fever patient some twelve or more days previously.
Yellow fever starts, like many another fever, with head-
ache, pain in the back and limbs, nausea, and vomiting.
DENGUE, BREAKBONE FEVER, DANDY FEVER 115
The peculiar features of the disease begin on the second
day, with tenderness over the stomach, and the whites of
the eyeballs begin to grow yellow with jaundice, while the
gums are spongy and blood may be squeezed from them.
To personally avoid the disease, one should only go out-
doors in well-lighted places (the Stegomyia may frequent
darkened woods) between the hours of 9 A. M. and 3 p. M.,
as the mosquitoes are not active during this period. After
3 P. M. one should either seek elevations, where there are
no mosquitoes, or remain in a thoroughly mosquito-
screened veranda or room and sleep in a room high above
the ground under a mosquito bar.
Mosquitoes already in a room should be killed by fumi-
gation with sulphur, as advised under Malaria. If it is
essential to be outdoors in the evening one should wear
head nets, gauntlets, and leggings.
Screening of the house is even more important than in
the case of malaria, where the method is described. A
mosquito bar for beds should be made of fine bobinet,
hung from an oblong frame above the bed.
The frame is better a little higher than the bed, and may
be made by tying upright posts to the bed-posts and run-
ning, a cord about the top of these on which the net is hung.
It should not be slit on the side, but be made of one piece,
which should hang from the inside of the frame, so as not
to be interfered with by the posts, and be tucked in at the
head, foot, and sides of the bed at night and also by day.
The beds should be three-quarters size, because if one's
body projects against the mosquito net in narrow beds a
mosquito may bite through the net.
DENGUE, BREAKBONE FEVER, DANDY FEVER
Dengue is transmitted from one individual to another by
a special mosquito (Culex fatigans), and this is the only
116 THE PREVENTION OF DISEASE
known method of communication, as it is not contagious
in the ordinary sense. The special germ which is the cause
of the disease has not yet been certainly identified. The
disease occurs in tropical and subtropical countries, as in
India, China, and the Philippines, and in our Southern
States, as far north as Virginia. Except in the tropics, it
always appears during the warm season. Dengue attacks
a large part of the population, and when the writer was a
youth he acted as understudy for the medical profession in
St. Augustine in carrying about medicine and advice for
the doctors who were bedridden, together with everybody
else, during an outbreak.
Three to five days after exposure the patient comes down
with high fever, chilliness, and excruciating pains in the
head, back, legs, and joints, especially the knees. These
symptoms continue for three or four days, and then the
fever departs for two to four days, only to reappear again
for a few days longer, although the disease does not usually
last much more than a week. . Various eruptions are usu-
ally present, and there may or may not be swelling in the
painful joints.
The writer attributed his escape from dengue to previous
dosage with 10 grains of quinin daily, but this means of
prevention is denied by some of the leading medical author-
ities. The only known opportunity of escape is by avoid-
ing all mosquito bites by means suggested under Malaria
and Yellow Fever. Fortunately, while dengue is exceed-
ingly painful it is not a fatal disease.
CHAPTER VI
GERM DISEASES (Continued)
Tuberculosis, Colds, Influenza, Cerebrospinal Meningitis, Infantile
Paralysis
TUBERCULOSIS
TUBERCULOSIS is the chief destroyer of the human race.
Yet the deaths from it are steadily declining; so much so,
that while it has been estimated that one-fourth of all
deaths in Europe in the last century were due to the dis-
ease, at the present time it produces but one-tenth of all
deaths in the most enlightened communities.
This result has been accomplished by methods of pre-
vention, depending upon our increasing knowledge of the
disease and the various means by which persons become
infected. Our exact knowledge of the contagiousness of
tuberculosis dates from the discovery of Koch (in 1882)
that it is caused by a special germ ; in fact, this epoch marks
the beginning of our knowledge of germ diseases, since the
germ of consumption was the first to be thoroughly studied
and proved to be the one and sole cause of tuberculosis.
