{181}
Diphtheria is a disease of children, but it also can be fatal to adults and to children old enough to receive the last Sacraments. It is caused by the Klebs-Loeffler bacillus, and it most frequently attacks the throat and nostrils. It can start in a cut in the skin, or on any mucous surface, as the inside of the eyelid. The contagion is not in the breath, but it can be coughed out. It is in the saliva of the patient and it gets on his hands and on what he and the nurse touch. It is not nearly so infectious as smallpox and scarlet fever.
In visiting such a patient the priest should be careful not to touch anything in the room, and he should wash his hands in the bichloride solution after a visit. He must also wet the soles of his shoes with the solution. He should be very careful lest a child suddenly cough fine sputum containing the bacillus into his eyes. Diphtheria in the eyes would destroy sight, and I have seen a pair of spectacles save a man in a case like that. A detailed description of the disinfection in diphtheria is given in the chapter on Infectious Diseases in Schools.
Glanders is sometimes transmitted from beasts to man, and it is almost always fatal in the human subject. The disease is caused by the glanders bacillus. Horses, asses, dogs, cats, goats, and sheep are susceptible to the disease; pigs are somewhat susceptible; cattle and birds are immune. The infection is in the discharge from the nose of the patient and on the skin eruptions. The same precautions are to be taken as are needed in a diphtheria case.
Influenza, called popularly the grippe, is caused by the bacillus influenzae, which was isolated by Pfeiffer in 1891. The bacillus is found in the nasal secretions and in sputum; it dies in from twelve to twenty-four hours when dried. The disease is contagious, and it is often fatal in alcoholics, the overworked and harassed, and in those that have chronic diseases. In any case it is a serious malady. Disinfect the hands after visiting a case.
Dengue becomes epidemic at times, especially in the Southern States. The disease is very severe, painful, and depressant, but the mortality is quite low except in complication with other maladies. Its cause is not known. It is{182}very contagious and has symptoms which belong to the class of disease in which are scarlatina and measles. The priest should act as in a case of scarlatina.
There is a form of pneumonia which spreads so widely and rapidly that it is called epidemic pneumonia. In visiting patients afflicted with this disease the priest should act as in a diphtheria case.
Epidemic cerebrospinal meningitis is a very fatal disease at times in America. Even those patients that survive are frequently made blind or deaf, or are left injured otherwise. The malignant type is nearly always fatal. In some epidemics the mortality is as high as 75 per centum. The visiting priest should act as in a case of diphtheria, although the danger of direct infection is not great.
Tuberculosis is a chronic febrile disease, caused by the bacillus tuberculosis, a parasitic micro-organism discovered by Koch in 1882. One-seventh of mankind die by this disease. The bacillus remains virulent a long time after it leaves the human body, but it is soon killed by sunlight.
Tuberculosis of the lungs is spread especially through sputum. In the room occupied by the patient, the clothes, furniture, walls, doors, and floor are infected by the bacilli coughed out, even when the consumptive is careful to disinfect the sputum, and, by the way, he rarely is careful. When the priest visits a consumptive's room he should disinfect his hands with bichloride.
Leprosy is caused by the lepra bacillus, discovered by Hansen in 1871. It is present in many parts of the body, especially in the glands and nervous tissues, and it is found in the mucosa of the mouth and in the nasal secretions. It is very profusely distributed in the corium of the skin. The name comes from, scaly.
Leprosy is present here and there along the Mississippi valley from Minnesota and Wisconsin to Louisiana. It is found also in California, Florida, and the Dakotas, in the Philippines, the West Indies, and the worst infected part of the world is the Hawaiian Islands.
The bacillus has not been found in rooms used by lepers, nor in the soil of their graves. Inoculation by leprous{183}material has failed so far undoubtedly to cause leprosy. There is much dispute concerning the contagiousness of this disease. The Dominican Sisters nursing in the Trinidad asylum have been in constant contact with the lepers for about thirty years but none of them has yet contracted the disease. Zambaco Pasha tells of a family which has lived in the leper asylum at Constantinople for three generations and no one in the family has been infected. Father Damien, however, in Molokai, and Father Boglioli, in New Orleans, did contract the disease. There have been cases of infection from man to man, but ordinarily it seems that some unknown factor must be present to insure infection.
A priest need have no more fear in visiting a case of leprosy than he should have in visiting a case of tuberculosis—not so much. He may wash his hands in bichloride solution after anointing a leper, but it is scarcely necessary to do even that.
Actinomycosis (, ray-fungus) is a disease caused by actinomyces, a micro-organism that partly resembles a bacterium and partly a fungus. The disease can be fatal. It is very improbable that it ever passes from man to man, but as a matter of prudence the priest should wash his hands in bichloride after anointing such a patient.
Septicaemia, or blood-poisoning, can be brought about by different pyogenetic bacteria,—the varieties of the staphylococci (irregularly grouped cocci), streptococci (chain-cocci), pneumococci, and others. The danger of infection is so slight that it may be neglected.
Erysipelas can be fatal, especially in alcoholics, the aged, and in chronic diseases. Erysipelas is contagious, especially if the bacteria get into an abrasion in the skin. Patients having this disease sometimes grow delirious and violent, and the priest should be careful how he handles them. Disinfect the hands after anointing such a patient.
