The elements of military hygiene, especially arranged for officers and men of the line

UNIVERSITY OF CALIFORNl
AT LOS ANGELES

GIFT OF

Larry Laughlin

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MILITARY HYGIENE

THE ELEMENTS OF
MILITARY HYGIENE

ESPECIALLY ARRANGED FOR OFFICERS
AND MEN OF THE LINE

BT

P. M. ASHBURN

MAJOR, MEDICAL CORPS, U. S. ARMT

g5^^aas5

BOSTON AND NEW YORK
HOUGHTON MIFFLIN COMPANY

COPyiUGHT, 1909 AND I915, BT PKRCY M. ASHBURN
ALL RIGHTS RSSERVED

600

1915
PREFACE TO THE SECOND EDITION

Since the first appearance of this book there has been
a notable and gratifying increase in the interest that
line officers and men have manifested in matters of
hygiene and sanitation, and a corresponding increase
in the effectiveness of disease - preventing measures.
That this improvement has occurred is not necessarily
^ evidence that the book has been instrumental in bring-
< ing it about, but expressions of opinion from various
SB officers have led me to think it a possible factor, and
z have in that way encouraged me to revise and in parts
rewrite it, while a supplementary chapter has been
added, in the belief that interest in the subject entitles
the reader to a knowledge of advances more recently
made, and in the hope that such interest and the use-
fulness of the book may ba increased.
December 8, 1914.

C3

3

346655

PREFACE

There can be little or no doubt that the sanitation of
the army would be greatly improved if line officers
and enlisted men should become more interested in the
subject, and cooperate more freely and intelligently
with medical officers in the efforts to promote it.

This book is written in the hope that it may both
inform and interest them and so gain for the medical
officer the sympathy and cooperation that he always
needs, but now too seldom has. It is also hoped that
medical officers themselves, especially those of the
volunteer service and militia, may find the book useful
in their dual capacities of administrators and teachers.

CONTENTS

PART I.— THE RECRUIT AND HIS ENVIRON-
MENT

I. The Recruit 3

II. Personal Hygiene 20

III. Foods and their Preparation . . .32

IV. The Hygiene of the Barracks . . 54
V. Camps 73

VI. The Hygiene of Moving Troops . . 103
VII. The Hygiene of Hot and Cold Climates 122

PART IL — THE CAUSES OF DISEASE

Vni. The Remote or Predisposing Causes op

Disease 147

IX. The Immediate or Exciting Causes of

Disease 162

X. Disease-Carriers 187

PART III. — THE PREVENTION AND
CONTROL OF EPIDEMICS

XI. The Defenses against Disease in General 207
XII. Diseases due to Infection through the

Alimentary Tract .... 223
XIII. Diseases due to Infection through the

Respiratory Tract ..... 255

viii CONTENTS

XIV. Insect-Bobnb Diseases 275

XV. Venereal Diseases 312

SUPPLEMENT

XVI. The Prevention of Mental and Nervous

Diseases 335

Index . . . . , . 345

PART r

THE RECRUIT AND HIS
ENVIRONMENT

•• Health and a good constitution are better than all gold ; and a
strong body than wealth without measure."

EccLESiASTicus 30 : 15.

MILITARY HYGIENE

CHAPTER I

THE RECRUIT

One of the principal factors in military hygiene is
the individual soldier, or, as he comes from civil life,
the recruit. If he enters the service in good physical
condition, in good health, and with sufficient intelli-
gence to apprehend and apply the instruction he re-
ceives in military hygiene, the problem is almost half
solved. The final acceptance or rejection of recruits now
rests almost entirely with medical officers ; but in cer-
tain ways line officers exercise a considerable influence
in the matter : in the acceptance at the recruiting station,
and in requesting special authority to enlist because of
special qualifications. For these and other reasons it is
important that they should keep well informed as to the
requirements necessary and the qualifications desirable in
recruits. We will therefore briefly consider some of these.
The age limits for first enlistments are from eighteen
to thirty-five years. Preferably men should be chosen
between twenty-three and thirty years. Be-
fore the age of twenty-three years most °
men are immature, their muscles are not hardened, their
hearts not so strong, their minds not disciplined by expe-
rience, their appetites and emotions not under control ;
while their susceptibility to impressions from their en-
vironment is such as to make it undesirable to limit
their associations exclusively to adult unmarried males.

4 THE RECRUIT AND HIS ENVIRONMENT

After the age of thirty years the man's habits of body
and mind are fixed, he takes instruction less readily,
his body may have begun to deteriorate, particularly if
it has not been well cared-for, and, in many instances,
he seeks the service as a refuge, after failing in other
walks of life. Many good men may be obtained before
the age of twenty-three and between the ages of thirty
and thirty-five, but in general the case is thought to
be as stated.

The size of the recruit is not a matter of the great-
est importance, provided that the development is nor-
mal and the man strong and active, except
as it applies to assigning him to duty. It
is obvious that a very large and strong man is better
suited for coast-artillery work than for the cavalry, and
that a small, wiry man is in that respect better for the
cavalry. The proportions of weight and chest measure-
ments to height are published from time to time in
general orders, and those proportions usually represent
very well those of strong, well-developed men. An in-
crease of weight, if associated with great breadth of
shoulder and large chest measurement, is not necessarily
harmful, being usually indicative of strength and en-
durance. The sturdy, stocky Japanese coolie exemplifies
this. Obesity, whereby the man is burdened with his
own weight, is of course objectionable.*

^ The following table copied from the Medical Record of September
5, 1908, and compiled from the data of the Mutual Life Insurance Co.
of New York, by its Chief Medical Director, is interesting as indicat-
ing somewhat " the influence of overweight and underweight on vitality."
The weights considered normal by the insurance company are some-
what in excess of those prescribed by the War Department, the in-
crease averaging about 10 pounds at the ages 25-29, and for height*

THE RECRUIT

The chest should be freely mobile, that is, both sides
should move freely, symmetrically, and equally, in ex-
panding and contracting. The measured
chest expansion should generally corre-
spond with the figures published in the general orders;
yet it should be remembered that one man with very
ordinary lung capacity may, by use of the shoulder and

below 70 inches. A weight 20 per cent below the average is considered
" underweight," and 20 per cent above the average, "overweight."

Table showing the Percentage of Deaths in all Classes, and some Indi-
vidual Diseases, among Overweights and Underweights, and the
General Experience of the Mutual Life Insurance Company.

Causei of Death.

Over-

Under-

weights.

teeightt.

9.67

9.28

4.00

3.06

1.27

1.21

1.47

2.04

13.07

24.59

2.93

16.98

4.40

5.57

3.40

0.65

19.08

12.16

14.14

8.47

1.80

0.84

16.01

11.69

12.94

8.54

8.54

15.78

6.87

12.34

10.61

8.54

3.47

0.65

12.01

7.42

11.07

5.30

1.20

0.47

None

2.04

7.07

5.57

4.20

3.43

2.87

2.14

2.60

2.50

General
Experience,

Class I. General Diseases — Acute . .

Typhoid fever

Malarial fever

Influenza

CImb II. General Diseases — Chronic

Tuberculosis

Cancer .... ...

