease in stables prevented by such an arrangement of the stalls that the animals cannot come in contact with each other, etc. Disinfection. Sputum cups and their contents are best disinfected by steam sterilization or boiling for half an hour. Boiling for five to ten minutes is insufficient to kill all the bacilli. Merely scalding the sputum cups is quite ineffectual. Fif- teen grammes of sal soda to the litre of water in the steril- izer markedly facilitates the cleansing of the cups. When dricd sputum is present on objects to be sterilized they should be exposed to moist heat at 100° C. for one hour. Eating utensils should be treated similarly, as badly washed cups, glasses, forks, etc., especially if roughened or jagged, might very well spread the disease. If five per cent. carbolic acid is used, add it in an equal volume, and mix it well with the sputum, letting it stand twenty-four hours. \ A shorter period is unsafe. The cup should be disin- gO HYGIENIC (MLASUNES, fected both on the inside and outside. Strong mineral acids are effectual, but disagreeable as well as dangerous to handle. Corrosive sublimate is ineffectual. 29.—Typhoid Fever. CAUSE : BACILLUS TYPHI ABDOMINALIS. F., P. Mode of Infection, ete. The infection is spread through the dejections of the patient gaining access to the water supply. From this source various foods, vegetables and milk may become contaminated, the organisms multiplying readily in the latter. The bacilli may remain alive several months in the water-supply. They withstand drying for upwards of three months, and consequently might float in the air as dust. Linen and bedding may remain infectious for months. When putrefaction is not too active the bacilli withstand the process for three months. They are, more- over, relatively resistant to carbolic acid. The bacilli are destroyed (Sternberg) by an exposure to moist heat at 56° C., (138° F.,) for ten minutes. Preventive Measures. Where the disease is prevalent, only permit the drinking of boiled water or that which has been brought recently IVERELALTION FO [NPECTIOUS. DISEASES. QI from a source of known purity. Guard against contami- nation of any water supply by typhoid dejections. With this object, when in the country, where there is no proper sewerage, bury the dejections deep and far removed from the water supply. Dejections should always be disinfected until convalescence is well established. The sick-room: No foods, such as milk, bouillon, meat, etc., should be left standing in the sick-room, as the bacilli multiply readily on gaining access to them. All vessels, feeders, cups, jugs, bedpans, etc., that are used for the patient, should be marked and kept entirely for the use of that patient, and should be cleaned by boiling. No discharges from the patient should be left under the bed; the bedpans should be promptly removed, and be provided with a cover. Mattresses and pillows, when liable to become soiled, should be protected with close- fitting rubber covers, and, both linen and rubbers be immediately removed when soiled. Soiled linen should be handled as little as possible, and be placed in a pail at the bedside for immediate removal and disinfection as early as possible. After the patient has had a discharge cleanse the nates with toilet paper, and afterwards with compress cloth (moistened with one to four carbolic acid), and both are to be burnt. The attendant should disin- fect his hands in three per cent. carbolic acid after they Q2 HYGIENIC MEASURES have been in contact with any object about the patient which may have become contaminated. Disinfection. The discharges of the patient should be disinfected promptly—this being best accomplishcd by means of milk of lime, directions for the preparation and use of which will be found on pages 19 and 40; chloride of lime solutions (pages 20 and 41) are also recommended. The handling of soiled linen, etc., has been considered on the preceding page—directions for the disinfection thereof, pages 13 and 38. 