Tetanus, or lockjaw, is not communicable except by inoculation. The bacillus, which was isolated by Kitasato, the Japanese bacteriologist, in 1889, is found everywhere in soil, hay dust, floors, on old nails, especially on the floors of old wooden slaughter-houses. It grows best in deep wounds{184}where it is shut off from the oxygen of the air. Hence the danger of treading upon a nail that has been lying near the ground.
Beriberi, a disease observed especially among seamen, appears at times in our coast towns. It is always a very serious malady and sometimes it is rapidly fatal. The infective agent, which is not known, is not undoubtedly communicable from man to man, but it is carried from place to place, and it clings to ships and buildings; it thrives in hot, moist, crowded places. The priest should disinfect his hands after visiting a case.
Anthrax, called also wool-sorter's disease and splenic fever, is a very fatal disease, and the bacillus is communicable to any one through an abrasion of the skin, through the intestines by swallowing it, or through the lungs by breathing it in in dust. Disinfect the hands and the shoes after visiting a patient. Be careful not to touch anything in his room.
The bacteria that cause typhoid fever, Asiatic cholera (which has been epidemic in America) and epidemic dysentery must get on the hands, or on food, or in water, and thus reach the mouth and be swallowed before they produce these diseases. Act in cholera as in anthrax, and disinfect the hands after visiting a case of typhoid.
The bubonic plague, the most fatal of all epidemic diseases, has already appeared in California and Mexico. It is caused by a specific bacillus isolated by Kitasato and Yersin in 1894. The disease is communicated by contact and it is seemingly also miasmatic.
The terrible plague of the Black Death that swept over Europe from 1347 to 1350 was a malignant form of the bubonic plague. Over 1,200,000 people died in Germany, and Italy suffered much more. In Vienna for some time about 1000 people a day died and were buried in great trenches. Venice lost 100,000 inhabitants, and London lost more than that. In both Padua and Florence only one-third of the inhabitants were left alive; at Avignon the Rhone was consecrated so that bodies might be thrown into it for burial; and ships drifted about the coasts of Europe{185}with dead crews. Hecker, in his study of this plague, says that nearly one-fourth of the population of Europe died in that visitation. Civilisation was wellnigh overthrown in the panic. In Germany, Italy, and France the Jews were accused of poisoning the wells and thus causing the plague, and they were slaughtered by thousands. At Strasburg 2000 Jews were burned to death in one holocaust; at other places, as at Eslingen, in despair the Jews set fire to their synagogues and destroyed themselves. The Great Plague of London in 1665, in which 70,000 persons died, was also the bubonic plague.
The mortality is about 90 per centum in some epidemics. The bacillus leaves the body in the faeces, flies carry it to food, it thus gets to rats and mice, and it is carried from place to place. Rats, however, are commonly infected as if by a miasm before the disease appears in man. There is dispute as to the communicability of the plague from man to man by contact with fomites, but it is practically certain the disease can be thus transmitted. Kitasato once succeeded in producing the disease in animals by inoculation with dust taken in an infected house. Merely touching a patient does not apparently convey infection, yet some authorities hold that in time of epidemic the contagion is transmitted even through the air, especially on the ground floor of houses. Perhaps mosquitoes are the medium of infection, as they are inclined to fly low.
In visiting a case of bubonic plague the priest should be as cautious as if he were attending a smallpox patient. After death by smallpox, plague, typhus, cholera, scarlatina, diphtheria, and measles the funerals should be private and the bodies should not be taken to the church.
Malta Fever, or bilious remittent fever, is found in some of the islands taken from Spain. It has a low mortality and is not contagious. Bruce in 1887 isolated the bacterium that causes it.
We do not know the cause of yellow fever despite the claims of Sanarelli that he has isolated the specific micro-organism. Recently American physicians discovered that it is transmitted from man to man by mosquitoes that belong{186}to the genus Stegomyia, the Stegomyia Fasciata especially. If a yellow fever patient is put into a room in which the mosquitoes have been killed and the doors and windows are screened, he is as harmless, as far as contagion is concerned, as a man with a broken leg. The disease is not spread by fomites.
Malaria is caused by plasmodia, which are protozoa, not bacteria, and it is carried from case to case by mosquitoes of the genus Anopheles. So certain are we that this is the mode of infection that the expression "no anopheles, no malaria" has almost become a medical axiom. A bite from an anopheles mosquito does not cause malaria unless the particular mosquito has previously bitten a malaria patient.
The stegomyia flies and bites in the early afternoon and again at night, the anopheles flies and bites after sunset. In visiting a case of pernicious malaria or one of yellow fever avoid the bites of mosquitoes by gloves and a piece of netting, and there is no danger whatever.
The stegomyia mosquitoes are tropical and subtropical, but they can live as far north as Philadelphia and even farther. The anopheles is especially a northern insect. The ordinary culex mosquito, when it alights upon a wall, stands with its body parallel to the wall, as a house-fly stands; the anopheles mosquito stands with its tail raised from the wall at an angle. A mosquito lays its eggs in any pool of still water, and the "wrigglers" seen in an open rain-barrel are the larvae from these eggs. The larvae come to the surface of the water to get air, and they may be smothered with petroleum; but the only effective way to get rid of malaria and yellow fever is to drain or fill pools of water and marshes. Mosquitoes will breed also in the small still bights along the edges of running streams; in old tomato cans that contain rain water; in any still water, fresh or salt.
