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THE MAUI NEWS
SATURDAY, SEPTEMBER 11, 1909
3
College
Men
Lecture
I
College of Hawaii Professors
Lecture.
(Continued from last issue.)
Sonu'tiiiiPS tlii'io is direct contact
between tlic patient unci tbc victim,
but innro often tbe victim is un
known to tbe pntient. Tbe modes
of convoynnco nmy not be always
know, but modern bacteriology
sbowstlint there must be some mode
of conveyance, and that the disease
cannot be produced by bad air, bad
water, bad food, faulty plumbing or
by climatic' conditions unless the
typhoid bacillus is present. San
itarians hold that every case of
typhoid is a focus of infection, that
virulent bacilli can and do leave the
body of the patient and that these
bacilli may become scattered and
give rise to new cases, unless proper
precautions are observed. '
Carriage by water is one of the
most important modes of transmis
sion and the one which, by reason
of the magnitude of its effect in
large communities, and the specta
cular character of frequent epide
mics, lias most attracted the atten
tion of the public Transmission
by ilies from infectious matter in
the privy, to food in the kitchen,
or from improperly guarded fecal
discharges to unscreened houses is
probably of frequent occurrence,
especially in summer and in rural
districts ami may be one of the
causes of the summer and autumnal
typhoid. It is also well recognized
that milk, oysters, and other shell
fish, raw fruits and vegetables from
gardens fertilized by human excreta
or handled by persons sick with
typhoid,' may carry the bacilli. Nor
should transmission by contact b
overlooked; a patient who sneezes
in his nurse's face: . a convalescent
who handles a piece of cake or other
dainty and passes it to another
member of the family, or who
shakes hands with a friend or who
uses the "family towel," may un
wittingly spread the disease, for
typhoid is both infectious and con
tagious.
The first fight against the spread
of typhoid bacilli must be made in
the sick room, and this responsibili
ty rests upon the attending physi
cian. The first duty of the doctor
is of course to his patient, but his
second is toward the other members
of the household, and the third to
the community; and, the physician
who neglects the last two should 1m?
considered guilty of malpractice, as
truly as he who neglects the first ;
The conscientious doctor therefore
acts in a dual capacity as medical
adviser and sanitary guardian, ex
.officio. Inasmuch as modern modi
cal treatment does not aim directly
at destroying the bacilli in the body
but rather endeavors to maintain
the normal functions in order that
the body may protect itself, the
number f bacilli discharged ' from
the body is necessarily large and it
is therefore of prime importance
that all discharges be effectively dis
infected. This duty usually falls to
the nurse and should be done in ac
cordance with regulations of the
Health Board or as the physician
directs. The original responsibility
rests with the physician and he
should not only give explicit direc
turns regarding disinfection, but
should see that they are carried out
The usual disinfectants employed
are chloride of lime, corrosive sul
lunate, ordinary slated lime, car
Imlie ac-iil, for formaldehyde, and it
is important that a sufficient quan
tity be employed to secure thoroug
disinfection. In a large majority
of typhoid cases, particularly among
the lower classes, disinfection
now conducted is a mere farce. Th
disinfection and disposal of typhoi
excreta is a matter of public concern
anil should Ik- supervised by tl
local health officer, just as much
rooms in which diptheria and sear
let fever cases have Urn confined
are disinfected. It cannot Ihj ex
jwteil lliat tlic iicluiil work bo ilone
by ii public licit 1 1 1 1 agent, but tlic
oard of health should furnish the
chemicals and see that they are pro
perly used. Harmonious action be
tween the health board, the physi
cian and the nurse does much to
ward efficient disinfection. If the
public health board is to share the
sponsibility of disinfection, they
must be informed of the occurrence
f the disease, and most sanitary re
gulations require physicians to re-
ixrt cases of typhoid as they occur;
ut there is an almost universal
arelessness among physicians in re
porting cases, which is most dicre-
litable to the profession, as it shows
not only a lack of appreciation of
the value of public' sanitation but
an utter disregard for law. Health
officers wJio arc responsible for the
nforeement of its registration laws
should be far more strict and should
exact full penalty for non-com
pliance. The existance of an epide
mic in a community is frequently
not recognized until delayed reports
accumulate in the office of the
health board, or until local gossip
or the local press has called atten
tion to it. Many days of valuable
time, which might have been used
in searching for the cause of the
disease, or in inaugurating a system
of prophylactic measures are thus
st, and it is no exaggeration to
state that many lives have been lost
K'cause of the failure of physicians
report their cases promptly.