30.—Typhus. CAUSE : UNKNOWN. Mode of Infection, ete. Highly contagious, the infectious matter is retained a long time in clothes and bedding. Unsanitary conditions, poverty, and crowding of persons promote the develop- ment of the disease. Preventive Measures. Isolation, especially in tents, is recommended, combined with complete and prompt disinfection of apartments, clothes, etc, IN RELATION TO INFECTIOUS DISEASES. 93 Disinfection. See ‘‘ General Directions.” The disease is infectious in the first degree. 31.—Varicella (Chicken-pox). CAUSE: UNKNOWN. Mode of [nfection, ete. A contagious disease of childhood which occurs in epidemics or sporadically. (One attack does not afford protection against variola.)—(Osler.) Exact knowledge regarding the mode of infection is wanting. Preventive Measures. ‘Isolation. 32.—Yellow Fever. CAUSE: UNKNOWN. Mode of Lnfection, ete. There is no evidence that this disease is acquired through contact with the sick to a greater extent than cholera or typhoid. It can be carried by fomites. There is much that is obscure about yellow fever ; namely, 94 HYGIENIC MEASURES its singular attachments, exhibiting a remarkable indiffer- ence to topographical and social conditions. There 1 no satisfactory evidence that the disease is contracted by the use of contaminated water (as in cholera and typhoid), whilst there is evidence that the atmospheric air acts as a carrier of the infectious agent (Sternberg). The most frequent agency in the dissemination of the disease from place to place is through yellow-fever patients, but as we do not know how they act as carriers, it is best to guard ourselves in every direction by a thorough system of dis- infection. One attack immunifies, as does also long residence in places where the disease is endemic—exceptions to this rule are rare. Preventive Measures. According to Sternberg, countries where the disease is not endemic should observe the following precautions ; (1) exclusion of the exotic germ of the disease by sanitary supervision at the port of departure of ships sailing from infected ports, and thorough disinfection at the port of arrival when there is evidence or reasonable suspicion that they are infected ; (2) isolation of the sick on ship- board, at quarantine stations, and, so faras practicable, in IN RELATION TO INFECTIOUS DISEASES. 95 recently infected places; (3) disinfection of excreta and of the clothing and bedding used by the sick and of localities into which the cases have been introduced or which have become infected in any way; (4) depopula- tion of infected places—that is, the removal of all suscep- tible persons whose presence is not necessary for the care of the sick. During an epidemic, individuals who remain in the locality should avoid the regions in which the disease prevails most ; they should live temperately, avoiding all excesses, and should be careful not to get over-heated, either in the sun or by exercise (Osler). Time quarantine of ships and persons on board has been shown to be unreliable. The ship may remain infected indefinitely, and for this reason should be disinfected as soon as practicable. Healthy individuals should be re- moved from shipboard or the infected locality to a healthy place. Sanitary improvements in cities and vessels sailing from infected ports are most effectual (Sternberg). Disinfection. Excreta and articles soiled therewith should be disin- fected—the same system being pursued as in typhoid fever (p. 92). Regarding the disinfection of ships see page 50. 