AUSTIN ÓMALLEY.
{187}
Cases of diphtheria, scarlet fever, measles, and even smallpox are not seldom found in schoolrooms, and much anxiety can be averted and the spread of infection can be wholly or in great part averted by a knowledge of disinfection.
The laity will often follow the advice of a priest in matters of hygiene when they are inclined to rebel against the regulations of health departments and the suggestions of physicians, therefore a preliminary explanation of methods for the prevention of infection in the family will be advantageous; prevention in the family is also intimately connected with prevention in the school. Methods useful in the family are useful also in convents and boarding-schools.
As regards diphtheria, the chief causes of the spread of this disease are mistaken diagnosis, imperfect isolation, incomplete disinfection, and, paradoxical though it may seem, a lack of susceptibility to the disease in a large number of children.
Many physicians are still under the grave error that diphtheria can always be recognised without the aid of the microscope, and that membranous croup commonly kills. All scientific writers upon diphtheria agree that it is caused by the Klebs-Loeffler bacillus. They also hold that there is a disease called membranous croup, as distinct from diphtheria as typhoid is, but that membranous croup is a comparatively harmless and non-contagious disease. Two per centum is a liberal mortality in membranous croup, yet a certain class of physicians are constantly reporting deaths from this disease. In a series of 286 cases (not deaths) diagnosed as membranous croup by physicians of New York{188}City a few years ago, Park found the diphtheria bacillus in 229, or 80 per centum. I have never examined the throat of a child dead from so-called membranous croup in which I did not find the diphtheria bacillus. This is the experience of almost every bacteriologist who has had to do with diphtheria. Some men report deaths from diphtheria as thrush! These deaths might just as truthfully be attributed to the wearing of linen collars.
On the other hand, according to Baginsky of Berlin, Martin of Paris, Park of New York, and Morse of Boston, from 20 to 50 per centum of the cases admitted even to diphtheria hospitals have not diphtheria at all. Bacteriologists find that about 35 per centum of the cases reported by physicians to be diphtheria are really nothing but tonsilitis or pharyngitis, with now and then a case of membranous croup. Without a bacteriological diagnosis, therefore, 35 families in each 100 quarantined (where quarantine laws exist) are unjustly quarantined and subjected to the trouble and expense of useless disinfection. The suffering this can cause to a poor family, whose small business is often ruined by quarantine, is a matter for very serious consideration. Again, no matter what experience a physician may have had, he can not in many cases differentiate diphtheria in its early stages, or in children of good resisting power, from comparatively harmless throat affections. The extraordinary resisting power against diphtheria shown by some children and adults has been described by Wassermann (Zeitschrift f. Hyg., 19 B., 3 H.). He found one series of 17 children, from one and a half to eleven years of age, and 34 adults, in which 11 children and 28 adults were not only immune to diphtheria, but some of them had enough antitoxin in their blood to neutralise a tenfold fatal dose of diphtheria toxin. This explains many mysterious outbreaks of diphtheria: such immune persons are infected and they carry about the disease unconsciously because they are not ill themselves. I have seen a mother kiss a child dying of malignant diphtheria and the woman did not get even a sore throat, but I know of another case exactly like this in which the mother died from the infection.
{189}
There are bad cases of diphtheria which the experienced physician can diagnose as soon as he enters the patient's room without even looking at the throat, but the lighter cases that are dangerous are not easily recognised. I have seen two children of a family in Washington attacked with a slight throat soreness after one child had died of diphtheria in the house. The cases of these two children would never even suggest diphtheria if that first child had not had the disease. Both these patients died within ten days of syncope without the formation of any membrane, but the diphtheria bacillus was present microscopically. To the moment of death there was nothing in the symptoms of these two children to show diphtheria to the naked eye. From a personal experience with more than 800 cases of diphtheria in hospitals and as a medical inspector, I feel certain that light attacks of diphtheria can not be diagnosed without the aid of the microscope.
The immunity mentioned above explains the fact that the Klebs-Loeffler bacillus is sometimes found in healthy throats, and the person that has such a throat is really more dangerous than a patient that is ill with diphtheria, because we cannot guard ourselves against him. School-children at times have what appears to be mere sore throat but which is really diphtheria in the naturally immune.
All cases of sore throat in school-children should be examined bacteriologically, but unfortunately the bacteriological examination for diphtheria is a complicated process which requires an expert bacteriologist and a laboratory. The cost of a laboratory fitted for this diagnosis alone is not great, but it is not easy to persuade small city governments that they need such plants.
The only resource, then, is to treat every suspicious case of sore throat as if the disease were really diphtheria, until a diagnosis is established as near the truth as possible. Children that are afflicted with throat inflammations should be kept from school. The people should be taught the necessity of isolation and disinfection; they should be warned against patent disinfectants, and told to ask competent physicians to advise them in disinfection.
{190}
Diphtheria is not directly caused by unhygienic surroundings. A disregard for hygiene disposes a child for infection if the child is exposed to the bacillus. The specific germ must be introduced into the patient's mouth or nostrils. When a child is infected with diphtheria the breath is not a medium of contagion. The sputum, spat out or coughed out, is a means whereby the disease is spread. The bacillus is in the patient's mouth and nostrils; it gets upon his hands by contact, upon eating utensils, upon whatever touches the mouth of the sick person. The bacillus does not float in the air of even the sick-room, except in those cases where dried sputum is stirred up by sweeping or attrition of other kinds.