Diabetes

Class III. Diseases of the Nervous System

Cerebral Congestion and

Hemorrhage, Cerebral

Softening, Paralysis . .

General Paralysis and other

forms of mental alienation

Class IV. Diseases of the Circulatory

System

Organic diseases of the heart
Class V. Diseases of the Respiratory

System

Pneumonia

Class VI. Diseases of the Digestive Sys-
tem

Cirrhosis of Liver ....
Class VII. Diseases of the Genito-urinary

System

Bright's Disease and Nephri-
tis

Class IX. Diseases of Skin and Cellular

Tissue

Class XI. Old age

Class XII. Violent causes

Casualties

Suicides

Class Xin. Ul-defined

8.90

3.94

1.24

1.00

19.56

12.42

4.18

1.25

17.44

12.32

1.30

1185
10.76

11.86
9.03

10.19
1.00

8.78

6.66

0.50
1.50
7.42
6.21
2.20
3.98

6 THE RECRUIT AND HIS ENVIRONMENT

back muscles and retraction of the abdomen, show an
apparent expansion of 3^ inches, while his companions
with a capacity as great, may, through ignorance of
tricks or of what is desired, show only 1| inches. It is
desirable that the chest be fairly large, to afford ample
room for the free working of the heart and lungs, as on
such finally depend both strength and endurance. A
generally well-developed and strong man will show
well-developed and prominent chest muscles.

Certain types of chest frequently indicate a predis-
position to, or the actual existence of, disease, and de-
mand careful consideration even when not constituting
actual causes for rejection. The long, narrow chest, with
prominent or " winged " shoulder-blades, depressed or
flat below the collar-bones, and forming an acute
angle at the divergence of the ribs below the breast-
bone, frequently marks a predisposition to consumption,

A large, barrel-shaped chest, as deep from front to
back as transversely, and showing a relatively small
movement, is often associated with emphysema and
asthma.

A chest more prominent on one side than on the
other is apt to be associated with curvature of the spine,
or old or chronic pleurisy.

Marked prominence or depression of the breast-bone,
especially if associated with "beading," or lumps on
the ribs near the breast-bone, frequently results from
rickets, and may be accompanied by other bone de-
formities.

The abdomen should be well muscled, and firm when

... the applicant is standing. It should move

easily and naturally in respiration, should

not be pendulous, and should be firm, particularly in

THE RECRUIT 7

its lower parts, just above the groin. "Weakness here
will be indicated by a bulging if the patient strains, as
at stool, or if he stands on his toes and coughs hard.
Such bulging, especially if it be marked or shows a
tumor-like swelling, indicates a predisposition to, or
the actual existence of, a hernia.

The umbilicus or navel is another frequent site of
hernia, and should be noted in that connection, as
should any abdominal scars resulting from operations,
as for appendicitis. Another, though less frequent, site
of hernia is the femoral. This is shown by a fullness
or swelling in the lower part of the groin, in the high-
est part of the thigh rather than in the lowest part of
the abdomen.

Large masses or tumors that can be felt through the
abdominal wall, or that can be seen to produce in-
equality or fullness, are causes for rejection.

Distention or prominence of the veins on the sur-
face of the abdomen, or a varicose condition of them, is
generally an evidence of impaired circulation or liver
disease, and should cause rejection.

Hemorrhoids, or piles, while apparently not con-
nected with the abdomen, are the result of distention
of the rectal veins, and may be due to liver disease, to
abdominal tumors, to constipation, or other intra-ab-
dominal conditions. They are manifested as tumors,
usually of a bluish color, within or about the anus, which
vary in size from that of a small pea to that of a man's
thumb. Of themselves they are not a cause for rejection
unless of large size or producing symptoms, but their
presence should always be noted. Internal piles are not
visible, and usually make their presence known by burn-
ing or irritation in the rectum, or by the passage of

8 THE RECRUIT AND HIS ENVIRONMENT

blood in the stools. In examining for them, note should
also be made of other abnormal conditions of or about
the anus, such as fissures or cracks in the skin and
mucous membrane ; fistulas, little openings near the
anus from which there may be a slight discharge of pus
or fecal matter ; or abscesses or boils. Any of these
conditions may so disable the man as to unfit him for
service.

A history of abdominal trouble, such as severe indi-
gestion» gallstone colic, vomiting of blood, should cause
rejection.

The examination of the head is very important, as
revealing defects in most of the special senses and as
_, J offering important evidence as to the man's

character, habits, and abilities. The evi-
dence on the latter points is to be gained largely from
the shape of the head and the expression of the features,
and, while such evidence is not always reliable, certain
heads and faces are so distinctly indicative of stupidity
or vice that there should be no hesitation in rejecting
their possessors. Then, too, hideous or disgusting de-
formities should at once cause rejection, for the sake
both of the victim and those with whom enlistment
would associate him, even though they are not of a
character to incapacitate directly. The vision and hear-
ing should be tested in strict accordance with the regu-
lations governing the subject, and failure to meet the
requirements is cause for rejection.

In addition to the test for vision, however, the eyes

should be examined for any signs of inflammation, red-

-j ness, watering, drooping of the lids, scars

or deformities, granulations, styes or boils,

undue prominence of the eyeball, inability to move the

THE RECRUIT 9

eyes in all directions, and discoloration or blurring of
the cornea.

The ears, in addition to the testa for hearing, should
be examined for any discharge, whether
watery or puinilent, and if present it should
be a cause for rejection.

The nose should be examined as to its freedom from
obstruction, by having the applicant close first one side
and then the other with his fingers and then
breathe and blow through the free side. In-
cidentally this may call attention to a foul-looking dis-
charge or a foul-smelling breath, either of which may
justify rejection. A sunken or much scarred nose is
often an indication of syphilis, while a red, bulbous
nose, even if not indicating alcoholism, is sometimes an
indication of indigestion. It should be noticed that the
man habitually breathes through his nose.

The mouth and throat should always be __
r n • J Mouth

carefully examined.

The condition of the teeth is the first point to be
noted here. It is desirable that all should be pre-
sent and good, but there must be at least .
enough to permit of proper mastication of
the food, and for this purpose at least four grinders
are demanded, two above and two below, and so dis-
posed as to permit their effective use. Enough of the
front teeth should also be present to permit of the bit-
ing of food and to preserve the symmetry of the face.
At times men are accepted with no upper teeth, but
wearing plates. This should only be done by special
authority and in special instances. Insufficient or poor
teeth are apt to produce digestive disturbances, partic-
ularly on campaign, when hard bread may be issued,

10 THE RECRUIT AND HIS ENVIRONMENT

and when the preparation of the food in general may
not be as good as in garrison. The examination of the
teeth should not only relate to their presence and the
presence or absence of cavities, but also to their state
of cleanliness. Neglected, filthy teeth and gums may
seriously menace the general health, while they cer-
tainly predispose to loss of teeth, and, in many instances,
indicate general carelessness or filthiness. Sores or
ulcerations on the lips, tongue, gums, or inner sides of
the cheeks should be carefully noted, as they may in-
dicate syphilis or other general disease, and should at
least lead to further and more careful search for syphi-
lis. The same remark applies to milk-white patches,
seen especially on the tongue.