There are three tilings, therefore.
which the physician can do to pre
vent the spread of typhoid fever
laerlli; first, to adopt such meas
ures with the patient as to reduce
as far as possible the number of
acilli which leave the body; second
, or'ler proper disinfection accord
ing to the requirements of the
health board; and third, to report
the case, as soon as suspected, to
the lioard of health, in order that
the public authorities may supply
the needed disinfectants,, and super
intend the disposal of infectious
matter.
Sanitary science has been called
the Gospel of Cleanliness," and
this lias a special moaning in cases
of typhoid whore "disinfection and
cleanliness' are so important. Jf
wo consider that the walls of the
sick room constitute the boundaries
of the first barrier, the second line
of enclosure is that which surrounds
the promises whore the patient
dwells, Some typhoid bacilli are
sure to pass out of the room," and
upon the nurse and attending mem
bers of the family devolves the real
task of extermination, and control.
This includes disinfection of fecal
matter, of urine, of sputum- and
vommitted matter, of water used in
bathing the patient, of bedding,
towels, napkins, handkerchiefs,
sponges used about the patient; dis
infection of knives, forks, spoons,
cups, etc. used by the patient, dis
infection of the han'fls of the at
tendants, of water-closet or privy
seats, and privy vaults and cess
pools, proper disposal of excreta and
urine by burial or otherwise and the
screening of privy vaults to prevent
access of flies." Inasmuch as the
typhoid bacilli do not form spores,
and are easily killed, the disinfec
tion of infectious matter from
typhoid patients js not at all diffi
cult. The chemicals required are
not expensive and may be easily
and safely manipulated. They
should however, be used in arge
enough quantities to thoroughly mix
them with the discharges, and to
give them time enough to act.
There is no hotter substance for the
general purposes of disinfection than
slaked lime. It has many ad
vantages also and is so well known
that no one fears its use, w hich can
not Ik' said of some other disin
fectants, many of which have odors
which people dislike, are powerful
poisons and must Ik- used with can
tion.
Almve all things, cleanliness i
required on the part of attendants,
lx)th in the interests of sclf-proto(
tion and that of preventing the
spread of the disease to other nieiii
iters ol the lioiisi'hoM. tins is
especially necessary in the sick
room. A drop of urine or a spook
of fecal matter no largeithifn a pin
head may contain hundreds of thou
sands of bacilli, hence care against
the spattering of such matter is im
portant. In caring for a patient.
the hands of the nurse are very like
ly to come in contact with infections
matter. Washing and disinfecting
the hands after leaving the bedside
are therefore demanded. A care
less attendant going from the iVd-
side to the kitchen and there pro-
pairing the family meals may convey
the disease to the entire household.
Cases in which this has occurred arc
on record. The sick room should
be thoroughly screened to prevent
flies from carrying about the infec
tion. The work of disinfection and
the can; exorcised by the household
of the typhoid patient constitute the
second and most important barrier
against the spread of the disease.
The final responsibility for the
prevention of the spread of typhoid
fever rests with the 'public, acting
through their board of health, and
in general this requires:
1 Consideration of reports of
physicians.
2 Diagnostic tests,
I? Supervision of the disposal of
infections matter.
4 Distribution of disinfectants.
5 Purification of sewage.
Many doctors hesitate to report
cases for fear that their reputation
may suffer through an occasional
faulty diagnosis. Everything should
be done to make the work of report
ing as easy as possible. The board
of health having received the report
of suspected ease should ho prepared
to verily the same, winch involves
the application of the Widal test to
the blood of the patient, or sunn
equivalent test and requires the
services of a bacjcriologist and a
laboratory equipment. Most of the
large cities are now able to do this
work, but in the ease of small com
munities which cannot bear the en
tiro expense, it should bo lone by
the county, or state, or conducted
by some cn-nperation basis. '
The largej- questions of the dis-
posal of sewage and other wastes of
the community are emphatically
public matters though they fall
within the domain of the enginoer-
ing departments of a city rather
than that of the department of
health as ordinarily constituted. A
number of years ago a sewerage sys
tem was considered to be complete
if it satisfactorily collected without
nuisance the sewage from the houses
itnd let it go somewhere, anywhere,
into the harbor, into the lake, or
into the river, according to situation
out of sight, out of mind. Sewer
gas was regarded as dangerous; the
sewer liquid was regarded merely as
a nuisance. Now this is reversed
and the liquid sewage, germ laden
and 'infected, is known to bo the
thing to be most feared. Sewage
disposal is therefore not looked upon
as being quite as important as sew
ago collection. Recent years have
seen some extraordinary develop
ments in the art of sewage purifica
tion and coining years are destined
to see far greater advances. There
is much misconception of the sub
ject of sewage disposal. Sanitary
problems are not noecssarily involv
ed although they usually are to some
extent. In some places it may be
merely a question of nuisances, ami
it must be rcmuuiljcrcd that a st ream
that has bad odors and which is of
fensive to the sight will not cause
typhoid unless the typhoid germs
are in the water and unless the
water gets into the mouth.