96 HYGIENIC MEASURES SURGICAL DISINFECTION. } (a) Preparation of the Patient for the Operation. The patient is bathed the night preceding the day of operation, the part is shaved and covered with green soap for one to three hours, depending on the degree of sensi- tiveness exhibited by the patient. The soap is then washed off, if possible the whole body being bathed at the time, and the part well scrubbed with a brush to re- move the layer of epidermis that has been acted on by the soap. This is followed by a moist dressing of corro- sive sublimate (1 : 1,000) applied to the part until before the operation. In certain cases permanganate of potash and oxalic acid are applied as in hand disinfection. (Halsted). for Gynecological Operations ( Kelly ). The patient is bathed daily for usually three days pre- ceding operation. ‘The last bath should be taken four to six hours before operation. ‘The parts are scrubbed with soap and water, shaved, and washed with alcohol and ether (the alcohol to dehydrate and the ether to dissolve away fats). Finally the part is washed with 1 to 1,000 ! Methods of disinfection employed in the Surgical Departments of the Johns Hopkins Hospital, Baltimore. IN RELATION TO INFECTIOUS DISEASES. 97 sublimate and a compress moistened with it placed over the part and covered with oiled muslin and a bandage. The process of disinfection, at times, including the use of permanganate of potash and oxalic acid is repeated before the operation. (6) Preparation of the Operator and his Assist- ants; Garments Worn, Sterilization of the Hands » Rubber Gloves. The clothes to be worn by the operator and assistants : White cotton suits fresh from the laundry, where they have been sterilized, should be used. Preparation of the hands; The nails should be short and smooth. Scrub the hands and forearms well with soap and water (not less than 40° C., 194° F.) for five minutes ; then place them in warm super-saturated aque- ous solution of permanganate of potash, rubbing the skin well whilst in the bath, and keeping the parts therein until they are stained of a deep mahogany color (one minute usually) ; then decolorize completely in a warm, super-saturated, aqueous solution of oxalic acid, and finally wash off in sterilized salt solution or water. Rubber Gloves are best sterilized by boiling five minutes in carb. soda solution. They are not injured thereby. They should be worn by the assistant who hands the 7 98 HYGIENIC MEASURES instruments. Finally the hands and forearms can be immersed in sublimate solution (1:1,000) for ten minutes. (The action of these agents is chiefly one of oxidation, This is the only method of hand disinfection which has stood the test of recent bacteriological examination.) (c) Preparation of Operating Table and Room. No dust should be present in the room. All removal of dust should be done with a moist cloth or swab moist- ened with carbolic acid (five per cent.) or sublimate (1 :1,000). No currents of air should be permitted ; doors and windows should be kept shut. (2) Disinfection of Instruments and Vessels. Instruments are best sterilized by being maintained a half hour at 100° C. (212° F.) in the Arnold or other steam sterilizer. Rusting of instruments is prevented by their immediate removal from the sterilizer whilst hot. Disinfection of instruments by means of one per cent. soda solution (Schimmelbusch)' maintained at boiling point for five minutes has also been used, and is applica- 1 Behring showed that soda lye at 85° C (usually of the concen- tration 1.4%) invarably killed anthrax spores within ten minutes and oftenin less time. Schimmelbusch showed the pyogenic staphylococci and B. pyocyaneus to be killed by an exposure of three seconds to boil- ing 1% soda solution, and anthrax spores were killed in two minutes. IN RELATION TO INFECTIOUS DISEASES. 