In ill-kept mouths the gums may be spongy and bleed

spontaneously or on pressure, or pus may exude from

_, between them and the teeth ; or they may

be greatly retracted and expose the roots

of the latter.

In these and other cases the teeth may all be present,
yet in such poor condition as to forbid proper mastica-
tion, or to threaten their early loss.

The most common and easily detected throat trouble
is enlargement of the tonsils. This condition usually
__ indicates a liability to frequent attacks of

sore throat, and should always excite in-
quiries as to this, and while not necessarily a cause for
rejection, unless very marked, should be noted as a
point against desirability. Ulcers, white patches, mem-
branes, and an appearance of acute inflammation in
the throat, should cause rejection.

Hoarseness, or loss of voice, or cough, should at least
delay, and if persistent prevent, acceptance.

THE RECRUIT 11

Numerous scars on the tongue, lips, and cheeks, unless
clearly and certainly accounted for other-
wise, should cause rejection as being prob- °

ably due to bites during epileptic fits, or to syphilitic
or other ulceration.

Too much importance should not be attached to a
coated tongue, but a raw-looking, bright red, or tremu-
lous one should direct careful scrutiny to the general
condition and the habits.

Enlarged lymphatic glands, or " kernels," are most
frequently noticed in the neck or under the jaw. They
are frequently indicative of inflammation or »
ulceration in other nearby regions, espe-
cially the mouth or throat, and their pre- ^
sence should lead to careful examination for such con-
ditions ; but at times their presence is indicative of a
general infection, such as syphilis. Usually, if the en-
larged glands are numerous, or the enlargement great,
they constitute a proper cause for rejection. When the
enlargement is localized at one part of the neck only,
it points to an infection entering at a part near it.
Thus such a gland at the angle of the jaw may be due
to inflammation of a tonsil of the same side ; one under
and near the jaw to a bad tooth, etc.

The scalp should be carefully examined as to its
cleanliness and general care, for the presence of lice,
which may be seen as such or may be re- •
vealed by the " nits " or eggs, little whitish
bodies attached firmly to the hairs ; for ringworm,
scabbiness or scald-head, patchy baldness, wounds or
scars, etc. The presence of vermin is a cause of rejec-
tion in two ways, as indicating a lack of personal care,
and as a danger to be introduced into crowded barracks.

12 THE RECRUIT AND HIS ENVIRONMENT

Superficial suppurative scalp diseases should generally
cause rejection, as being contagious or as being caused
by scratching excited by lice. Patchy baldness, if the
patches are sharply defined and the skin is smooth,
clean-looking, and not scarred, is apt to be harmless.
If the skin is infiamed and scarred, and stumps of
broken hairs are present, it should cause rejection. Ir-
regular and incomplete baldness occurring in patches
or tracts, giving at times a " moth-eaten " appearance,
is most apt to be due to syphilis, and should cause care-
ful examination for other signs of that disease.

The upper limbs should be examined as to their de-
velopment and musculature, their free mobility in all
joints and in all directions, the presence of
all bones and joints, and a reasonable
amount of dexterity and strength. Atrophy or wasting
of a group of muscles or a part, inability to bend or
make free use of a joint, and similar defects, should
be carefully looked for, as they may otherwise be
missed. Loss of one or more joints of a finger, swelling
and deformity of a joint (baseball finger), or stiff con-
tracted fingers are not uncommon, and, if in the fourth
or fifth fingers, are not serious matters, though they
should be noted. If in the second or third fingers, the
matter is more serious, yet the applicant will usually
be able to handle a gun and perform his other duties.
Loss of a thumb is a serious defect, and in most instances
would justify rejection. All deformities from badly
united fractures or other causes should be noted, and
should cause rejection unless the applicant can demon-
strate his ability to execute the movements necessary
in the performance of his duties.

The legs should likewise be examined as to their

THE RECRUIT 13

development, musculature, size, mobility, etc. The ap-
plicant should be required to move all the t g^g ^j, j
joints, to jump, hop, and otherwise demon-
strate his ability to use his limbs. Marked
deformities, such as clubfoot, shortening of one leg,
stiffness, marked swelling or marked limitation of mo-
tion in a knee or hip, should at once cause rejection.
Less marked deformities, such as knock-knee, bow-legs,
crooked shins, etc., need not cause rejection unless man-
ifestly interfering with the free use of the limbs, or
rendering the subject's appearance ludicrous or unmili-
tary. Here, again, marked wasting of a part or of a
group of muscles will often be found due to a joint
lesion, a paralysis, or other nervous trouble, that would
serve to disqualify the applicant. In addition to these
defects, common to both arms and legs, the lower ex-
tremities are subject to other affections rarely or never
seen in the upper.

Varicose or dilated veins are often seen. They usu-
ally show as swollen, bluish, and more or less tortuous
vessels beneath the skin, and may be individually as
large as a man's finger. They are most commonly seen
on the lower legs, but are not very rare in the space be-
hind the knee, and may extend up the inner side and
front of the thigh to the groin. If marked, they should
caiase rejection. If only slight, and in otherwise desira-
ble applicants, they may be passed, but should always
be noted. At times they cause the appearance and per-
sistence of very chronic ulcers, which occasionally bleed,
pain, or otherwise disable the man. Such ulcers are es-
pecially apt to show on the front or to the inner side of
the lower half of the leg. They are long in healing, are
apt at any time to break open again, and when healed

14 THE RECRUIT AND HIS ENVIRONMENT

usually present brownish, discolored scars. Such ulcers,
or such scars if accompanied by varicose veins, should
cause rejection. The legs are especially prone to chronic
ulcerations^ which may be caused by syphilis, tubercu-
losis, leprosy, and other infections. In general these are
causes for rejection.

A rough, nodulated, tender shin-bone is not an un-
usual sign of syphilis.

The feet require particularly careful examination, as
on their integrity, usefulness, and strength (or what we
might call their durability) depends a large part of the
man's capacity for " soldiering." The best known and
probably the least important of the foot-ills is corns.
They are best known because most persons at some time
have at least one, and they are one of the least impor-
tant ills because in most instances they cause not even
serious inconvenience, and they usually disappear with
the use of properly fitting shoes and ordinarily good
care of the feet.

If numerous and painful, however, or if soft corns,
situated between the toes, they may justify rejection.

Sweating feet, which soften, blister, redden, and burn,
may cause rejection, as they are not apt to stand much
marching.

Stinking feet may justify rejection in most instances,
as constituting a nuisance in barracks.

Bunion, an inflammatory and deforming joint-afFec-
tion, usually at the base of the great toe, will, if very
marked, disqualify.

Hammer-toe, a condition in which a toe is flexed and
the end presses on the floor, while a knuckle projects
above, is very apt to cause lameness and may justify
rejection.

THE RECRUIT 15

Overlapping toes may disqualify in a somewhat simi-
lar manner.