In a boarding-school or family when a diphtheria patient is found, select a room set off as far as possible from the rooms commonly used, and before putting the patient into this room remove all curtains, upholstered furniture and carpets from it that are not so cheap or so worn that they may be destroyed after the patient's convalescence, or which are of such texture that they will not be destroyed by water or disinfection by heat. In any case the less there is in the room the easier the disinfection will be.
Use the mattress upon which the patient had slept before you discovered the nature of the disease. Books should be removed, because an infected book can not be disinfected except upon the outside. The room is not to be swept while the patient is in it,—dust may be wiped up with a damp cloth. The cloth is to be disinfected before it is sent out of the room.
The popular notions regarding sulphur as a disinfectant after diphtheria are erroneous. Sulphur fumes in certain definite quantities will disinfect after smallpox, scarlet fever, measles, and some other diseases; these fumes will also kill the diphtheria bacillus, if the bacillus is wet and exposed directly; but if it is buried in sputum or in clothing the fumes will have no effect whatever upon it. The disinfectants to use are acid bichloride of mercury and heat. Formaldehyde does not penetrate well enough to be reliable in diphtheria.
{191}
When the patient is taken to the room prepared, let a mixture of one ounce of bichloride of mercury in the powdered form, in two ounces of common hydrochloric acid (not the dilute hydrochloric acid used in medicine), be obtained. This is a violent poison, and it must be kept out of the reach of children and careless persons. Two teaspoonfuls of this solution in an ordinary wooden bucket filled with water to within two inches of the rim makes the disinfecting mixture. A wooden washtub nearly filled with this disinfectant, mixed in the bucket as directed, should be kept near the door of the room, and all towels, sheets, and soiled linen must be soaked in this tub for twenty-four hours. After that any one may handle these articles with perfect safety. The articles that have been soaked for twenty-four hours should be rinsed in ordinary water to remove the acid, and they may then be washed. The nurse should not touch the outside of the tub with infected articles while putting these in the disinfectant. Do not make the disinfectant stronger than directed here, or it will destroy the articles soaked in it, and for the same reason do not leave them in it longer than twenty-four hours.
If the attendant can be kept isolated with the patient there will be less liability of carrying the infection through the house. In a majority of cases in families, however, the mother is obliged to care for the patient and to attend also to her household duties. In the last case, let her keep near the door of the room a cotton wrapper which can be put on over her dress whenever she enters the room. She had better tie a towel over her hair. In the room a china-stone basin should be kept, containing a gallon of water, in which there is a teaspoonful of the acid bichloride. Every time the attendant touches the patient let her wash her hands in this mixture, using no soap. She should remove her finger rings or they will be blackened. The patient should not be handled except when absolutely necessary, to avoid needless exposure to infection; it is also injurious to a child ill with diphtheria to lift it up. The nurse's covering wrapper should be soaked in the tub as often as possible. Some ignorant persons give as an excuse for a lack of care in{192}handling patients having contagious diseases like diphtheria, that they are not afraid of the infection. Fear has nothing to do with the matter.
Food is to be taken to the door of the sick-room by some one other than the attendant. The tray should not be carried into the room. After the meal, take to the door a pan containing water, and let the attendant set the dishes, knives and forks, and the food handled by the child, under the water without touching the rim or sides of the dish-pan. Then any one may carry the pan to the kitchen, where it is to be set upon the stove, and the water holding the dishes and the rejected food is boiled for an hour. After that process the contents of the pan are safe, and they may be handled for washing. Cloths used in wiping the mouth of the patient are to be wrapped in paper and burned. Dejecta should be covered with fresh chlorinated lime, one part to two of water.
After the patient begins to convalesce the danger of infection grows greater. When the membrane has disappeared, and the child is able to run about the room, the attendant ceases commonly to use the throat-spray because the process is troublesome. In such cases the diphtheria bacillus remains in the patient's mouth for some time—from a few days to weeks. During the most of this time the child is as dangerous to others as it was while it was ill. In one case in my own experience, the bacillus remained present for eleven weeks from the date of diagnosis, and I then lost sight of the child. In the tenth week the bacillus present when in pure culture killed a guinea-pig in thirty-six hours. This is, of course, an exceptional occurrence; but the routine practice is to keep the patient isolated for three weeks after the membrane has disappeared, unless a bacteriological examination shows that the bacillus is absent. The bacillus remains after the use of antitoxin just as if antitoxin had not been used.
When a child is to be released from the sick-room, bathe it carefully with soaped warm water, washing out the hair and under the finger-nails carefully. Then wet a towel with the disinfectant (the acid bichloride of mercury,—a{193}teaspoonful to a gallon of water) and go over the body with it; afterward rinse with ordinary water. Do not let the disinfectant enter the child's mouth or eyes. Next, without allowing the child to touch anything in the room, especially avoiding the door-knob, send it to another room and dress it in clothing that has not been near the sick-room. If, after this process, other children are infected, the explanation is that the child had been released too soon—before the bacillus had disappeared.
It commonly happens that a child has been going about the house for some days before a physician has been called in. In that event you have the house to disinfect. You must then wet with bichloride everything the child has touched, and boil all eating utensils.