99 ble to all instruments except knives and needles, which are sterilized for two minutes at this temperature. The soda prevents rusting and increases the sterilizing power. The instruments are very slippery when removed from the soda solution, and it is well for this reason to rinse them in carbolic acid solution (five per cent.), after which they are placed in the trays containing carbolic acid solution (five per cent.) (Halsted). The dishes in which the instruments are placed can (1) be filled, for one hour preceding the operation, with sublimate (1 to 500), or carbolic acid (five per cent.), these solutions being poured out and the dishes hal filled with sterilized water, into which the instruments are placed ; or (2) dishes and instruments can be washed with hot water immediately after an operation, and dis- infected before the next operation by being allowed to stand one hour filled with 1 to 4o carbolic acid. Vessels which contain salt solution should be disinfected with corrosive sublimate (1 to 1,000). (e) Dressings and Ligatures. Bandages, absorbent cotton, moss, and gauze should be exposed to a temperature of 100° C. (212° F.) for one hour in the steam sterilizer. ‘Towels should be similarly 100 LIVGIENIC MEASURES treated, and can be kept until needed in covered jars containing sublimate (1 to 1,000), or carbolic acid (three per cent.). Rubber protective should be placed for twenty-four hours before using in 1 to 1,000 sublimate. Iodoform gauze prepared simply from sterilized gauze. As an occlusive dressing the following is used with steril- ized gauze cut to proper sizes. k. Washed ether and absolute alcohol equal parts ; recrystallized corrosive sub- limate q.s. Anthony’s snowy cotton. Add the cotton until the consistency of simple syrup is reached. Prepare carefully, avoiding as much as possible exposure to the air. Place in perfectly dry, wide-mouthed bottles before adding cotton. Ligatures: Silk, silkworm-gut, and silver are placed in test-tube-like glasses plugged with cotton, the first being wound on glass spools. They are sterilized for one half hour on two consecutive days in the steam steril- izer. They can then be indefinitely preserved if kept dry to prevent the moulding of the plug. The latter can be burnt off before being withdrawn if it has been exposed to the dust. Catgut should be kept reeled in absolute -alcohol. Previous to using it, boil it in the water bath for half an hour. Do not use steam or oil as the catgut is rendered brittle. PVeKeCALION WTO SNFECTIOUS DISEASES. IO01 (Y) Disinfectant and Sterile Solutions Em- ployed and thetr Preparation. Carbolic acid, five per cent. ; sublimate, 1 to 1,000; for irrigation, normal salt solution (6 to 1,000) sterilized by heating over the flame until the boiling-point is reached, and then maintained at 100° C. (212° F.) for one hour (on three successive days) in the steam steril- izer to prevent too great an evaporation during steriliza- tion. For washing, sterilized water may be used, being prepared in the same way as the normal salt solution. Pe , 4 se ete k Ube; INDEX. PAGE AGCHIMORIV COStein AY Ne tee tech oars wna etre mes Ns hate orlSa seb hora ve Cancers! ote 54 PAOLIN ORM VCOSI Sipe ater nisin akin semi ivorneieiste cine mel ciel Teena coud also tiie sheers ear 54 * BAUSCLOUN AP nINS harvey chelsea dete Vote cece de aelreee Nese s 54 se MOG S.OLANTECHOM Ni shld seule Sao crete oats wetter oe lok 54 iT preventive measures in........ Sep a onsrarsl a charade fate: Ss stencienciatssets 55 PN ETALLOM LEC. cietelasie stevie sicisieislelc <6 De ststaptaraccte Breleyel ist oneh ie ouobela: cae’ s/eveheie toy ete\etsiieys 52 Agents used in disinfection............ saigule Wetiivtle oes S Mya ota ae tasters steriysl v's 3 GAM OO Lalit COLE CLATEICLES us nis atke ae Arne laPalmialcicl,(eratershalarc love ots ela sroeie! eels eels 25 Ameceba dysenteriz.................. TASB AE te on, yeh GINO oP Be aN A RR A RR PAIN CE DIC AY SENLELY stewie cleietsic sles y ster eisicisisis 1s Nestenteler stu starteic. sie visintete ses tes 61 PALO INL RRR Mire OTA (ast else ta wie'sta's ofarere'aie!sain de VES Se aed te ds ga eiede'ee ee, 205.85 SMMC AITSC LOL sammie be coe say et siessFetete a ein oieie es, vier shea ola el slevove wale Ors « ai aleietdietis oa 55 ISITE OCLC Sm Meee tral he pefarsie hei Nal-tet Lateral ole let tiaihahctelatelale cco ielerele eis slate 57 PETNOC GLOLINTECHIOMNIT eeyscnisisse tas peaies Datee es oe etter aweled a ceveled valy's © 55 METOLEVCNLIVeLIMEASUTCS I sire isesv es cia ed ciuisiwesn de hls ele see viaas 56 PAILISG PLUCK ciara cieitertere has five pis ersiers cle os Seigigv ey wisisrsie eae e's Sich Bioksete 2 PAC Peni Cl All Grcteretere eh cietistelersversyarc aise tiaiiis aie tis is ieisiais wate tae eis sieis dele dacs ac alegiele s 32 4c Bacilisiant Dra cisenertaataeetamrec cece Se teiis sleet to eiw oly wie pousieialtielelGidialsiel’s Sie dlere cy SE CHUTE NOT 12e Gia srattier casts 'alsloipierslafeisisisieys aig Cishelele eidse s SHAD CE SPL cA SEIS Oko: 59 POET EINITUL GIR Z ON Eatery fy ck ay fs dig ehh c oixis's vis Uarels o's been keh ee ¥seeasines : 66 SSDS MRP cpmet ete s tee a ep ialefisiale aisietales ale sia ele wipie elaielelee¥'a.e Place’ astve nice 67 BUMMEMOXUL ANCL pert atic atatapst cle ecersiar cafe viele css cts s viel eieiéie oP 'g wigieciag o/o's'e Qeiaid » hers : 63 MRO NALS: WIR SA pack le 2G « Gs eiealdis «sls ate clea Pt rie'saisla sv ats eles ¢ sie 69 oe VELA Unyeremeotce ease ic etre ate naiahd ace cel ai'e diel aide ere W's aiethlaivwie'a te eelets 83 SRLU DET CULOSISE Mont Criran siaacduinte Sana: catsetie ca caleles sieges £38 Rls @nsiers 87 ARMECVI DELIA D COMMAS Siecle ce Sie ol te recie cP autrsierelsie’ es leis dl didialant vierefS)abelere aateiene go IB CALINOMCIOLIES acntevumettaceristcais Heid s'a cleietn ta cle lerale eleie! etbiavs/e lone MES rae ae leitclae 36 SEMI ECTCCACtIC GSR tae Gaels ea sees ss Sats be helen s saue ds Fouad p4 pe 25 Bed DAMECISINT CCLIOM OM CONLENES Of seieaicrs cities on cieldie fivieioa'<\cle'so'sin tie ee ciaisists 45 ES COSLOH Clertateratn trie mete its aispats eaisyavaie att egein aier> clene’ erelstosloislsl si @iers's' "1 « 4 -5)0\ srelle/e/* 44 Exits AO Up CAUl] Comtotr sscyais elite Gidlciere tlarcietarcists aye) ecote is ccait ole wleve, siete a lieiatare the ois, 54 Blankets, disinfection ch Pao) Sees TS Ntbise SAE Ma chhietere Lh We Sishere tenes II PE SDAMAT COLNE Sey de iar ve tiie hts ce celeas ances oars Een O Ek ERE ER oe 36 103 TO4 INDEX, be 6b Care of patient's person . san eentaseise rite Carelof. sick=roO nan nese ied tue ole aroaiee Gee nuareentate eee ewww eene Carpets ic .aiccum soamuieb eles as e> Carts for transportation......... er ea? Cause and mode of spreading infectious diseases........ Cerebro-spinal meningitis................ Cesspools, disinfection of................. Chemical disinfection.......... Chicken pox.. smetezasles Children in infected houses...... Chloride of lime..... Chloride of lime solution......... Choleraw.c. oseus cheats: ey eee eee eee ee seer eee Ce weet eee Cy SS IGALISE) Obes cutie coariei e COR Rene re MeuchiSINfECtION TdTiaeL cele eee oe oe t= mode’ of infection in-s..