Deformities of the arch of the foot are very impor-
tant. It may be too high, so that the weight is borne on
the ball of the foot and the heel, the intermediate parts
remaining clear of the ground. This is a relatively rare
condition, but may disqualify. A common condition is
the opposite, ox flat foot ^ wherein the whole length and
breadth of the foot touches the ground and the arch is
almost or entirely obliterated. Such a foot in a white
man is usually a poor marching foot, and, unless the
applicant is a desirable man and states that he is a good
walker, and that the foot never gives him trouble, it
should cause rejection. When passed, its existence
should always be noted, in case the man should be dis-
charged for it later. The condition is more common but
less important in negroes, but it may cause trouble in
them also, particularly in the course of long marches.

Another type of weak foot is not really flattened but
tends to rotate outward, thus bringing the inner margin
of the foot nearer to the ground and more directly
under the weight of the body, where a greater weight
comes upon it, causing it to tire and eventually to break
down and become flat. It may justify rejection.

The genitals should be well-formed and normal.
Both testicles should be present and in the scrotum ;
it should be possible for the applicant to ^^
retract his foreskin, and the penis should
not show gross deformities, such as the opening of the
urethra being placed far back from the end. Scars on
the penis should prompt investigation as to their na-
ture, whether syphilitic, chancroidal, or otherwise. The
man should be required to express the contents, if any.

16 THE RECRUIT AND HIS ENVIRONMENT

from the urethra. Pus should at once cause rejection,
as should any ulcers or sores on the penis, redness,
puffiness, or signs of marked irritation about the
urethra, or the presence of vermin, commonly known as
crab-lice. Inflammation of the glans beneath the fore-
skin, and venereal warts, while not in themselves dis-
abling, will often justify rejection as capable of exciting
suppurative buboes, and as resulting from venereal
disease or uncleanliness, or both.

Buboes are swollen and inflamed lymphatic glands,
and are found in the groin. They may be single or
multiple, on one or both sides, and may vary in size
from that of a small cherry to that of an orange.
While not all groin buboes are venereal, the great ma-
jority of them in applicants for enlistment are, and
they justify rejection, even though the applicant insists,
as he probably will if his venereal disease is not plainly
evident, that they are due to " strain."

Varicocele is a condition of enlargement of the veins
of the scrotum. It is most often found, and is apt to be
most marked, on the left side. The condition frequently
causes no symptoms, though it is often said to cause
pain, and is apt to be pleaded as an excuse from arduous
duty. If present, it need not cause rejection unless very
marked or unless the applicant says that it produces
symptoms, but when passed it should always be noted,
and the applicant be made to agree to be operated upon
if symptoms begin, or if the condition comes to interfere
at all with his duties.

Hydrocele is an enlargement of the scrotum, usually
on one side, caused by an outpouring of clear fluid into
the membranous sac surrounding the testicle. It pro-
duces a tense, painless, and often translucent swelling,

THE RECRUIT 17

which may at times be hard to distinguish from a tumor
of tlie testicle or a hernia. Any one of the conditions,
however, may suffice to exclude the applicant in time of
peace.

While not much reliance can be placed on an applio
cant's denial of venereal disease and his assertions as to
perfect genital health, he should be questioned on the
subject, and should be asked as to the frequency of
urination and his ability to pass a good stream of urine.
Dribbling or inability to pass a good stream, or to hold
or control his urine, should cause rejection.

The skin will necessarily be noticed and examined
during the examination previously described. One of
the first and most important points to be «, .
noted is its cleanliness. A dirty, foul, stink-
ing skin usually indicates the type of man not wanted in
our army, and it justifies rejection without further exam-
ination. Certain men, however, appear with their skins
soiled with sweat and dust simply because of lack of
opportunities for cleanliness, and if their general appear-
ance and their stories indicate that they are desirable
men, they should be given an opportunity to bathe and
then be examined. It must not be forgotten that a
filthy man may bathe for examination, but reveal his
usual habits by his linen. However revealed, filthy
habits should cause rejection.

A skin showing the marks of severe and generalized
scratching is usually indicative of disease or vermin
infestation, and is therefore objectionable.

All forms of contagious skin diseases, such as ring-
worms and syphilitic eruptions, should cause rejec-
tion, or, in the person of an enlisted man, call for
prompt treatment. As the line officer cannot be ex'

18 THE RECRUIT AND HIS ENVIRONMENT

pected to differentiate such affections, he will be on the
safe side if he treats them all as suspicious, though he
should if possible learn to recognize acne, the common
" pimply" eruption seen on the chests, backs, and faces
of many young men. It is usually not a severe affec-
tion, and as it may coexist with good health and good
habits, it should not cause rejection.

While a few men who are not really physically fit
get into the service, there are a good many more who
-,, are morally or mentally unfit, and they

are the men who later spend much of their
time in the guard-house or who swell the
number of desertions. Against this class of men the
recruiting officer works at a disadvantage. Unfortu-
nately, almost any man, no matter what his character,
can get letters of recommendation, so that such letters
are really of little importance, and the officer is forced
to rely largely on his own ability to judge men by ap-
pearances, — a notoriously unsafe thing, and an almost
impossible thing for some individuals. Some aid is ob-
tained, though, by attention to the applicant's general
bearing, his facial expression, his quickness of appre-
hension, the condition of his person and his clothing,
and such evidences of alcoholism, venereal disease, good
habits, and truthfulness as the examination may bring
out. When a man declares that he never drinks, although
his breath is strong with alcohol at the time, or that he
has never had venereal disease, though he shows a scar
on his penis and another in his groin, or has a suppura-
tive bubo that he says is due to a strain, the inference
is fair that he is a liar and undesirable.

Under our system of voluntary enlistment, and as
long as there are plenty of applicants, it is better to

THE RECRUIT 19

reject all those about whom the officer cannot feel well
satisfied ; and this whole chapter is based on such an
assumed condition of affairs. In time of war, or when
the supply of applicants for enlistment is not up to the
demands, many men can be passed who would be ex-
cluded under our assumed conditions ; but in all such
cases they should only be passed by medical officers ex-
ercising great care, and every defect should be noted,
both as to its presence and its degree, as constituting a
possible ground of application for a pension.

The man being in the service and any defect coming
to his commanding officer's attention, he should be re-
ferred to a medical officer to have it corrected if prac-
ticable, but at any rate to have it noted, in the interests
of justice to the man and to the government, and, if
it be sufficiently serious, to have the man discharged
before he breaks down in time of stress, with possibly
serious results.

In this as in nearly all respects, the medical officer's
duties can be performed more promptly and effectively
if he has the cooperation of the line officer.

Official guidance in the examination of recruits is
found in General Order 66, W.D., April 18, 1910, and
in regulations and orders issued from time to time.