As to the disinfection of the room and its contents: the irritation of diphtheria causes a large quantity of saliva to flow from the patient's mouth; this infected saliva runs down upon the pillows and soaks into them. It may also soak into the mattress. If a town has a steam disinfecting plant, there is no trouble in dealing with bedding and carpets after diphtheria and other contagious diseases; such a plant, however, costs at the least $6000. It is safer, in the absence of steam disinfection, to destroy pillows by fire; but if these are opened and the filling put into tubs or barrels containing two teaspoonfuls of the acid bichloride of mercury to each gallon of water and soaked for about two days they will be safe. The ticking in this case should be boiled in a wash-boiler, and the filling is to be rinsed before drying. The mattress is less liable to infection but it may be infected. If a piece of oil-cloth or rubber sheeting is spread beneath the bed-clothes under the patient and the mattress is kept well covered during the course of the disease, the filling of the tick will most probably be not infected. The loss of a good feather or hair mattress is considerable in the house of a poor man, and these often may be saved. To disinfect the surface of a mattress place it on chairs in a small room or in a closet and pour upon a cloth under it 500 cc. of formalin for each 1000 cubic feet of air-space in the room or closet—multiply the length by the height by{194}the width of the room or closet to get the cubic feet of air-space. Leave the room or closet shut tightly for twenty-four hours. The Trenner-Lee formaldehyde disinfector is a good apparatus for disinfecting. The smaller size costs twenty-five dollars.
If anything is to be sent out of a room to be burned, spread a piece of old carpet, bagging, or similar useless cloth outside the room door, set on this the articles to be destroyed, wrap them carefully in the fabric, tying all with cords; then take the bundle outside the town in a covered wagon, pour kerosene oil on the package without opening it, and set it afire. Afterward wash the wagon with the acid bichloride.
Wet the furniture and floors of the room with the acid bichloride. Do not merely sprinkle the solution about, flood everything with it, because the germ is killed only by direct contact; and remember that a diphtheria bacillus magnified 800 times is not larger than the eye of a needle. The bichloride will spoil gilt picture-frames, therefore use a 10 per centum solution of pure carbolic acid on these and all other metallic surfaces. Coins should be boiled, and paper money should be dipped in the 10 per centum carbolic acid solution and dried at a stove. Money is frequently found in smallpox rooms under the patient's pillow.
Formalin is the best disinfectant for wall-paper unless the child has spat upon it—then use the bichloride. Sometimes the bichloride will not injure the wall-paper, but if there are gilt figures upon it these will be blackened. Sulphur fumes are no better than formalin—not so good, and they injure and blacken tinted and gilded wall-paper, silks, satins, and other fabrics. If you determine to have the room repapered, wet it with bichloride before you bring in the workmen.
It is difficult to disinfect a carpet except by steam, and on this account the carpet should be removed from the room before the patient is brought into it. If it has been kept in the room, wet it thoroughly with the bichloride, when you are disinfecting, if you can not have it disinfected by hot steam. The wetting commonly spoils the carpet, consequently it may be necessary to bum it.
{195}
Keep cats, dogs, and especially kittens, out of a diphtheria room. Kittens will take the disease easily, and cats and dogs will carry about the contagion. If a valuable dog should get into the room, disinfect its hair thoroughly with the acid bichloride and then rinse the hair. Be careful to disinfect its feet.
While using the bichloride do not forget the window-panes, the door-knobs, and that part of the chair-legs which touches the floor. After you have used the bichloride expose the room to the gas from formalin. Hang up sheets wet with 500 c.c. of formalin for each 1000 cubic feet of air-space, and close all keyholes and cracks; then leave the room shut for twenty-four hours.
As to the use of antitoxin as a preventive and cure for diphtheria, too much praise cannot be given to that wonderful discovery. Reliable diphtheria antitoxin, used in proper quantity and early enough, is almost an absolute cure. Where it fails it has been used too late or not in the proper dose. In any case its only evil effect may be an attack of nettle-rash or hives. The few deaths that have occurred in its use were caused by an ignorant use of the syringe. If you find a physician opposed to the use of antitoxin this simply means that he is a quack. One serious disadvantage in the use of antitoxin is that it leaves the dangerous bacillus in the throat of the patient about as long as an unaided convalescence would leave it. The membrane often will disappear in twenty-four hours where antitoxin has been used, and the child will be playing about the floor. Then the mother will say the child never had diphtheria; she will not disinfect, and she will let the child run about the house.
The free book system that prevails in some schools is a prolific source of infection. Books are infected at home or by children from infected houses, and mixed with other books in the school. The diphtheria bacillus will cling to a book for at least a year. If books are given to the children, give them outright; do not let the books be mixed in the schoolroom.
Drinking-cups used in common are another source of{196}infection. Let each child have its own tin cup. The clothes-rack in a school also spreads infection. Room enough should be given to each hook to keep the hat and coat of one child from touching those of another, and a wooden partition standing out from the wall about eight inches should separate hook from hook. The janitor should wash the clothes-racks with the acid bichloride solution every time he sweeps.