There are some astonishing facts which we must first
consider before we can have a rational conception of the
disease. While the name "tuberculosis" strikes terror in
those afflicted with it, yet the really important matter is
not so much whether one has tuberculosis as whether one
has it in a serious or active form. Or, in other words,
whether the disease is in an active state, or whether
117
118 THE PREVENTION OF DISEASE
it is inactive or healed. Now for the facts: Over 90
per cent, of city dwellers show signs of tuberculosis in their
bodies after death from any cause; 60 per cent, show signs
in the lungs. The tuberculin test, which is used in living
patients, is so delicate that it will not only show active
and serious tuberculosis, but the presence of minute and
even practically healed small, diseased areas in any part of
the body. By this test 90 per cent, of all children are
proved to be tuberculous by' the age of twelve, and 60 per
cent, of healthy young adults. If the whole population
of city and country are considered, it is estimated that
from 50 to 70 per cent, are tuberculous in some degree.
It will thus be seen that while 1 in every 10 persons dies
of tuberculosis, 8 in every 10 become infected with the
disease and recover in most cases the disease being so
slight that the patient is never aware of any disturbance
caused by it.
To prevent tuberculosis one must know how it is
acquired. The disease is not directly inherited from either
parent; that is, the germ does not pass from either parent
into the embryo (child) at the time of conception. If either
parent is tuberculous the disease may be communicated to
the child soon after birth. A certain susceptibility may be
inherited (recent research rather points to the existence
of some immunity against the disease in the offspring of
the tuberculous) and a peculiar build may predispose to
consumption. In some families various members suc-
cumb to the disease at a certain age, as from eighteen to
twenty-five. Among the children of 1000 families tuber-
culosis was found to be 10 per cent, more common in the
offspring of tuberculous parents. This does not neces-
sarily show heredity or susceptibility, but is what would
be expected in the case of children exposed to a contagious
disease.
TUBERCULOSIS 119
It is now generally accepted that childhood is the age
at which tuberculosis is more frequently acquired, al-
though it may lie dormant until adult life and then become
active as consumption. The supposedly inherited build
suggesting "greater susceptibility to tuberculosis is that
represented by pale, thin, blond, delicate-skinned persons
with sloping shoulders, projecting shoulder-blades, and
long, narrow, and flat or rounded chests. It is probable
that these persons are already sufficiently infected with
tuberculosis to cause their inferiority in physique.
Consumption in children that is, tuberculosis of the
lungs is comparatively rare. Tuberculosis in them be-
gins in enlarged glands of the neck, the bones and joints,
and brain. Ninety-four per cent, of children have en-
larged glands in the neck and 80 per cent, of these
are tuberculous. The germs enter the system by three
paths, either through the mouth and throat, from the
intestines, or in the air taken into the lungs. The latter
pathway was formerly thought the most frequent one,
but it has been shown that tuberculosis germs swallowed
by calves or injected into their tails enter the blood and
may only lodge in their lungs and not cause disease at the
site of entrance into the body.
What is the most common path by which the germs
enter the human body? This is still a debated point.
The germs arise from patients with consumption who
have the disease in an active form; that is, the lungs are
ulcerating, and the broken-down tissue, containing millions
of germs, is coughed up.
The germs soil the fingers, pillow, handkerchief, and
various objects, food and utensils handled by the patient,
and enter into the dust of the room. Children crawling
around, placing all kinds of objects in their mouths and
sucking the fingers, toys, and other contaminated objects,
120 THE PREVENTION OF DISEASE
are thus apt to get the germs into their mouths, which are
absorbed into the blood from the mouth or digestive tract.
Then there is great danger from consumptives with germs
in their sputum (expectoration), when one is in close
proximity to them during coughing, from the minute
droplets sprayed into the air. Children run great danger
from the milk of tuberculous cows. This disease is ex-
tremely frequent in cattle in some herds as many as 90
per cent, are affected; among 24,000 cows in Massachusetts
50 per cent, were tuberculous, and throughout the whole
country 10 per cent, of the milk cows are tuberculous.