lucre -arc various methods ot sow-
age purification, some of them mod
ern, involving septic tanks, chemi
cal precipitation basins, contact
beds, sprinkling filters, etc. These
and similar agents arc usually ins
talled for the purimse of improving
the chemical character of the sew
ago, and to prevent its subsequent
decomposition, with attendant nuis
ances. If properly built ami proper
ly operated, and enlarged from lime
to time according to need, they ac
complish in a satisfactory manner
the work for which they are design
ed; they oven do mon they ac
complish a marked bacterial purifi
cation of the sewage. I!ut the chief
function of such processes is to ties-
troy dead organic matter, not living
organisms, although living organ
isms are involved in tie- process.
They do not render sewage fit to
drink; and if the ollhu lit is turned
into a stream which is used fur
drinking, some danger of contami
nation still remains. Some systems
reduce the danger of contamination,
but (hey do not wholly remove it.
In this respect the old systems of
purification by intermittent filtra
tion and broad irrigation are more
to be depended upon, but oven those
processes are not complete. There
is a growiiyj; feeling among sanitar
ians that nothing less than a sec
ondary filtration of the sewage efflu
ent, carried out substantially on the
linos of1 water purification, or a dis
infecting of the effluent by means of
chemicals, is necessary in order to
render sewage free from pathogenic
bacteria.
Whether or not the sewage of a
city or town should he purified to
such a degree as to destiny patho
genic bacteria, is a question which
must depend upon local surround
ings and must be decided independ
Vntly for each particular case. If
the sewage of a city flows into a
stream used in its lower reaches for
purposes of public water supply,
that city is at least morally bound
to keep infectious matter out of the
river. The courts are beginning to
decide that where a city is provided
with public sewers the municipality
is responsible for any damage occa
sioned by the pollution of a stream
by this sewage. Although thus far
this decision has been applied only
to cases of common nuisance, in
time it may be extended to cover
eases of infection .
The public authorities can help to
prevent the spread of typhoid as
well as other diseases by bringing
about conditions of general cleanli
ness. "Dirt breeds disease.'1 One
cannot toll how far this trite saying
extends, hut every year bears new
testimony to its truth. Hies, which
may be often the means of trans
mitting typhoid germs, develop from
i eggs'; and these eggs are very coin
monly laid in manure piles. Dr. L.
). Howard, the entomologist of the
lT. S. Department of Agriculture,
state s that' the house-fly prefer
manure asii brooding pi; , although
at may brood in other fecal matter.
Dangers may arise1 from the location
of stables, in crowded communities,
ami hence strict rules should he
made in regard to the t are ami stor-
lge ol manure. 1 lie disposal ol
garbage has a direct bearing on ty
phoid propagation, as the common
little fruit fly is likely to he the
moans of carrying the bacillus.
The war on flies has scarcely he
gun; when it does begin it will in
volve many reforms. Among these
will bo cleaner streets ami especially
the prompt removal of horse manure,
better care of stables, better care of
wharves ami markets, better pro
tection of garbage pails, better care
of vacant lots, and a general attempt
to eliminate the breeding places of
Hies and insects More attention
will be given to screening public
buildings, school houses, restaurants,
hotels, etc.
In these various ways the public
authorities representing the whole
people, can establish a final and ex
ceedingly important barrier against
the spread of the typhoid bacillus.
I'ntil recently the death rate in
our country from typhoid alone has
been a national disgrace, but thanks
to our leading sanit'iry experts, sueh
as llering, SojK-r, (iorgas, Wood,
Sedgwick, and others, that might bo
mentioned, typhoid is not the
scourge it was a generation ago, and
every year is witness to a decreasing
death rate from its ravages.
If a public authority undertakes
to supply a city or town with think
ing water, it would seem self-evident
that sueh autority assumes the res
ponsibility of seeing that the water
is pure and wholesome. If the supply
is furnished by a private water com
pany, it would seem that the burden
burden of protecting the consumer
against water borne disease rests
with the company ; yet in general
those burdens are lightly borne, and
in many eases, the failure to appre
ciate the In-setting dangers of jx1-
lution has resulted in wide-pread
sastors of appalling magnitude.
Sanitary reforms have been known
to be postponed because of conflict
ing political interests or liecausc of
fajlure to appreciate the public
langor.
Not long ago a suit was brought
igainst a certain western city to re
cover damages because i if the death
of a person who died from typhoid,
caused, it was alleged, by the in
fection of the public water supply.