CHAPTER II

PERSONAL HYGIENE

The recruit having been accepted for the service in
good health and good physical condition, it is his duty
to himself and to his government to maintain those
desirable conditions unchanged except for the better,
if it be possible for him to do so. It will be possible in
large part, if he is taught how to do it, and it is there-
fore incumbent upon his officers to teach him at least
the rudiments of personal hygiene, and those rudiments
may be summarized as follows : —

First of all he must be taught the importance of au
abundance of fresh air both day and night, as a
health-giving, strength-producing, and life-
prolonging measure. He must know that
" colds," sore-throat, pneumonia, and kindred troubles
are not caused by cold air, but by micro-organisms;
that those micro-organisms are much more numerous
and mucl^more apt to harm him in a warm, " close "
room, with impure and rebreathed air, than in the open ;
and that such diseases are more common in cold weather,
))aitly because in trying to exclude the cold, man is apt
to include such air. The habit of breathing deeply and
thoroughly changing the air in the lungs is imparted to
him by his gymnastic and military drills, and is helpful.
He should also learn early that his rest is important
and should be taken regularly, in order to
preserve his health and enable him, for that
reason, to do without it more easily when the neces-

PERSONAL HYGIENE 21

sity arises. He should get eight hours of sleep in each
twenty-four, while four hours more should be allowed
for meals and short rests, changing of clothing, etc. In
the remaining twelve hours he should do his work and
his play. Regularity in rest and work is of great im-
portance, and that is probably one reason that so many
men improve rapidly in physique after entering military
service. On the other hand, it is debilitating and de-
moralizing to steal the hours from sleep for drinking
and venery. It is desirable that the night's rest be taken
in clothing different from that used in the daytime, and
the latter should be allowed to air. Every man should
possess and use night-clothing, and the not uncom-
mon habit of sleeping in the underclothing should be
discouraged. No man should have a " barrack odor "
clinging to him, and, if ventilation and clothing are
looked after, he will not.

The most beneficial exercise is that obtained incident-
ally to work or recreation. Exercise taken purely as
such is usually repugnant, and takes on the .^
aspect of work to men who feel that they
already have an abundance of it. It should therefore be
taken with some other incentive than is furnished by
official orders. Baseball games, field sports, and other
athletic competitions should be encouraged, and the
effort should be made to interest and include all the men
in them, and not merely a baseball nine and a few ex-
pert athletes in each post. The objects to be attained by
exercise are the increase of the strength of the heart
and the capacity of the lungs (on which two depend en-
durance, the increase of muscular strength, of nervous
stability and control, of digestion and assimilation), and
keeping the emunctories (the channels of waste excre-

22 THE RECRUIT AND HIS ENVIRONMENT

tion, such as the skin, kidneys, and bowels) active.
No form of exercise at present encouraged in the army
fails to promote some of these ends, so they are all
good.

Cleanliness of person, clothing, and bedding should,
and usually does, become a habit of life with the soldier ;
_. .. but some men require much watching and
admonition to make it become so, and fre-
quent inspections should be made in order
that the admonition may not be wanting. In general, it
may be stated that dirty soldiers are either recruits or
men who through drink or vicious habits have suffered
in their self-respect. Body lice are rarely seen in our
service except in guard-houses, where they may be in-
troduced by captured deserters or other prisoners. Bed-
bugs are occasionally found, and head-lice and itch
infrequently. All of these pests should be carefully
watched for and exterminated when found, as not only
are they disgusting in themselves, and indicative of
careless or filthy habits, but it seems quite possible
that they may act at times as carriers of disease. Bed-
bugs, when once introduced in barracks, are at times
very hard to dislodge, particularly if the buildings are
old and show many cracks in the walls.

Personal cleanliness should be understood as includ-
ing the exclusive use of one's own linen and toilet
articles. Disease may be transmitted readily by the
indiscriminate or common use by several persons of the
same towels, sponges, wash-cloths, combs, hair-brushes,
shaving-brushes, etc. Some of the diseases which are
most readily transmitted by these means are itch, ring-
worms and other skin diseases, granulated eyelids,
gonorrheal infection of the eyes, body vermin, and,

PERSONAL HYGIENE 23

occasionally, such infectious diseases as typhoid fever
or smallpox.

It is not necessary that a man should bathe his body
daily unless he is engaged in particularly arduous or
dirty work, but he should bathe at least twice a week
in summer and once a week in winter, and as much
of tener as is necessary to keep his skin clean and free
from all odor, especially from the feet, crotch, genitals,
and armpits, and particular attention should be given
to those parts. Once or twice a week, or oftener if
necessary, the washable clothing, — shirts, drawers,
and socks, — should be changed, and fresh put on.
More frequent baths and changes do no harm, but
should not ordinarily be demanded, except in the tropics.

The soldier cannot well give too much attention to
his feet^ as he thereby keeps them in good condition
and directly increases his value as a soldier. Any trou-
ble with them should at once be corrected by the man,
by means of bathing, clean socks, properly fitting shoes,
proper nail-trimming and cleaning; or, if of a kind not
corrected by such means, it should be reported to the
surgeon.

The hands are not subject to so many disabilities as
the feet, but they should be kept clean and sound, the
nails clean and trimmed, and it should become a matter
of routine to wash them before taking food, as diseases
so diverse as lead-poisoning and typhoid fever may
result from the neglect of such a practice.

The scalp should not be neglected in the general
cleaning, and its cleansing is facilitated by having the
hair short.

Bedding should be aired and bed linen changed
weekly.

24 THE RECRUIT AND HIS ENVIRONMENT

The clothing issued by the government is nearly
always of good quality, and is furnished in sufficient
_. , , quantity to enable the soldier to be always

° comfortably, seasonably, neatly, and cleanly
attired in a uniform and soldierly manner, and as much
should always be demanded of him. He has to pay for
his laundry-work, and he should have enough done to
meet all the requirements indicated above.

The individual soldier has relatively little to do with
the choice of his food, and the subject will be dealt
_ . with at greater length in a later chapter.

° He has all to say, however, as to how he
shall eat what is served to him, and he should be taught
to avoid gluttony, to eat with an observance of the
decencies, to chew his food thoroughly and eat slowly,
to be as regular in his hours and habits of eating as
his duties permit, and to avoid the use at meals of the
enormous quantities of liquid, particularly coffee, in
which he seems to find delight. A ])int of water may be
taken with a meal without harm, but a pint of coffee is
apt to cause some disturbance, while a quart is much
more apt to do so ; and the fact that so little demon-
strable harm does result is probably due to the good
general physique and surroundings of the soldier. Many
soldiers, especially young ones, are prone to indulge at
almost every opportunity in the eating of fruits and
pastries, with less regard to the quality than to the
quantity. This tendency is lessened by a good company
mess, and it should be discouraged as apt to lead to
digestive disturbances.

Regularity of the bowels should, if practicable, be
established and maintained by regular habits, good
food, the use of fruits and bulky foods, such as vege>

PERSONAL HYGIENE 26

tables and oatmeal, and by exercise. Irritating or
highly-seasoned foods should be used sparingly, if at
all.

Among people of education and refinement cleanli-
ness of the mouth is of course as much of a routine as
cleanliness of face and hands, but persons
whose education and rearing have been less
carefully supervised are apt to neglect it,
and recruits and occasionally soldiers from the latter
class are at times seen with their mouths in a shameful
state as the result of such neglect.