Taking at random samples of mixed milk on the market it
has been shown that one in every ten will contain the
germs of tuberculosis and will communicate the disease to
animals. Even the milk from certified herds, which are
tested for tuberculosis, is not absolutely safe, as animals
develop the disease between testing times, and the writer
has known of one instance where 20 per cent, of the animals
in a certified herd were tuberculous through carelessness of
the management. The most glaring example of the danger
sometimes inherent in the (apparently) best and cleanest
milk which money can buy is that recently (1915) brought
to light in the case of one of the leading certified milk farms
hi the United States. In a herd of over 600 cows consider-
ably more than one-third of this number were suddenly
found to be tuberculous by the health authorities through
an accidental occurrence. Certified milk is the best raw
milk procurable as a general proposition, but it is far
from infallible in even the protection against tuberculosis,
which is the danger most readily avoidable. Proper pas-
teurization will make milk perfectly safe. It is estimated
by leading authorities that 15 per cent, of the deaths from
tuberculosis in children (under five) are due to cows' milk,
and that from 20 to 25 per cent, of all cases of tuberculosis
TUBERCULOSIS 121
in children arise from drinking cows' milk. Milk causes
8 per cent, of the total deaths from tuberculosis and kills
over 10,000 children annually in this country. Consump-
tion or pulmonary tuberculosis is not caused by the bovine
germ, but is always derived from a human source, unless
the bovine germs become altered by growth in the human
so as to simulate the human tuberculosis organism.
In children especially, diseased tonsils lead to enlarge-
ment of the glands in the neck, and these are frequently
tuberculous, as we have seen.
Diseased tonsils often act as paths of entrance for tuber-
culosis germs, and in 100 tonsils removed at Ann Arbor
one-fourth were found to contain such. The average of all
examinations by many doctors shows that only 15 per cent,
of removed tonsils are tuberculous (Ravenel). Adenoid
growths in children (see page 155) and enlarged tonsils
both interfere with breathing, and thus favor consumption
by reducing general vitality and by interfering with the
proper ventilation of the lungs.
To summarize, it may be said that in children the
greatest danger of tuberculosis is from food, especially raw
milk and food and other objects placed in the mouth,
infected by handling, by coughing, and by dust; while in
adults there is more danger from exposure to coughing and
dust. That the germs pass more often through the mucous
membrane of the mouth and intestines into the blood, and
less often lodge in the lungs directly from the air. That
consumption in adult life often follows tuberculosis of the
glands in children.
That infants and children are most susceptible, and
possibly the children of tuberculous parents possess less
resistance to the disease, but this appears to be doubtful.
That adults are comparatively insusceptible to tubercu-
losis either because they actually have it in a latent
122 THE PREVENTION OF DISEASE
form, or have recovered from it, and they do not retake
the disease (i. e., the reopening or "lighting up" of former
tuberculosis or the entrance of a fresh supply of tuber-
culous germs into the body) unless through long exposure,
or circumstances which greatly lower their general vitality
or local resistance, as by the presence of colds, bronchitis,
and influenza. Consumption is never communicated to
attendants in well-regulated hospitals, and in the case of
64 throat specialists constantly exposed to the breath and
coughing of consumptive patients for years not one devel-
oped the disease.
On the other hand, when proper precautions are not
adopted the danger of communication to adults living or
working in the same rooms with consumptives is consider-
able. This is so well recognized that in life insurance ap-
plications one is asked if he has lived or worked with a
consumptive.
Thus, Lampson, of Minneapolis (in 1913), examined 173
persons living in 33 families, in each of which there was a
known case of open consumption; that is, one in which the
tuberculous germs were expectorated. He found that 100
of these 173 individuals (exclusive of the known cases) also
showed evidences of tuberculosis, and in all the (54) mem-
bers of 10 families signs of the disease existed. Whereas, in
15 families, in which no case of tuberculosis was known to
exist, there were 80 persons, and only 2 of these gave evi-
dences of tuberculosis.
Nevertheless, the consensus of medical opinion is
that 9 in every 10 adults are immune to tuberculosis.
This is based on the fact that having once had tubercu-
losis one rarely wholly recovers. Small areas in the body
contain living germs of tuberculosis, and although they
are enclosed by inflammatory tissue, yet the germs are
often found circulating in the blood of apparently healthy
TUBERCULOSIS 123
persons. Therefore, as 9 out of 10 adults have tuber-
culosis, they cannot take it again. An active tuberculosis
in adult life means a breaking down of old latent trouble.
