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We covered this point more or less briefly in discussing sterilization in the operating room, protection against the infection of wounds at the time of the operation, etc.; but there is another large class of infections that come later on, and that are due primarily, and I might say exclusively, to uncleanliness in the institution. One of the chief of these sources of annoyance is the bacillus pyocyaneus, or the ordinary green pus bacillus. The presence of this germ is annoying rather than actually harmful, because its presence is too often not recognized, and we let it go with the mere statement that the patient is not in good physical condition, and consequently the wound does not heal well. This infection usually comes late or toward the end of a surgical case, and so interrupts eventual recovery that the patient is held in the hospital much longer than would have ben the case if no infection had occurred.

The next most troublesome germ that we have to deal with is a diplococcus of gonorhoea which finds its habitat in the children's wards, and can easily run into the epidemic form of gonorrhoeal vaginitis. In our own institution we make smears of every female child seeking admission into the hospital. Nearly all of these cases come from the lower classes of society, and the patients usually visit the institution for some other trouble. We decline to take them wherever it is possible to do so, but where they must be admitted they are given a special nurse, and every instrument and utensil, and all dishes, clothing, bed linen, etc., are confined to the apartment, or thoroughly disinfected before again going into circulation. These cases, as a rule, do not get well within the ordinary time limits of an acute disease hospital, and the best that we can hope for is to subject the disease to a rather latent form, and we find that usually the infection returns actively after the child goes home and falls into the old unclean ways. The encroachment of this disease has assumed with us dimensions large enough to warrant community action, and it is certainly too widespread to be attacked by a single institution. It is a question what percentage of the next generation of women is to be rendered sterile by pus tubes from this source alone.

Subjectively we have to deal with, in addition to the germ diseases above named, typhoid bacilli, the diplococci of pneumonia, tubercular bacilli, the germs of the exanthema

In our

toustous diseases, the staphylococci of suppurating joints, etc. But these latter are rarer than the former, and their elimination or subjection is only a question of ordinary care.

The first intimation that the pyocyaneus bacillus has infected the institution will be information from the laboratory that many of the smears sent out are obscured as to diagnosis by the luxuriant growth of pyocyaneus cultures.

Of course, the cure against invasion by these germs is cleanliness, and the other necessity is frequent and active fumigation. Fortunately, the pyocyaneus especially is rather easily destroyed; and the maximum formaldehyde will practically eliminate the bacteria.

own institution we have elaborated an opsonic department, and we are doing an immense amount of experimental work, especially, with the staphylococcus, and I might add parenthetically, with some extraordinary results. We are just now preparing to institute work more particularly into the fields occupied by the streptococcus, the tubercular bacillus, and the micro-organism of gonorrheal arthritis. The interest of the hospital administrator is, of course, concerned with the furnishing of the proper laboratory equipment, and facilities for this work. There is no doubt in my mind that vaccine therapy, or the so-called theory of the opsonins, is just on the eve of sonic tremendous impulses, and the progressive hospital administrator must reckon with this field of hospital work at once if he is to be in the great forward movement.

HYDRO-THERAPY.

From the standpoint of the hospital administrator, the department of hydro-therapy, at least at the present time, is rather a simple affair. The principles underlying water treatments of various sorts are not especially in our domain, and even in the medical profession there are so many mooted questions concerning the use of water in the treatment of disease that the safer plan for the hospital is to simply equip itself so that the principle forms of treatment can be given. Only very recently the manufacturers have discovered means for the perfection of a control table that will permit of douches, showers, needle sprays, bidets, and the like, at any pressure and any temperature desired. It is only within the last three or four months that the Michael Reese Hospital has been able to definitely control the temperature of its bath waters so that there is no danger of burning or shocking the patient. Before that time it was not an unusual occurrence that the temperature of the water would change suddenly, either to hot or cold, for a matter of fifteen or twenty degrees, which meant more harm to the patient in the way of nervous shock or fright than any possible good that might have been accomplished by the bath properly administered. We are now able to control our temperatures within two or three degrees of variation for hours at a time. The various sprays just mentioned, with an ordinary bathtub for giving salt rubs, sea-salt baths, and the like; a sweat bath cabinet, ordinary massage tables, and a Neuheim bath, would seem to complete an equipment that would meet practically all the requirements of medical men. The Neuheim may be given with the ordinary chemical bricks that will produce aerated water, or the simpler, though more expensive, method is to use carbonic acid gas from the ordinary commercial tanks. In our own case, we use an ordinary gaspipe coil in the bottom of the bath tub, nickeled to prevent oxidation, and with small holes at intervals of one-half inch or so to facilitate the escape of the gas along the full length of the tub or either side.

