SANITATION AT DARTMOUTH COLLEGE

IT has been our belief at Dartmouth that an ounce of prevention is worth many pounds of cure. The College has at hand an unsurpassed plant for the care of sickness, but it has, nevertheless, been unceasingly solicitous that sickness should be prevented. It is, perhaps, a subject of public interest what is being done here to prevent infectious diseases from gaining a foothold. So far as we have been able to learn, Dartmouth is the only college where anything like the following has been attempted. I will therefore speak of a few of the methods in this unique work.

The conditions in college communities are unlike those in the larger (towns and cities. About the middle of September each year about one thousand men arrive in town from all parts of the States. Some of these men come from sections of the country where infectious diseases are prevalent, or they may contract disease on the train or in some other way. Many are tired from their long journey and consequently are more susceptible to disease. Some of them find in Hanover conditions different from those at home, many have to become accustomed to new climatic conditions, different food, water, and many other things. One can see, therefore, how important it is to pay due regard to the buildings in which they are to live, the water, ice, food, etc., which are necessary for their well being.

Of the utmost importance to the health of a community is its water supply. The water supply to the College is from two sources, namely, the Hanover village supply and the aqueduct. The aqueduct comes from a number of springs situated about two and one half miles south-east of the village on a wooded hillside, with no buildings on the watershed. The springs are protected by wooden frames. The water is carried to consumers through lead pipes and is stored in tanks and cement-lined cisterns.

The chief supply (the village supply) comes from a reservoir, which is situated about three miles east of the post-office and 155 feet above the main street. The reservoir covers about thirty-three acres, has a capacity of 166,000,000 gallons, is supplied by springs and brooks, and the water is carried to consumers through iron pipes. The area of the water-shed is about 1250 acres, and the entire watershed, upon which no person lives, i's now owned by the water company. There seems to be no possible chance for contamination with materials injurious to health.

The water is examined chemically twice each year, and bacteriologically once each month. Specimens are taken from the reservoir and from taps, the number of bacteria are counted, the colon bacillus searched for and guinea pigs inoculated. I have a fixed limit of bacteria per cu. cm. which I think is safe. This limit has neverbeen reached. When bacteria do increase in numbers, I make careful inspection and take into consideration the season of year, weather, etc., and in every instance, so far, I have to my own satisfaction determined the cause of the increase.

The ice comes from two sources the reservoir, and a small deep spring pond, and the men who harvest it are instructed as to the proper hygienic way.

Milk comes to the students from nine different sources, and each is examined bacteriologically six times each year. The farms have been inspected and their water supplies looked into, and suggestions made as to the care of cows, barns and other buildings, and drainage. In every instance these suggestions have been carried out by the farmers. Cows in the different herds have all been tested with Tuberculin and all infected animals killed.

The men board at the Commons, at the Inn and in numerous clubs in private houses. These houses are inspected and the surroundings, put into a good sanitary condition. Raw oysters, are not used unless with lemons, oysters for stews are cooked twenty minutes so as to kill all bacteria, and celery from farms where human excreta is used for fertilizer is not allowed. Celery is brushed vigorously with a firm brush to remove as much as possible of the thin outside skin. All oysters which are shipped to a distance are soaked and generally fattened by the dealers, and of course it is impossible to know whether the oysters are contaminated or not, so it seems best to take all the known precautions against infection.

All College buildings are heated from the central heating plant ; the older buildings have been renovated, and the new buildings are built with special reference to ventilation, light, etc. The buildings are all connected with sewers, and this year all the eating clubs are also connected, where two years ago there were nine clubs not connected with sewers. This problem of getting the people who run eating clubs to connect with sewers, and to co-operate along these lines, was rather a delicate one, but I was able to solve it by telling the proprietors that unless they did comply, the parents of the men boarding with them would be notified that the conditions were not healthful. These eating clubs not under the direct control of the College have given considerable trouble, but they have all fallen into line, so to-day I have no trouble with them whatever; in fact, they have become interested themselves and are glad to follow instructions. I mention this fact to illustrate how it is possible to persuade the people to co-operate if you adopt the right course of procedure.

The College buildings are inspected several times each month, and the basements are whitewashed once a year to let in light and prevent the growth of bacteria, moulds and fungiCultures are taken from time to time of the air in all lecture rooms, recitation rooms, basements, and the Chapel, and if there are above a certain number of colonies found growing on the media after being exposed for ten minutes, careful search is made to ascertain if possible the cause, and in every case the room or building is disinfected. Specimens of sputum are examined for Tubercle bacilli whenever found on the walls or floors of closets, or on the ground around College buildings. About one hundred fifty specimens of sputum are examined each year. Two years Tubercle bacilli were found in two different dormitories, and after considerable search the infected individuals were located. One was a student who seemed practically healthy except for a cold'. After consultation he was advised as to treatment, and the results are all that could be desired. The other case was that of a workman, who was isolated and advised as to treatment. No one can say what harm these two cases could have produced had they not been discovered.'

Drainage from buildings is by sewers which empty into the Connecticut River, one about one mile north of the Campus, the other about one mile south of it. Within a few years the sewage will be taken care of by the septic tank method, plans for which are now under consideration.