They should be taught (a) that such ailments as
indigestion, toxic absorption, toothache, sore throat
and sore mouth may result directly from such neglect,
while many serious diseases are much aggravated by it,
and (b) what will probably be more effective, that its
existence is a mark of poor rearing and inferiority.

Every company commander should instruct his men
somewhat as follows : —

1st. Every man should have a tooth-brush, and
should so use it at least twice daily, and preferably
oftener, as to remove from the teeth and gums all par-
ticles of food or other foreign matter, brushing away
from the gums and in all cracks and crevices.

2d. That he should after each meal remove from
between the teeth, with a wooden or quill tooth-pick,
or with a thread, any pieces of meat or other food, and
not allow it to remain and putrefy.

3d. That he should promptly consult a dentist or a
medical officer about any trouble arising in the teeth
or gums. The medical officer can at least give him
proper advice, and in many instances proper treat-
ment.

.26 THE RECRUIT AND HIS ENVIRONMENT

Much harm is done by careless spitting, urination,
and defecation in improper places, by men ignorant of
_ the harm they may thus do. Because appar-

_ . ently healthy themselves, it does not occur
r fl Of ^ them that they may, in answering a per-
, fectly natural call, transmit disease to oth-

ers. Yet, as will be shown in other places,
they may be giving off the organisms causing typhoid
or other infections in their urine or feces, or those
causing diphtheria, tuberculosis, or other disease in
their spit, and such organisms may then soak or wash
into the water-supply, or may be carried as dust or
mud to the mouths, hands, food, or breath of healthy
persons, and so infect them. Decency and patriotism
should prompt a man to show as much regard for the
health of his comrades as for his own.

The question of venereal disease will be dealt with
in a subsequent chapter. Much of it could be avoided
if the ignorance and misconception regard-
_ ., ing sexual life could be dissipated. Every

man should know that sexual continence
is compatible with perfect physical health, while its
maintenance is far greater evidence of character and
" manliness " than is the association with prostitutes,
the abasement of virtuous girls, or the lowering, self-
respect-destroying and demoralizing practice of mastur-
bation. The sexual organs and sexual desire are placed
in man that he may procreate and replenish the race ;
but there is no physical penalty for his failure to do
so, and the sperm necessary for the purpose will be dis-
charged in sleep when it has accumulated sufficiently.
" Wet dreams " and involuntary seminal emissions are
not, therefore, necessary evidences of "loss of man-

PERSONAL HYGIENE 27

hood " or of any other disorder, but are seen to be the
natural and healthy method of disposal of the sperm
not used in the legitimate sexual intercourse of married
life. Every normal man has periods of sexual excite-
ment and desire, which constitute one of Nature's pow-
erful influences in the perpetuation of the race; but
self-respect should prompt and self-command enforce a
determination that such desire shall not lead to acts
that violate the laws of religion and society. These
periods of excitement and desire can be made less fre-
quent, and continence promoted, by the avoidance of
fasciviousness in speech, conduct, reading, and thoughts,
by thorough cleanliness and otherwise complete neglect
of the genitals, and by a regular, sober, active life.

The habitual and excessive use of alcohol is every-
where conceded to be harmful, while the moderate or
judicious use of it excites much discussion, . . , ^
but is, in this country at least, falling into
disfavor. Owing partly to the prohibition of the sale
of wines and beer on government reservations, the con-
ditions under which a soldier now indulges in alcohol
are in most instances not conducive to " moderate " or
judicious use of it ; so that, laying aside all theory,
and dealing only with the condition confronting us, it
is our duty to advise and encourage total abstinence in
the soldier. This we may be able to obtain in certain
instances, but it does not seem probable that it will be
a universal characteristic of soldiers during the active
service of the readers of this paragraph. We should,
however, particularly try to inculcate it in the young
recruit, as the man who does not begin to drink before
he is twenty-five years of age is much less apt to become
a drunkard or a habitual user than he who begins before

28 THE RECRUIT AND HIS ENVIRONMENT

he is twenty, and there is a good chance that, if he
abstains nutil that age, he will always do so. On the
other hand, the impossibility of knowing who are, and
who are not, capable of using alcohol judiciously should
prevent our encouraging what we regard as judicious
use in soldiers. Every military post shows in its guard
reports, its sick reports, and in unrecorded ways, the
injury and loss of service resulting from excessive use
of alcohol ; so that it is not necessary either to quote
military statistics or to go to civil life for the lesson.
However, the very nature of a soldier's calling so re-
stricts his freedom of action, so excludes him from many
refining and restraining influences, and so throws him
in the way of temptation to drink, that we should highly
honor him in the mass for his good conduct, and encour-
age him in it as an individual.

If used at all, alcohol is preferably and least harm-
fully taken with or after meals.

It will do little good to warn men against the use of
strong alcohol, of flavoring extracts, bay rum, and wood
alcohol, as only abandoned drinkers use such prepara-
tions as beverages, and such men are not apt to heed the
warning. However, it is important to know that wood
alcohol and its preparations are more poisonous than
ordinary alcohol, and that death, or complete and per-
manent blindness, may follow their use.

Probably the least harmful and the most general of
the so-called " bad habits " is the use of tobacco in one
form or another. In our army the methods
of using it are smoking and chewing. Of
these chewing is probably the most objectionable as
fouliniT the mouth and causing promiscuous spitting.
Moderate smoking, indulged in after meals and in

PERSONAL HYGIENE 29

periods of relaxation, cannot be said to be very harm-
ful, if at all so ; but smoking in excess may do harm by
causing digestive, respiratory, and nervous disturbances,
among which may be heartburn, headache, palpitation
or irregularity of the heart, insomnia, tremor, cough,
and hoarseness. Just what constitutes excess may not
be stated, as an amount harmless to one man may be
enough to cause injury to another. In general terms we
may say that an amount causing any of the above-named
or other symptoms in any man constitutes an excess for
that man. As to the various methods of smoking, the
same general principles apply. Cigar, pipe, and cigar-
ette are equally harmless if not used to excess. The main
objection to cigar-smoking is the expense ; to pipe-
smoking, the irritation of the mouth, in rare instances
eventuating in cancer ; and to cigarette-smoking, the
habit of inhaling the smoke and thus exposing a much
greater surface to the fumes, causing irritation of the
vocal organs and the bronchial tubes, and the habit of
rolling and smoking a cigarette at each opportunity, so
that the total number consumed becomes excessive. The
habit of smoking and the proper indulgence of the habit
do the soldier so little harm and so greatly increase his
comfort and contentment that they should not be inter-
fered with. Stale tobacco-smoke in quarters, however,
gives a very unpleasant odor, and the room should be
daily opened and aired sufficiently to prevent or dissi-
pate this.