An extra dose of germs derived from exposure to a con-
sumptive will rarely harm the adult already suffering
from a latent form of the disease. The belief is then
prevalent among the leading authorities that 9 in every
10 adults may be exposed to active consumption with
impunity. But a child, or the tenth adult who has
not been, protected by a previous mild tuberculous in-
fection from milk or from human beings, will probably
have the most fatal form on exposure to the disease
as the aborigines succumb to it and other contagions.
Consumption is one of the less severe forms of tubercu-
losis dependent upon a partial immunity existing in the
subject. This is not a plea for unnecessary exposure to
tuberculosis, because an individual does not usually know
whether he is susceptible or not, and children must be
protected at all costs.
Certain occupations favor the incidence of tuberculosis.
Some of these produce irritation of the membrane lining
the air-passages, as the dusty trades stone-cutting, metal
grinding, working in wood and certain textiles, mining.
Glass-blowers, cigarmakers, hat and cap makers, printers,
and bookkeepers have been found especially susceptible to
the disease. While glass-blowing may mechanically irritate
the lungs, yet in many of these occupations the chief harm
is done by ill-ventilated quarters, lack of sufficient space,
overheating, overwork, and underpay. Industrial workers
constitute about one-third of the population, and furnish
about half the deaths from tuberculosis in this country,
and by removal of the dust, through propeny controlled
sanitation of factories, the number of cases and deaths
from tuberculosis may be reduced by one-half, as has
124 THE PREVENTION OF DISEASE
been accomplished in the cutlery industry in Germany
(Kober).
It is thought that persons who develop sudden and acute
tuberculosis late in life are those who have escaped the
disease in childhood, for with a mild form of tuberculosis,
such as most of us have, one acquires a certain degree of
immunity, as in the case of individuals recovered from
measles or scarlet fever. In calves the injection of small
doses of living, non-virulent (human) tuberculosis germs
produces an immunity which persists for an uncertain
period. The germs of tuberculosis may live for years in
an apparently healthy person and may even be found
in their blood. In healed areas in a lung or gland the
germs become so surrounded by scar tissue that they
cause no sign or symptom because they are shut off from
the circulation. But let a person become "run-down"
and his resistance lowered, and partial immunity caused
by a mild infection with tuberculosis in childhood no
longer protects him; the tissues about the germs break
down and the germs escape into the blood to cause active,
serious disease in some part of the body. In most cases
we are wholly ignorant of the presence of tuberculosis germs
until many years after their entrance into our bodies.
Every cause tending to lower the general health as dis-
ease, overwork, undernourishment, dissipation, bad habits,
overcrowding, and poverty favor tuberculosis, which
causes one-third of all deaths between the ages of twenty
and forty, the time of greatest stress and strain from work
or dissipation.
A large portion of consumptives do not cough up matter
containing the germs because the diseased area is not con-
nected with the air-tubes and is surrounded by a wall of
inflammatory tissues. If there is no expectoration, or if
frequent examination of the expectoration shows that
TUBERCULOSIS 125
it is free from germs, the patient cannot transmit the
disease to others unless his condition changes.
What are the early signs of tuberculosis in adults?
Loss of weight, loss of energy and ambition, and a tired
feeling; digestive disturbances; frequent and prolonged
colds; pleurisy or spitting of blood; pain about the shoul-
der-blades or between the shoulders; hacking or tickling
cough in the throat, hoarseness; fever and night-sweats.
The existence of one or more of these symptoms should
cause the subject to seek medical advice.
A proper medical examination will include taking tem-
perature at two-hour intervals for several days, examina-
tion of the expectoration, if any, tuberculin test and re-ray
examination, besides the ordinary tapping on the chest and
listening to the breath sounds with the stethoscope. It is
often impossible to make a positive diagnosis because the
symptoms and signs are indefinite. The x-ray and tuber-
culin test may indicate tuberculosis, and yet the disease
may not be in an active state.
But in all doubtful cases the treatment is never doubtful.
The same upbuilding which is most suitable in tubercu-
losis will be indicated in debility from other causes.