Suppose a child having diphtheria is found in school, or one is discovered as coming from a house where he was in contact with diphtheria. The discovery is made commonly after the child has been spreading infection for some days. Do not frighten the youngster, but find out from him what parts of the school-building he has been visiting. Then send him and the other children home. Rooms in which the child has not been are not infected, and only that which he has touched is infected in any case. Wet everything in the building and outhouses with which he possibly could have come in contact with the acid bichloride. Burn his books and papers, or, if this action may cause difficulty with parents, let him take his books home and inform the health officer of that fact. When he returns to school be sure of the history of his books. Use formalin or sulphur in the infected rooms, and classes may be begun again the next day. If within the week any child shows signs of sore throat send it home immediately.
Sulphur must be burned when used as a disinfectant, and to be effectual four pounds should be burned for every 1000 cubic feet of air-space in the room. A teaspoonful of sulphur when burned will fill a house with choking, dangerous fumes, but two pounds of sulphur burned in an ordinary bedroom will have no effect whatever on the diphtheria bacillus and very little on any other disease. Sprinkling disinfectants about a house, and setting saucers containing disinfectants in rooms is nonsense—the quantity must be sufficient and be in actual contact with the contagion. A deodorant does not disinfect because it removes a stench.
To burn sulphur set a coal-hod or an old tin pan on two bricks in the middle of the room, but see that there are no{197}holes in the bottom of the hod or pan through which burning sulphur could drip to the floor. For a like reason see that the pan is not too narrow nor too shallow. It is safer to set the bricks in a tub filled with water up to the top of the bricks. Use powdered sulphur in preference to the cakes sold by the druggists, and fire this sulphur with a red coal. The room should be moist with steam when the sulphur is set afire so that the fumes will act effectually. Leave it shut tightly for twenty-four hours.
In the Northern States diphtheria is most prevalent in October, November, and December; scarlet fever is an April disease, but it may occur at any time. It is easier to spread the infection of scarlet fever and measles than that of diphtheria, but it is not so difficult to disinfect after scarlet fever and measles as after diphtheria. The contagion of scarlet fever does not resist the fumes of sulphur or formalin. Disinfect a room after scarlet fever as for diphtheria but be sure to use also either sulphur or formalin because the contagion can float about a room. Eruptive contagious diseases like scarlet fever, smallpox, and measles so affect the skin that during convalescence the cuticle scales off. In severe cases of smallpox and scarlet fever the entire outer skin of the hand may peel off like a glove. The contagion is always found in the scaling skin. As the patient grows stronger the scales become finer, until at last they lie as mere mealy dust in the hollows of the elbows or other parts of the body. Down to the very last these scales are infectious, and they will retain the infection for months, probably for a year or more. The scales float in the air of a sick-room, fall on the clothing of visitors, are carried away by the shoes of those that leave the room. The scaling may continue for three weeks—it commonly does. These three diseases are infectious before the scaling begins, sometimes before the rash is well out. A very light attack of any of these diseases in one child may infect another fatally. Insist upon keeping a scarlet fever or measles patient out of school until all scaling has ceased.
Chickenpox is almost a harmless disease, but it is more infectious than even measles. Be cautious with it because{198}nearly every epidemic of smallpox begins through some one mistaking smallpox for chickenpox, although there is little or no similarity between the diseases.
A child with tuberculosis of the lungs or a child infected with acute syphilis should not be permitted to go to school under any circumstance.
In the chapter on The Priest in Infectious Diseases will be found an account of the necessity of vaccination as a precaution against smallpox.
Tinea Favosa, or favus, is a contagious and a very stubborn disease of the skin, caused by the fungusAchorion Schoenleinii. It produces yellowish crusts about the hairs of the scalp and other parts of the body, and it destroys the hair. It attacks also the finger-nails and the skin that is without hair. In the later stages of the disease there is a foul odour. It is one of the most difficult of the scalp-diseases to cure; months and sometimes years are required to get rid of it.
A child with tinea should be kept away from school; and his desk and what he touches should be washed with the bichloride of mercury solution. Burn his books and papers.
Ringworm is a kind of tinea, and it is caused by various mould fungi. Tinea Tonsurans is ringworm of the scalp; Tinea Circinata is ringworm of the body; Barber's Itch is another form; there is also a ringworm of the finger-nails; and Pityriasis Versicolor is still another form. All are contagious, and some are difficult to cure because the parasite gets down between the skin and the hair-follicles and an antiseptic can not reach it. Children affected with these diseases should be kept away from school until they have been cured.
The presence of lice and of the Acarus Scabiei can bring about acute and severe skin eruptions. The Acarus Scabiei causes itch, but fortunately it is rare in America. These parasites go from person to person, hence a child having either should be kept from school until he is clean. A thorough washing will remove lice if they have not yet inflamed the skin, but itch requires a more vigorous{199}treatment. The desks of such patients should be disinfected and their clothing should be baked. They will probably be reinfected at home if the treatment is not applied to other members of the family.
Contagious Impetigo, or porrigo, as it was formerly called, is a skin disease common among children, and it may affect adults. It appears to be of parasitic origin, but the specific organism that causes it has not been isolated. The lesions in this disease are commonly discrete—separate one from another—but they may be crowded together. They are vesico-pustular and they are sunken at the top in the typical form. If they are not broken by scratching, they dry into a yellowish crust. The disease affects only the skin, but as it is contagious a child affected with it should be kept from school until cured. The desk and articles used by the child should be disinfected, and his books are to be burned.