Of course, the entire efficiency of the bathing department of any hospital will depend on its personnel. In our own case, we divide our bathing into shifts, the mornings being devoted to female patients, the afternoons to male. We have a female operator for the women, assisted, if necessary, by the nurses from the training school, who in that way get at least some substantial knowledge of hydrotherapy, massage, and the like. We have an expert masseur who operates in the afternoons for men, and who has been trained thoroughly in the requirements of the medical men who utilize our bathing department. These experts are drilled carefully in the principles of gross anatomy, especially of the bones and muscles. They are taught the physiology of the circulatory system, and the method employed is to work from the doctor's prescription, and the field covers not only massage and the baths but the Schott and the Oertel systems of passive resistance gymnastics for weak hearts. If we are prepared to carry out this general program in our bathing department, we can consider ourselves fairly well equipped to give to each physician about what he wants in the realm of hydro-therapy. Of course, there are many variations and many differences in minor details of the outline I have given, but the principles are practically taken into the reckoning.

MILK IN THE HOSPITAL.

There has been so much said and written about milk, and there are so many differences of opinion among medical men as to the employment of milk as a food for the sick, that w

are almost at our wit's end when we attempt to settle upon any policy in the employment of that article of diet.

Of course, we all know that the ideal milk is that which has just been drawn from the healthy cow, before it has come into contact with hurtful atmospheric conditions, and before its own chemical constituents can have had time to undergo changes. Unfortunately, this ideal condition is not obtainable in the ordinary hospital, and it becomes a question, therefore, not what we would like to do, not ideal conditions, but what is the best use we can make of the milk that we must receive at our door. It is not practicable for the ordinary hospital to maintain its own herd, and it is wholly out of the question, from the standpoint of economy, to buy a certified milk even for special cases. About the best that we can expect in a hospital milk as it comes to us is milk perhaps 24 hours old, three to three and one-half per cent butter fat, and that has been handled under such conditions that the bacterial count will run an average of about 75,000 per c.c. Most of this milk contains colon bacilli, and some of it will contain such pathogenic germs as typhoid, tuberculosis, and in the east more especially the germs of the foot and mouth disease, as shown by Dr. Bush, of Mt. Vernon. Fortunately for us, all of these harmful bacteria are rather easily destroyed.

In our own institution we recognize four kinds or states of milk: (1) raw milk, used for well people in the hospital and in the kitchens; (2) pasteurized milk, which we give to adult convalescents and certain sick children in whose cases it is not contraindicated; (3) sterilized milk, used to tide over critical periods in a certain class of extreme cases; (4) peptonized or modified milk, which we feed to our malnutrition babies. Of course, the plant in each hospital must be taken on its own merits, and therefore the time and the intensity of heat required for either pasteurization or sterilization of milk will vary with the mechanism of the apparatus used.

It will hardly be profitable to discuss the merits or demerits of raw milk, except to indicate the methods by which we keep our supply under close observation at every stage. In our own institution the milk comes to us in bulk, and it is at once subjected to tests for butter fat content, and for the bacterial count. The contract which we have just now provides for milk of a four per cent butter fat and a maximum bacterial count of 25,000; another clause in the contract provides that the milk shall not be more than twelve hours old. Daily we submit the milk to the Babcock tester for butter fat, the apparatus being a part of our milk station machinery, and we pass carefully gathered samples through the laboratory for the bacterial count. The bacterial count means very much more to us than the actual state of the milk. It is a positive proof to us whether or not our dairyman has given us last night's milk this morning, or whether he has mixed with it a quantity of yesterday morning's milk, in which latter case the count will have run up very far above the requirements of our contract, and on more than one occasion our dairyman has been astounded to receive from us a note stating that our supply yesterday contained a large quantity of milk at least twenty-four hours old, and in every case the fault was acknowledged and an apology came back with a promise that it would not occur again.

I am taking the liberty to subjoin under this head of my paper a report from our associate bacteriologist which will indicate one of the processes by which we have arrived, after long and tedious tests, at our present method of milk treatment. Without referring to the time and intensity of heat that we employ in our pasteurization, for these are matters of mechanism, what we actually do to milk is about as follows: We decline to pasteurize milk or to use it for the sick if it is higher than our maximum bacterial count—that is, 25,000—because even after pasteurization a milk of high count will still contain active toxines as a product of the germs that were present, that will do quite as much harm in

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