Now in regard to the preventive measures to be adopted
in the case of children of tuberculous parents. The danger
to infants nursing tuberculous mothers is slight from the
milk, but there is more danger to the child from soiling of
the breast and other objects by the mother's fingers, and
she would very probably be too much debilitated to under-
take nursing. (In cows the milk is chiefly infected from
the germs in manure, which commonly contaminate their
milk.) So that nursing a tuberculous mother is undesir-
able, and the child should be brought up as much apart
from tuberculous parents as possible and should stay out-
doors the greater part of the time. A separate room is
126 THE PREVENTION OF DISEASE
advisable for a nursery, with no unnecessary furniture, cur-
tains, or carpet to catch the dust, and every effort should
be made to keep children from placing, toys, pencils, and
various objects in their mouths. \f
Great care should be taken to wash their faces and hands
three times daily before eating and to brush their teeth at
least twice daily after meals. Separate eating and drink-
ing utensils, handkerchiefs, table, bed and body linen
must be provided for children, and all objects coming in
contact with consumptive parents or other persons should
be avoided. The effect of crowding is seen in the observa-
tion of Knopf, that 42 per cent, of all cases of tuberculosis
occurred in families living in one room, while but 6 per
cent, of all cases were seen in families living in four or more
rooms (Berlin) . Parents whose expectoration is filled with
tuberculosis germs had better themselves be removed to a
hospital to prevent infection of children. This applies
more especially to the poor. Advanced cases of consump-
tion, when bedridden and unable to care for themselves,
are the chief source of danger in spreading germs and
tuberculosis. What is worth doing for animals is certainly
worth doing for children. It is generally recognized that
the only way to keep calves free from tuberculosis, when
born of tuberculous cows, is to raise them in separate
barns, yards, and pastures, and to feed and water them
from separate utensils. In youth overstudy and over-
athletic training are equally harmful, while late hours and
the use of alcohol, tobacco, and excesses of all kinds should
be especially avoided in young adult life by those who have
been exposed to consumptives. In case any of the symp-
toms noted above develop in such individuals medical
advice should be sought, as these are often premonitory
of active tuberculosis and a change of life at this time is
usually sufficient to avert the disease.
TUBERCULOSIS 127
Marriage should not be considered in the case of a person
who has active lung tuberculosis with germs in the expec-
toration. Whether marriage is proper in the case of indi-
viduals with healed, inactive, or closed lesions in the lungs
depends upon all the circumstances involved, and an
expert should decide. A person may have active tuber-
culosis, apparently recover, and yet be a carrier of tuber-
culosis germs in his expectoration, as in the classical
instance of the recovered consumptive who caused the
death of four wives by tuberculosis while remaining in
apparent health himself.
A patient with active tuberculosis who is able to be
about and care for himself may not be a source of any
danger to others by conscientiously adopting the follow-
ing precautions: His expectoration should always be
deposited in a pasteboard box, made for the purpose,
which is daily burned with its contents. The use of hand-
kerchiefs or cloths leads to soiling of the hands, pockets,
bed clothes, etc. When coughing in the presence of
others a paper handkerchief should be held before the face
to prevent spraying of the germs into the air of the room.
Any object placed in the mouth should be burned, as
toothpicks, cigar butts, etc.
The tooth-brush should be used three times daily, over
the toilet and not over a wash basin. The face should be
kept shaven and the face and hands washed frequently.
It has been found that the ordinary washing of eating
utensils is sufficient to prevent contagion from them, but
the napkin should be kept in a separate envelope unless
used but once.
The bed and body clothing should be boiled for ten
minutes before being sent to the laundry. The patient's
room should be cleaned without stirring up dust, using a
moist cloth or wet broom, or, better, vacuum cleaning.
128 THE PREVENTION OF DISEASE
The bed should be covered with a counterpane which is
frequently washed, and the upper sheet should be turned
down well over the blankets to protect them from the
patient's coughing and sneezing.
With such precautions patients make safe companions,
as shown by the fact that there is no danger from patients
to attendants in well-regulated sanatoriums.
New York, under the supervision of Dr. Herman Biggs,
is the model city of the world in the public control of tuber-
culosis. The death-rate from tuberculosis has been reduced
50 per eent. in the last twenty-five years, or from 3.98 to
1.97 per thousand. This is accomplished by compulsory
notification of cases, printed instructions sent to patients,