The suit was lost, but there are some
who believe that sueh suits will not
e lost in the future; when the pub
lic authorities will beheld legally as
well as morally responsible for
leaths duo to infected water.
Filtration affords the safest pro
tection of surface waters against
water borne diseases. This has boon
proved by long exerienee abroad,
and this truth is being constantly
demonstrated in America. In Law
rence, Mass. the typhoid death rate
after the city filter was put into use
fell from an average of 121 to 2(1 per
100,000. After the construction of
the filter in Albany, N. V , it fell
from 101 to 2(i; in liinghainpton,
from 1'J to 11; in Watertown from
7 to 27. In Philadelphia the death
rate has decreased greatly in those
sectHins of the city where the filters
have boon completed.
The two principal systems of
water filtration are sand filtration
that is, filtration at a slow rate
through bods of fine sand, sometimes
acres in extent; and mechanical fil
tration, which consists of a rapid
straining of the water through coar
ser sand after a process of chemical
coagulation. Each of these two
methods has its own field of useful
ness, and each is able to bring about
a satisfactory degree of purification
if properly carried on. Sand filtra
tion is especially useful and econo
mical for clear and colorless waters;
mechanical filtration is demanded
for waters which are either very
muddy or much stained. Often the
choice of the two systems is merely
a question of cost, and in most
oases, is a complicated engineering
problem, demanding the services of
an export. Filters purchased as a
ready made machine, are almost
never as satisfactory or as econo
mical as those designed by a com
petent engineer to lit the particular
local needs.
Typoid has in the pat been the
great scourge ot our army camps
and it has always been easier for
our soldiers to withstand bullet and
bayonet than to guard against the
ravages of the insidious bacillus.
That this was so in early days was
due to ignorance; that it has heen
so in recent days, lias been due to
carelessness; and if it continues, to
be so in the future, the ,vord
"criminal'' may not bo too strong.
At liloonifontein, in the South
African campaign duringthc mouths
of March, April ami May 1!)00 there
were 1700 cases and S'.K) deaths
among 10,000 troops. During tin
Spanish war of 18D.S, among 10S,-
000 troops quartered in our army
camps there were 20,700 cases of
typhoid and loSO deaths, and these
typhoid victims constituted of
all those who died from disease.
Such a death rate is simply appall
ing. It amounted to 11(10 per 100,
000 and the records did not cover a
whole year, but only the sunimt
months. The enormity of tlu
epidemic can he appreciated when
compared with the average of '55 per
100,000, for the cities of the United
States. The report of the com
mission which investigated these
epidemics states that the transmis
sion by personal contact, to the
agency of flies, and to the spread
of dry fecal matter' through the air
as dust .
When the appalling ravages of
typhoid ami the accompanying great
financial losses are considered, for
the average value of life of persons
dying from typhoid is glUol.U),
the sums siM-nt in preventing the
disease appear U-ggarly. This is
true all along the line from the gov
ernment of the nation to that of the
smallest village.
We need a national department
of health, thoroughly organized and
endowed with authority. ' The an-
una I provcntaoie losses trom typhoid
would more than support such a de
partment . i 'in' army medical corps
entirely inadequate to the service
mil organized upon a wrong prin-
iple. The losses of the . Spanish
war from typhoid would have paid
for an adequate service ten timis
over.
.Many cities of the country have
no hoard- nt health or health olll-
er- or if Ihev have, these officers
lie 1 1 1 1 1 -1 1 in nai uly, serving
without pay, and knowing little
iboiit tin- principles of sanitary
science. I o remedy these conditions
cost money, but it will pay. It
will pay not only in the satisfaction
having clean and healthful cities
to live in, not only m the joy of
having relieved suffering, and saving
f the dying, but it will pay in hard
ash. Although this country has a
oug road to travel before reaching
the goal of sanitary perfection, yet
luring the last decade it has t ravel -
1 a long way on that road. The
nation should lie proud of the state
of Massachusetts for her pioneer
work in sanitary science, it should
be proud of such an example as the
it v of Montclair, N. .1. jealously
guarding the health of her citizens;
it should be proud of the work done
by many civic organizations; many
an editor in his chair, many a law
yer struggling tor hotter sanitary
laws; many a family physician
loingsolf-sacrilicing work that liuiii
inity never dreams of, and many an
engineer working out on a large scale
what the laboratory student has
earned from his test tube and
microscope. 1 ho I nitod Mates
loiild bo proud of her citizens wlio,
ill ever increasing numbers, and in
many states are taking an intelli
gent interest in the care of their own
premises, in the sanitation of their
city, and in the universally import
ant subjects of health and clean
liness.
60 YEARS'
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