There should be no necessity for telling men to dress
properly for the season and the climate, but the neces-
sity nevertheless exists, owing to the carelessness, igno-
rance, or perversity of men. It is neither profitable nor
wise for an officer to undertake to prescribe just what

30 THE RECRUIT AND HIS ENVIRONMENT

his men shall wear at all times, as men differ in their
capacity to stand heat and cold, and one man may be
able to maintain the highest degree of health
*^ ' and comfort by never wearing flannel under-
clothing, while his neighbor may promote
both by wearing it the year round, and the
rest of the men in the squad-room by wear-
ing flannel in winter and cotton in summer. But men
should be taught that exposure to either heat or cold
lowers the resistance of the body and predisposes it
to disease ; that body- warmth is promoted by woolen
clothing and that linen and cotton make cool clothing ;
that alcohol is not a fit substitute for an overcoat or a
rain-coat ; that wet feet should be dried and dry cover-
ings substituted for wet ones after marching or other
exercise ; that good intentions or thoughtlessness do
not justify reckless exposure to extremes; and that it is
their duty to the government, as well as to themselves,
to use discretion in dress and to try at all times to
avoid sickness.

Exposure to strong sunlight is by some persons al-
leged to be the cause of some of the evils heretofore
credited to the heat of the sun, and it is further stated
that these effects may be obviated by the use of hat-
linings and underclothing of black, red, or orange, to
exclude the actinic rays. However, rather extensive
observations and investigations made by various work-
ers in the Philippines have afforded little or no support
for such assertions.

In all climates and at all times the dress should be
comfortable, and should hamper the movements, espe-
cially of the chest and abdomen, as little as possible.
The equipment should be as light as circumstances will

PERSONAL HYGIENE 31

permit, should also be arranged with the idea of inter-
fering with motion, particularly of the chest and ab-
domen, as little as possible, but should contain the
necessary articles.

While the government supplies the necessities of the
soldier and supervises his hygiene to a considerable
extent, it is seen already that the man himself is re-
sponsible for much, and there are a few more golden
rules that he should learn early for his own protection,
and that will bear frequent emphasis and repetition,
especially in campaign.

1. Be clean in person, clothing, and surroundings.

2. Eat no food but good food, and only with clean
bands.

3. Drink no water from unauthorized or doubtful
sources, unless it is boiled, — plain, or in tea or coffee.

4. Abhor, avoid, and destroy vermin, whether lice,
fleas, ticks, flies, mosquitoes, roaches, mice, rats, or other
varieties.

CHAPTER III

FOODS AND THEIR PREPARATION

It is now trite and partly true that " an army travels
on its belly," and plainly evident that the health and
happiness of the individual soldier depend very greatly
on what he puts into his belly. This is a matter largely
in the control of the company commander, and it is
therefore important that he should have some know-
ledge of foods and their preparation, and should pay
great attention to mess-administration. Many company
commanders do so, but others, knowing little of the
subject, delegate the entire matter to their mess-ser-
geants, who may know less, and the men suffer. The
government ration and the regulations concerning its
use are very liberal, and if a company does not have
an abundance of good, nutritious, and attractive food,
the fault is nearly always in its handling after it reaches
the company.

Foods are of different classes, and a judicious and
proper mixture of these is necessary for the classes
maintenance of health and strength.

Proteids^ or albuminous foods, are the class repre-
sented by the white of egg or lean beef. They occur also
in vegetables, beans and peas being particularly rich in
proteid, and this fact makes an exclusively vegetarian
diet a health-sustaining possibility, which a proteid free
diet is not. Animal proteid is more easily and com-
pletely digested than that from vegetables, and to most
persons is also more agreeable. An exclusive meat diet

FOODS AND THEIR PREPARATION 33

can maintain health and strength for long periods of
time, and recent careful observations on the Eskimos
of Disco Island in Western Greenland show that they
maintain excellent health and nutrition on a diet almost
exclusively of meat. " The physical endurance of Es-
kimos nourished in this way is conspicuous, as is tlieir
resistance to the rigors of the climate."

Fats are the class of food represented by the fatty
tissues of animal bodies and the various vegetable oils.
They are very valuable as foods, owing to their great
fuel- value and the amount of nutriment contained in a
small bulk ; but if taken in excess they are difficult of
digestion and cause dyspepsia and diarrhoea. They are
especially valuable in cold climates, a fact which we
recognize in our practice of eating pork and other fat
foods more freely in winter.

Carbohydrates are the sugars and starches, repre-
sented by cane-sugar, fruit-sugar, and others, and by
starchy vegetables such as potatoes and grains. For
practical purposes we may say that the carbohydrates
are of vegetable origin. Cellulose, as found in the husk
and fibre of plants, is another form of carbohydrate,
having a food-value for herbivorous animals but none
for man. The carbohydrates have about the same
fuel- value, weight for weight, as the proteids, and less
than that of the fats. Starches may be taken in large
amounts, but sugar, if taken in excess or in too con-
centrated a form, causes dyspepsia and other disorders.

Inorganic salts, as represented by common salt and
other salts contained in foods, have no fuel-value, but
are necessary in maintaining the nutrition of the body,
and the same is true in even greater degree of water.

Organic acids, flavors^ and condiments, as found in

34 THE RECRUIT AND HIS ENVIRONMENT

fruits, many vegetables, and in spices, are of value
secondary to the preceding classes.

There is another class of substances that are not
carbohydrate, proteid, nor fat, that occur in very minute
quantities in foods, the existence of which has been known
for only a short time, yet they are very important and
their absence from the diet results in disease or death.
These substances are spoken of as vitamines, and, while
they are probably numerous, each appears to have a spe-
cific value, in that its absence causes a specific disease.
Among diseases caused by lack of vitamines are beri-
beri and scurvy, rickets probably and pellagra possibly.

The vitamine that prevents beri-beri is found in very
small amounts in meat and vegetables, in larger amounts
in peas and beans. It occurs in rice but is there found
only near the surface of the grain, in or closely adjacent
to the pericarp or brownish colored outside of the grain.
When the rice is highly milled and made white the outer
layer of the grain with its contained vitamine is removed.
Hence persons living principally on highly milled rice
are subject to beri-beri, while others living on unmilled,
hand milled, or undermilled rice do not have it.

Following the substitution of undermilled for highly
milled rice and the addition to the dietary of " mongo "
beans, beri-beri promptly disappeared from the Philip-
pine Scouts, from Bilibid prison, Culion leper colony,
and other places in the Philippines, and elsewhere.

Scurvy is caused by the lack of a vitamine that ex-
ists in fresh meats, fresh fruits and green vegetables,
but not in cured meats, in grains, dried fruits or beans,
hence the former great prevalence of the disease at sea
on long voyages, and in war, especially in besieged places.
Guinea pigs can be given scurvy by feeding them for

FOODS AND THEIR PREPARATION 35

about a month on bread and dried mongo beans. On
the other band a diet of bread and sprouted mongo
beans protects and maintains them in good health.

Infants nursed at the breast or fed on raw milk do
not have infantile scurvy. Fed on boiled or canned
milk they are liable to it unless also given orange juice,
meat juice, or other antiscorbutics.

For many years Voit's standard was taken as repre-
senting the approximate amounts of the three main
classes of foods necessary each twenty-four
hours for the maintenance of health and
vigor in the average working adult.

According to that standard the requirement was 118
grams of dried proteid, equaling about one ration of
beef, 56 grams of fat, and 500 grams of carbohydrate,
that is, of starch and sugar. The total value of this diet
was over 3000 calories.