Whooping-cough is very infectious, and, contrary to the popular opinion, it is frequently a fatal disease. There is a period of incubation for from seven to ten days, then a catarrhal stage follows in which the child has the symptoms of an ordinary "cold." In about another week the dry cough becomes paroxysmal with the characteristic "whoop" when the air is drawn in after the fit of coughing. When there is an epidemic of whooping-cough, children with "colds" should be sent home from school. The objects used by a child that has whooping-cough should be disinfected, and its books and papers are to be burnt.
Mumps can be a serious and a very painful disease and it is infectious to a marked degree. The specific organism is not known. Boys are more liable to this disease than girls are, and recurrence is rare. After a period of incubation, which lasts from two to three weeks, there is fever, pain under one ear, and the parotid gland swells. The disease is commonly mild, but it may affect a child seriously. The patient is to be quarantined, what it has touched should be disinfected, and its books are to be burnt.
There are a number of infectious eye diseases that occur among school-children. Acute Contagious Conjunctivitis,{200}or "pink eye," is one of the most important. One form of acute Contagious Conjunctivitis is caused by the Koch-Weeks Bacillus; it is "pink eye," properly so called, and it is very infectious. Objects handled by the patient can infect others and spread the disease. The attack is severe, but the prognosis for full recovery is good. The child should be strictly quarantined until all secretion from the eyes has ceased, and whatever he has touched is to be carefully disinfected.
Another form of Acute Infectious Conjunctivitis, less contagious than that caused by the Koch-Weeks bacillus, is brought about by the introduction into the eye of the bacteria that give rise to pneumonia. Commonly the pneumonia bacteria do not cause conjunctivitis unless the patient is susceptible in a special manner. As it is difficult to differentiate this second form from the first, the same precaution should be used.
Trachoma, called also granular conjunctivitis, Egyptian ophthalmia, and military ophthalmia, is a very serious inflammatory disease of the external eye which has of late years become prevalent in American cities, whither it has been brought by immigrants from eastern and southeastern Europe. Persons that have this disease on landing in the United States are deported, but despite this precaution it has crept in and is now endemic. It is contagious, and when well established it is extremely difficult to cure. If untreated it lasts for years and it may destroy the cornea and consequently the sight. A trachomatous child should be kept from school until it has been cured, and that cure will take a very long time.
The Gonococcus can be carried into the eye by handling objects like soap, towels, wash-basins, which have been used by persons afflicted with gonorrhoea. The infection of the eye is very severe and dangerous, and the usual quarantine is to be observed. The ophthalmia of the new-born is gonorrhoeal.
The Diphtheria Bacillus also may get into the eye, and set up a primary infection there. A membranous conjunctivitis, too, is at times induced by pus organisms.{201}Xerosis Epithelialis, tuberculosis, leprosy, and syphilis may affect the eye primarily, and additional forms of eye-diseases are found that are infectious. The general rule, then, is that children with any inflammation of the eyes are to be kept out of school until a physician pronounces them harmless.
AUSTIN ÓMALLEY.
{202}
Priests have to put up buildings for parochial schools, colleges, seminaries, orphan asylums, convents, and the like, but in such work sanitation is commonly given only a passing thought in connection with sewer-traps and these are left to the wisdom of a plumber. The physical welfare of youth is almost as important as its mental training, and there are many factors beside sewer-traps involved in the effort to sustain it.
If there is freedom of choice as regards the site of a schoolhouse or similar building, the top of a small elevation is to be selected. Such a position affords the best natural drainage, removes dampness, avoids inundations, gives full sunlight and the purer air. The top of a high hill may be too exposed to the wind.
Next to the top of a knoll, the southerly slope of a hill is to be chosen. The building should not be overshadowed by a hill, especially on the western side. Trees are not to be planted close to a building in which children live, and ivy and similar plants should not be permitted to cover the walls.
If a building is set in a hollow it will be surrounded with chill air and mists in the cold seasons, even if a costly drainage system keeps the cellar and basement dry.
A gravelly or sandy soil beneath a building is the best, provided this soil is not already saturated with organic matter, or is not close above a dense layer of clay or rock. Clay, marl, peat, and made soils should be avoided if possible, because they are full of organic matter; they are cold, and they infect the ground air. Rock does not make a good building site—its seams carry water.
{203}
The subsoil should be drained four or six feet below the cellar floor, and this floor is to be laid in concrete and cement. At the level of the ground there should be a course of hollow vitrified brick to exclude dampness and to give ventilation.
Limestone walls conduct more heat in and out than an equal thickness of glass, bricks, plastering, and wainscoting. The porosity of the building material determines the interchange of the air through the walls, and it affects the temperature of the rooms. If there is water in the pores of the walls heat is conducted rapidly, but air is not permitted to pass. Brick as a building material has many disadvantages, but on the whole it is best for schools, and it resists fire better than most stones. The harder the brick the better it is—vitrified brick is the best. Hard-pressed brick of a light colour makes an excellent outer wall-surface.
It is very doubtful that sewer gas escaping into a house will directly carry the micro-organisms of diseases like typhoid and diphtheria, but such gas is poisonous, depressant, and it renders the inmates of a house liable to disease; lessens their power of resistance. The typhoid bacillus and other bacteria can, of course, be carried into a cellar by the seeping in of drainage water. Infants kept in the upper story of a house in hot weather are more liable to intestinal diseases than are those that live on the lower floors, but here the weakening agent is heat. Tuberculosis, scrofula, rheumatism, neuralgias, bronchial, and kidney affections are made worse in damp houses.