-2+. see. “ee preventive Measures iNew. se aes Choleraistoolsintoie secs alae ss CULES ae ee Classification of certain diseases according to degree of their infectious- TESSa re ee wae ienven : Clothes, disinfection of........... Commercial disinfectants............... Concentrated sulphuric acid...... Contagious GiSGaSes: ois cscs v cteisue a eidaeras Convalescence...... VOD DELASIin Soriozale:stalore aelatertoany -Petatel tere Rape bac : COLDSEMys faster cooler ae Rigd haeaad eure Gorrosivessublimates.aacssnsarisce ieee GLeEwSiOl VeSSelS sa... acdele aeaieetaiercls AP a @rudejcarbolic'acid:...c:.nis ashe (CCUTLEAINIS BE ainicee aes oaletcoletem teers seen eeeeee Dampyidarkwhouses sui ete « DarkneSSiivss eect ouicte wasn Deodoranteeseccetne ccna aces Diphtheria’ .4i...s%-5 elaio. es = se SENG LOC OCCINeer ee etter ote, darlotsterecofe sleveleter es ioln erates 'e eta cha AVEOMRCLE Ps CLECLTIC eleierels cleinie/e\s'elele\eiels'¢/s o/s s/nlclo.e enisisicidi elelele vioe/s\« RRND TG SORTS Mei err e ere dire afore ete Mic avenue io clelons close el epi sittejelalets sle'aus s dace SS METIVOU GC ORiTl ECLIOMPIN persis anayejelcisieicis sie) osie'e sa 6 siareiclecs'soros'e s PFeVeNntiVE MEASUTES IN... 5... cece cece ewe esr eer cece sig Railway cars, disinfection Of..........s.sseseccsecesecseecneees BA Va PUNSUS iacnicines rors am News Heeb es eens cede ecnsemssoteeedes BCA DEINE TEV OG. Leese ele eles ss ae viedeu wie saine dees suletisiwanes cae Ss Sa CAUSCIOL.... “ou “e 6 ee FRO EMELIN eee cateslee etale arn sioee sere eer eeeee SH mode of infectionin........ ReaD el aterecte ccs of cteiare tieteveln ois preventive measures in....... see eee ee eee ee ee Ce re ed ce es Operatoranmdshis| assistantsietaciaccias ected sl lerefelelsleconsieysala cua 'ecs MatientelOl Operation. mecca cies se ceils mele oils ee Preventive measures in infectious diseaseS...............eeeeeee ee a es oe teens oer eeeeene eee reeeece eee ee eee a! eee e ne eee . MOAGE/Of INFECHON, 11.2 ooo. ce hci ke Soin cee abe veasteeeeceses PIEVENtive MEASUTES IM....... cree eeecesesceseccecccrees ee ee ee eee 109 PAGE 29, 73 72 73 7 27 31 27 98 97 96 33 33 42 as) 73 75 73 74 79 79 81 79 80 73 79 12 66 66 66 51 54 75 75 75 75 70 110 INDEX. PAGE Rubella, modejofinfection jinsswsa we nea deseo tnee ete ott eieiets 76 ws. Spreventive measures and idisinfeotion in, -nyene ss ses eee ese 76 Rubber gloves: isis Sg eias Sav eee ee ome Sale eie eee ret meters Char ene 97 eee dt SHEEES!. sau BAe domipneracian ata aatvvlo nel aFus caaaked caer a tel ste orn eter see 44 Scanlatinads sciss nares siete stsichis clea cis elsaratis stale sinsiotee eine ees Rin Seles ee aera 76 ay GISINFECtiON AN. 5 oa Cr cance coke cheeses eae eae at ee ete ae Cee 77 oe mode-of infection, Ines. vas cue ee ese eich aoe eee ee 76 4s ; preventive:measures In-waaeeres Asean crise eee itaee 77 pois) 0] Lor 2) bE ee Een Hai eA RAR ce, JME atin Bent ye CAUSE OLes soi lacs mieventiam syste attere ties fe.dus tava pecetote elite Alaris tials eae arene 79 25 disinfection*iniud:..mewdusceeas oot wie POsHAES 5 AUGlole thease eau Met 81 ut mode.of infection ins), cle >.cne al ste elesaninela cee eet 79 ee PLeVentiVe MEASUTES IMs. see oeiieliys Mu cetera lta L een Te 80 Ships disinfection ofj) wae. eee eee oe j Sielsorele tere’ Stole aners ee ea eens 50 SiGk=-roomMm | HOOKS Of ish jos joie te arn/a aushesloie nlesciele e alelcolete ote cick s atone eee aerate a7 placked limes). cp sien suns os sa) tales Jake aw pe eeis see mee ona i meee ae 19 Slops, disinfection Of; «cli scans oe es.cens tcean alias nd ee ee eee 37. SM AL POX. ai..