Only two cases of typhoid fever have originated in town in ten years. Last year we had two cases with one death. The facts are these: Every year the upper classmen make the Freshmen of the hall in which they live give them a "feed," as it is called. Two men came late to one of these feeds, and there was practically nothing left for them to eat but raw oysters. One man consumed tem- plates and the other three. Both these men had typhoid, both had positive Widal reactions, one died. None of the other men contracted the disease and very few ate any oysters. This to me seems proof enough that the oysters were the cause.

We have an isolation hospital where we isolate men having infectious or contagious diseases. As soon as a case is discovered the man is removed to the hospital, his room disinfected at once, all rooms where he has been since he had the eruption, if measles or scarlet fever is the disease, are disinfected, and all those men, so far as it is possible to determine, who have been with the patient a few days previous to the appearance of the eruption are watched closely in order to isolate them as early in the disease as possible should any of them become infected. Cultures are taken from all sore throats, whether diphtheria is suspected or not.

I know some of the readers will say that all this is foolishness, simply a waste of time.and money. I can do no better than to give you the figures.

For college years 1903-'04 1904-'05 (Number of cases) Bronchitis 11 10 Cold in Head 65 30 Influenza 59 21 Rheumatism 11 4 Tonsilitis 20 9 Measles 31 4

The diminution in the number of cases of cold in the head and influenza in my opinion is due, as we might say, to the wholesale disinfection of recitation rooms, lecture rooms, and more especially the Chapel. Influenza was very prevalent in all surrounding towns last year.

Measles is the only contagious disease which has given any concern in the past ten years, and the marked diminution in the measles cases last year as shown by the above table is striking. Two years ago we had five primary cases of measles with a total of thirty-one, last year we had four primary cases with a total of four, which to me proves that it does pay to do all this disinfecting. Of course drawing conclusions from work of this kind covering only a period of three years is rather bold, but it strikes me that lam justified in this case. I know that many believe measles is not a dangerous disease but a good disease to have and that to disinfect after measles is a needless procedure.

Is measles a dangerous disease ? I believe it is, Capt. Newth brings news to San Francisco that at least 25 per cent of the natives along the Arctic coast have died from measles during the past two years and there seems to be nothing to check the death rate. 'An epidemic of measles on the Kamchatka peninsula is reported to have carried off nearly the whole population of some of the country villages. It is said that nearly 10,000 persons have succumbed to the disease. An editorial in Merck's Archives points out the fallacy of the popular idea that measles is a harmless disease. The report of the New York Department of Health for the quarter ending March 31, shows the deaths from measles during the three months to have been 349, while only 356 deaths occurred from scarlatina during the same period. In 1900 the fatalities in the United States from measles numbered 12,866, and from whooping cough 9,958, while there were but 6,333 deaths from scarlet fever during the. same year. The fatality in the former diseases varies much with the character of the epidemic, and with the age of the patient, but the total mortality is very large and much greater than is usually supposed .

Among the laity it is generally thought that measles and whooping cough are not serious and that they do not require the attention of a physician or disinfection, while scarlet fever is considered very dangerous. The facts are that more deaths are due to each of the former diseases than to scarlet fever. Dr. Hay of the Public Health Association says that the subject of isolation and disinfection in measles is one of great importance. He states that in the past ten years measles and whooping cough have together caused 1451 deaths in Philadelphia while during the same period the total deaths from scarlet fever, diphtheria, typhoid fever, typhus fever and small pox have been only 671.

Dr. C. F. Wahrer of Fort Madison, lowa, in connection with quarantine against some diseases says that in the case of measles the disease is less severe in childhood and more severe after puberty. Epidemics among adults in camps and mines are productive of great harm. Hence it is not always best to keep children from being exposed to the disease. It should be guarded against in hospitals, crowded tents, etc. There is no good reason why healthy children above two years of age should not be exposed. A number of very prominent physicians did not agree with Dr. Wahrer. Griffith did not agree with this view. He said that in one large foreign hospital the deaths from measles in children were more than from either diphtheria or scarlet fever. Fischer would not allow children to catch measles if he could prevent it. He finds serious complications, as otitis media, empyema, nephritis and eye disturbances, to be too common to warrant it. Schamberg stated that the mortality from measles was greater than was generally supposed. The Chicago Health Reports for June and July show the following: June, 31 deaths ; July, 16 deaths.

The general prevalence of measles may be attributed to two important causes: (1) The infection of large numbers of individuals through mild and often unrecognized cases; and (2) The failure to enforce the sanitary precautions that would prevent the dissemination of the infectious materials.

Mild cases of measles are always the most dangerous from the public health standpoint. These cases frequently remain unrecognized and go through the community disseminating infectious materials. The true character of many of these cases remains unrecognized and consequently on restrictions are placed on the patient's movements. In the control of recognized cases of transtmissble diseases the two factors which are of the greatest importance are isolation and disinfection. The more complete the isolation and the more thorough the disinfection, the greater the probability that the infection will be limited to the primary source.

It would be practically impossible to carry out the work we are doing here if it were not for the co-operation of our medical students. This work makes possible a course in practical sanitation, and each medical student gets considerable practical experience each year along these lines. If it should become necessary, we could within forty-eight hours disinfect every College building, take cultures from every throat, and vaccinate every man in College.

The thing we are striving to do in connection with the College is to leave no stone unturned to prevent the invasion of transmissible diseases.