The chief defects in plumbing and drainage are the following: (1) Earthen pipe drains become broken or their joints leak, and they saturate the ground under a house with sewage. (2) Tree roots break and clog drain pipes. (3) The pipes sometimes have not fall enough. (4) Drains without running traps admit sewer gas. (5) Rats burrow along a drain pipe from the sewer into the house and admit sewer gas. (6) When the soil pipe from a water-closet is exposed in cold weather it may freeze up or be clogged by urinary deposits. (7) Rats gnaw through lead pipes and joints. (8) Two or more closets or sinks with unventilated{204}traps on the same pipe will siphon back sewage. (9) Overflow pipes sometimes have no traps and they let in gas. (10) Ash pits near a house carry moisture to walls, (11) Cesspools leak through the soil.
In planning a school-building the classrooms and the study-halls are the first things to be considered. The classrooms should be oblong, with the aisles running lengthwise. Each child should have at the least 15 square feet of floor space and 200 cubic feet of air space. A room 30 by 25 feet with a ceiling 13 feet from the floor will serve for 48 pupils and no more. This is the best size for a room when blackboards and maps are used in teaching, because a larger room sets the children in the back seats too far away to see without eye-strain.
Dormitories should have at the least 300 cubic feet of air space for each child, and great care is to be taken in the ventilation. Children about 10 years of age require 11 hours of sleep; under 13 years, 10-1/2 hours; under 15 years, 10 hours; under 17 years, 9-1/2 hours; under 19 years, 9 hours. Do not make children get out of bed before seven o'clock in the morning; do not let them study before breakfast, and do not force them to work after half-past eight or nine o'clock at night until they are at the least 17 years of age. The hours for work should be:
Ages--FromHours of work a week5 to 666 to 797 to 8128 to 101510 to 122012 to 142514 to 153015 to 163516 to 174017 to 184518 to 1950
Work given for punishment must be included in these hours. No one, even an adult, should study for more than two hours at a time without an intermission for a few{205}minutes. In a boarding-school no one under any pretext, even on rainy days, should be permitted to study during recreation hours, and the deprivation of recreation to make up lessons is a relic of barbarism. If a teacher can not get class work done except by shutting up children during recreation hours, remove the teacher or expel the pupil.
The amount of glazed window surface admitting light to a classroom or study-hall should be from one-sixth to one-fourth the floor space of the room, and this must be increased if the light is obstructed by neighbouring houses or trees. The light is to be admitted on the left side of the pupils,—all other windows should be counted as ventilators only. Windows facing the children or the teacher are to be avoided. In rooms fourteen feet high a desk twenty-four feet from a window is insufficiently lighted. The larger the panes of glass the better, and the external appearance of windows is to be sacrificed to good lighting. If screens are used to protect the glass from stone-throwing, allowance is to be made for the light the screens cut off.
If a room can not have enough light from the left side alone, put the additional windows on the right so that their lower sills will be eight feet from the floor; and be careful in this case that the light from the right is not brighter than that from the left.
Windows should have as little space as possible between them to avoid alternate bands of shadow and light. Set them up as near the ceiling as possible, since the higher they are the better the illumination; and they should not be arched at the top. The lower window sills may be about four feet from the floor. When window shades are used to cut off direct sunlight, they should be somewhat darker in colour than the walls.
If artificial light is used in boarding-schools in the study-halls, the best light is one that is as near in colour as possible to the white light of the sun, and ample, but not glaring. It should be steady, and it should not give out great heat nor injurious products of combustion. Hence the electric light is the best; after that, gas through Welsbach{206}or Siemens burners. Well refined kerosene oil gives a good light, but it is always dangerous. Acetylene gas is now used in a safe apparatus, and it also is an excellent light.
No colour that absorbs light should be used on the walls. Pale greenish gray, nearly white, is the most satisfactory colour. There should be no wall paper, curtains, or hangings of any kind in a school or college building. The wall decorations should be as plain as possible, with no roughened places to catch dust.
Stairways are to be well lighted; they should be at the least five feet wide, and have landings half-way between each story. Diagonal or spiral stairways are dangerous. Steps with six-inch risers and eleven-inch treads are the easiest for children, but six-and-a-half-inch risers may be used in high schools and colleges.
Carbonic acid in the air of a classroom is an index of impurity. External air has about three parts of carbonic acid in 10,000 parts of air, and above seven parts in 10,000 is injurious. Each person exhales about fourteen cubic feet of carbonic acid gas in an hour. There is no easy method of determining the quantity of carbonic acid gas present in a room, and we must therefore arrange the ventilation so that about 3000 cubic feet of fresh air an hour will be supplied to each person in the house.
Beside carbonic acid there are other impurities in house air, as dust, micro-organisms of disease, exhalations from bodies, sewer gas, and the like, which accumulate and do injury when the ventilation is defective.
If every person in a house has 1000 cubic feet of air space, natural ventilation will suffice ordinarily, but artificial ventilation is needed in schoolrooms and dormitories. The subject of ventilation can not be satisfactorily discussed in a short article, and those that are interested in school building should leave the matter to a competent architect, or study books and articles like J. S. Billings'Ventilation and Heating, Pettenkofer'sUeber Luft in den Schulen, and Kober's article on House Sanitation in theReference Handbook of the Medical Sciences.