%. cc eave avaisric oom ates tiaiele Seteloefelacate ences Mis abet teveusts orien Ee eerie 78 4 AISiNFECHION 1H .n\sois cise inialetaiele ead Home's BUI minie ts gine kl tea aR Rea 79 re mode of infection inser emieuinivas selene seve cst er eave ee tenes 78 se Preventive Measures in joc piypacies teilserrse me relael ol ederelancr neh cae 78 Soditim chlorides: io2s «.t).sas cub Gee Rr Ree tit. RPE ete SN Sr Spirillum cholerze-A Siaticze.). tetsu clei etree ete erat bras eee 57 HY sO DETRTCLETL, «<2 osc bie coe bs Cae oe eee ae ee are d yy AM rah ce 75 Sponges for removal of dust....... Hi aes be ocharstarois acs aie Pues 9 aes SNe Sen ere 23 SDOTES Siete sieve pina isrornts a o\aints lego treinienstee one teens Brattain ee tee AR yay eae tie 5 SDTAIY seicaGmicldic Gace Bes sie orb isa a cinvauate (ehepopel sta utente to SOR SISO Be AGE AAS SE Bir hit 22 Sputa; ‘disinfection rol Asse ovis wie neste ari eeeiere faee restate aie eee ee tener Ag AO Staphylocoactyless 8s ia ls bud slo ewete che ate epee SOMERS es on DMR E eae SOUT Steam “disinfectors Hoss c adel tee plant cae ae crane Pare emirate att ae 6 Shits SLEXLHZELS stat’ ale!igie atetiatctataleiolp lelatels wise statecaetantetee sea heise siatatel Hei sere 7 Sterile solutions employed’... ............5-.+- Fecietaaitare singin iis is SL Oe Stértlization ofthe hands. A744.) strc io sietun mesial ele aps anaes sues Rie ane iets 97 Slervizers Steam po cas dente cease dss MP eae SierAahatoleg ave ara: slosstoletomtore ie otetete 7 Stools, disinfection, Of F'{sinview sjors tens). wlels aieicheyperievareetem sietiteiele staat ene 19 SEPEPLOCOCEL GY store J cieididiomniete cin sie e nipke ihleca Sree el ohana neatetete ieteia i eyerate ear etseent tee ei 3 Streptococcus, ErysSipelatosiacs .ticci . ciacle fe sais eyo tetas teres atte ne ea olen mre tetorae 62 Sulphate) of arom. .te seieiats siishs @ cia AWp\e Bat SiaTANANE Slave mubie eres axe yoke sae enemy Tee Tae 3 SUED esis hei Spotl atest’ alata yetetatarlat hs tela d slat ater ecaldl anaveterans: ats Giuaiat as] slaha, ate nice ese eee 20 Sulphuric Acid... cece cece ese eee eee e ence eee e pete eee eeeeeeeenneenneeeneees 21 INDEX. Pett ¥ PAGE Mee MIDAUEIC BGI CONCEHITALE, ice tcc doe tec eev iver ccStsedotaesctsceg fof om 17 STEMI YO MUNNONG SCL Cl Clatctetercichct etait ah tie ela! Poo s/ajoieiavictsleie Melee ws elg. « nici aleve ideo acg.clele wie eles 21 MMMM TO CMKeGCCG ATLIClES. 205+. 12s sao. seWse elds skugieodecesdewere nes 25 REE PD FOLS ReME Lest lenereteestenmetecerar eft aia’e sleeves ate oieieis sis aseictevers pisyeWiss+ . 90 SV DMMIS RTI rele itis cites ivieiale ae aint ce s0disi6'e)s Sho Utbbmer onULOoon coe Bocas 20y OL - LISIIFCSCUIONEIN easerstc nro sieptiere tea 6 apielale niecwier eatery BSE en art re eS 83 3 MOGEOL INECLION [Ne ae aes a eae st eae ata) a Rover ate stace aerate ape cts meedetsen ete 81 PLSVEMUVE MEASLES 1iasleadenaes tee nes dereists Soest see e ae oy aierere 82 ce BRAT COBD AD ELTy ie arco eetay srtetsrre ton tatererna vats ek's afars lain Wiens diate: dia bie alaiaCeie cieseie pin 6.6 44 MRR EDULS gre yale ole) orcl civ hind oie Fala bsg 6) eleliys olaie's'e viprale Wisle ae ears = seh 6 8 eisaelae ewan deacl SQ, 03 os CauSenOfece sce s eee fe os saleid sae Bape ysees ate easiest Dass eslelt nae eie shee 83 pas CLISIMEE COLON PAIL ante aeieniraratciensr sa aretiare cha cialece lore niga as alsesa; acl sree lelsiwiors are 85 ok MOU EVOTRTSCLIOM IMs nectric seis eae sitio ais eialarelaleie e'ercis d's; slaves slaicie safe 83 ab preventive measures in............. Renate Natektres crelclctniele omisaieioret ee 84 PEO WISH CISIIIFE CLLOMINO Lite oct ere ea alofoiets es tetas, ioe araiole Biot eas ete wicls eb. o's simile II Transferring patient to hospital, precautions taken in.................66 42 Pichi WALS DITA iShmcrrectenterscd cir rarciseie se siecle ate! aieleveveters eco ote p sre fterereleyels co 4 c5 Sioiale 85 BIST ACHAUNIAS (Steele cssrcrevocetstcleyetas reve ate.s erste ahs «ie Aaa Nate eeeteye a pore se GaN detena ses asics 85 ss CAUSCLOL aria stile jslels a oaioke A ehbhcs ety ae 5 AI OLE ROSA COC 85 MOE Of MLECHOM Ms ea- te ac ais wteree See OC Bere sgrate le) ats 85 LEME RUIVERIeA SU Te Sul lionel aiciniercfstieis ci isie eietetclele feels fersia «Ys 86 SPT OMIOSIG iy sls pao: G clsln ats sehaisigisians sis Wald pes end wr p(e « Sides e a shes he oe oe wb ECANISCROL een eee ee eitakersrs oe naste ans ate ars aie se Sie sae sleselaeers : 87 CHSUTKEC UOTE LE ators te ete siersecnslae x viel el stare tists ohn tater hai areuoselel a jes: 9ie.0.e, sie 89 . MIOGE{O fe INLECLIOM ser seepeits 5 aie ane ohefalevavcisisie ate vise c/s ibue einje\es 6 87 6 DLE VENLUIV GINeCASUTES Tis .)oe tae dalele aielsieiciaisnielcitie sass ae s/evelere ; 88 Ay qaluvenvel RS &. on beat ooop GOGO ONO GOO CUDUGHDE doce OUeeLnEtAR ee apeooor 29, 90 z OO) GRIME) GViane Che tAnnad pad An noc Ode Rondon GoORCpapricodnbem toca go sf SEM CISTENLECLION Aina ci ciedie tists sisters als aeicre oie cla tersias Gietttalars’ © ote 6 92 s TRO CLOSE INTECLION Meret ele eailard gaye cvere eis. slere ajels leis esis f.aels o/s go DUC VETILiverMeaSUNES iti cies viele aviciclinimele sr ejsisisiele + oirinic'essteve go BIG TONGA "SLOONS ne ctalesetratelels © vieiels Sis alete oes Rati arelstrtces erotics & stolocidice set tae 19 eo oe me CLISITILG CLIOD I Altace trentelstcysisietas ss cse'a'e slole she's meeteie ape, atatat of ee levonsravecetelenstete 93 SIO CLOT ILE CLIO IT ewnic ter eiaieisieietivieie eas eles oo ole elec 01a (a: cie'sieiaiaseln. e's! ehs\s g2 66 PLEVEDUVS MCASUTES TN iis cewek case ceccssueensieverssvesne | Q2 T12 INDEX. ‘ PAGE Urine} dising ection: ofs.5 as's/ssae ater etsleis eine «citing cslanieitetas cin ek Selate mele eerste 40 Varicel lay. 2icierts o.0'91044 seas pis rave weietaleven chh-e allen) peters ae te ner Laer Sate Sree arate 93 ‘< mode‘of infection in... cts cones reeetactscirmeitio ncaa one strere ra eiatate 93 ‘E PLEVENEVE! MCASUTES IN sya lertetssteie errata teketeleier stele tere anetear 93 Vegetative forms of bactetial 3o.0- cn. hits sine male eee Cee aie ees iB Vehicles# publics. oi iis sicivcila ss cvsttie cis theisters olars iss rae ote eee ene atest etree een ote 42 Ventilation of sick-room...............- AE Per omeceh tite’ MECC Orie a She 24 Vermina sae iisc nas eae SS ¥ go: sap fhila evosegoh avele Ghee a) alge top ee aionehel eee. Memes etc te aceasta 5 Washes of dilute disinfectants: ....s\).tjecu ones Chand ie aaee ante meee 30 Weater-closets) ‘disinfection Of... 32. e nee coals tells ee eee eee een ay What is desirable in disinfectants in practice............ BP nooks Oosae 15 Whooping-coug hi. t2.\. vice lites nics oletore aie stole He pote mck oicls NCI che Rear t oe i MOE Of INFECKION MH. 1, sale os feslvtalolete eter etaleteneeeetaR Te 71 PIEVeEDtive Measures IN.y 5 «(emi es nie ve wale) Seis ees 72 Wrornd dressings siyes 502 kv) ca iislers stan, s thins’ 6's 0s pl alalsls ois es 2 ate ee 43 se ee WV ellOW (fEVer oa ocica sc cistinle ws lotions « cshfoae niet @ ci hina Sect eeiioe Cee eee oEcOMOs ai Hier GISINfeCtion Ines 55 cack cceetecekinieeeiie nce tee cer en toate Cerner: 95 rt “\ smodelof. infection iniwacnce ee ceceee eee Sot te eee cee 93 oe 6s PIEVENLYV.E MEASUTES Ie sls citelel pelt swlelels toile ciatlatoiere eietein a 94 5 mel 7 Ne ee ee Oe ea ye Loge bare eich beste } i : ay B. a FAN oti OS Ee ERM WE ct aes eos sn 1 en 734 Se a8 .y sia beee Fe ©. 19 "at pees Fee Dh b nS ki ‘od ty aN ae er be nA bbe 5 t Master Las ie Pte Ef BH HF wk hs st hy te : eu ae ROR AGS: Pita : ae eee meierge ss 4 betas per rete ib BAT op >| rhea. SAE SDI Susana ©: ae an ie 2 3 ; Z ae AR it - te OS BT LD PB rf 7 + te ab, 6. we MA Neat, timeslots cole a Fey 35 VERSITY OF ILLINOIS-URBAN ) 30112 067732468