More recently, Professor Chittenden of Yale Uni-
versity has shown that health, strength, and vigor can
be maintained by many individuals on half the amount
of proteid, without any increase in the fats or carbo-
hydrates.

Meats are mixtures of proteids and fats, and contain
water and salts also. They vary in palatability, cost,
digestibility, and nutritive value ; but all •Mp'afa
meats have nutritive value, though if dis-
eased or decomposed they are not available for use.

In our service beef is the standard meat for issue,
mutton, pork, fowl, and fish being substitutes issued
only occasionally ; and, considering the cost, nutritive
value, palatability, digestibility, tolerance, etc., it is
the most valuable meat.

Mutton is almost equally valuable for nutrition, but

36 THE RECRUIT AND HIS ENVIRONMENT

many persons dislike the taste of it, and almost all tire
of it sooner than of beef.

Pork is fatter than either beef or mutton, and is
therefore much more used in cold than in warm weather.
It is more difficult of digestion than beef and not so
generally liked, though bacon is much used in the army
and is a popular and valuable food, especially in the
field.

Veal is seldom issued to troops. Its nutritive value
is somewhat less than that of beef, and it causes diar-
rhoea in some persons.

Fowl, as chicken or turkey, constitutes a special
treat on national holidays and festal occasions. If
freshly killed and healthy fowls are served, it is valu-
able as well as appetizing food ; but when birds long
kept undrawn in cold storage are issued, as is not in-
frequently the case, their quality should be suspected
and each bird carefully scrutinized, and, if of doubtful
appearance or odor, rejected.

Fish vary greatly in palatability and nutritive value,
but all of them keep poorly, especially if allowed to die
slowly and if not packed in ice or frozen. The meat
should feel firm to the touch, and not crush on gentle
pi'essure. Dried and canned fish, as issued, are practi-
cally always good, but they are not suitable for fre-
quent or prolonged use, as men very soon tire of them.

Eggs consist of animal proteid and fat, and are
classed with the meats. They are nutritious and usually
easy of digestion. They may be cooked in a great va-
riety of ways as a main dish, and are very frequently
used in other dishes, such as puddings and cakes.

All meats should be eaten cooked, as proper cooking
improves the flavor, increases digestibility, and destroys

FOODS AND THEIR PREPARATION 37

parasites that might otherwise cause disease in the
eater. Among the disease-producing organisms which
may be conveyed by meats but which can be destroyed
by heat are : —

1. Tapeworms of various kinds, the three most com-
mon ones being transmitted respectively by beef, pork,
and fish, the meat in either case being " measly."

2. Trichina^ a species of larval worm which infests
the muscles, causing great suffering, and, at times,
death. It is conveyed to man by eating underdone
pork that contains the parasites.

3. Tubercle bacilli^ the cause of tuberculosis.

4. Bacteria causing some animal diseases, which
may reproduce the same diseases in man, or may
merely cause intestinal trouble. Paratyphoid, a disease
resembling typhoid, may be so produced, as may many
so-called " acute food poisonings."

6. Ray fungus^ the cause of actinomycosis or lumpy
jaw in cattle.

6. Typhoid bacillus, the cause of typhoid fever, may
be conveyed in oysters or other shellfish coming from
polluted waters.

7. The bacillus of anthrax, the cause of a very fatal
disease.

8. The bacillus causing " trembles " in cattle and
" milk sickness " in man.

Some diseases fatal to food animals do not affect man,
and the flesh of animals dead of such diseases can safely
be eaten ; but in general it is safe and wise to avoid all
such meat, as, though the disease killing the animal may
not affect man, chemical changes may have occurred in
it to give rise to poisons, and ptomaine poisoning or
*' meat poisoning " may result. Ptomaine poisoning may

346655

38 THE RECRUIT AND HIS ENVIRONMENT

also result from the action of bacteria contaminating
the meat after death, or even after cooking, and causing
changes in it. Such instances are seen when poisoning
occurs from cold meat or hash cooked some days before
use, or from canned meat taken from imperfect tins.
When the ptomaine or other poisonous products oi
bacterial action are once formed in the meat, they often
may not be destroyed by cooking, and all such meats
are dangerous.

Some few kinds of meat, principally fish, are poison-
ous in themselves, and may cause death.

Meats are preserved for use in a variety of ways, only
a small percentage of those furnished the army being
used so soon after killing as not to require some form
of artificial preservation. Of these methods of preserv-
ing, cold is the most satisfactory and best keeps the
meat unchanged, and by this means it may be kept for
months. It is applied so as to freeze or merely to "chill"
the meat, and its only effects are to render the flesh
more tender and to detract somewhat from its flavor,
particularly by causing an unpleasant change in the
taste of the fat. Frozen meat may be kept indefinitely,
but that which is merely chilled does deteriorate in
time, becoming soft, slippery, and flavorless. It should
not then be used as food. Cold cannot be depended
upon to destroy the germs or parasites in meat, though
keeping for a long time will destroy some of them.

Salting^ pickling^ and smoking are much used in
preserving meats, particularly beef and pork, and the
results are very good. Ham, bacon, and corned or
smoked beef are excellent and palatable meats for oc-
casional use, but they are not adapted to long use to
the exclusion of fresh meats, and when they are so used

FOODS AND THEIR PREPARATION 39

the health is apt to suffer. These processes tend to
free the meats from parasites, but cannot be depended
upon to do so, and the eating of raw ham is dangerous.

Canning, with its attendant sterilization of the meat,
preserves all of its nutriment and destroys all parasites,
but it melts the fat, gelatinizes the gristle, and softens
the muscle, so that the meat comes from the can less
attractive to eye or palate, but it is good and valuable.

Preservation by means of drugs and chemicals, other
than those used in pickling or salting, such as boric acid
or formalin, is forbidden, and meat so preserved may
cause sickness ; but for emergencies and occasional use
it would not ordinarily do so.

It is not desirable here to consider in detail the vari-
ous methods of cooking meats, but the company officer
should exercise a certain amount of supervision in the
matter, to see that his men's digestion is not injured
by an excessive use of fried meats, that their appetites
are not impaired by poorly prepared or poorly served
roasts, stews, and hashes. A company mess is often good
or bad as the cook knows, or does not know, how to
handle, prepare, utilize, and serve meats. Rather com-
mon faults in company cooks are as follows : —

Roast or baked meat is overcooked and dry, is taken
from the oven an hour or two hours before meal-time
and sliced, and is served with hot, greasy gravy to make
it warm.

Tough ends, scraps, and bones are not utilized in
making soup stock, as they should be.

Excessive fat is not rendered and utilized.

Hashes and stews are served with unnecessary fre-
quency, and become monotonous.

Lack of imagination or lack of knowledge on the

40 THE RECRUIT AND HIS ENVIRONMENT

part of the cook and mess-sergeant result in lack of
variety and attractiveness of the mess. Intelligent
supervision of the mess by the company commander,
the preparation of bills of fare in advance, so as to in-
sure variety, and the study of good cook-books will
obviate this.

The principal carbohydrate food is bread, and its
importance in the mess is scarcely, if at all, secondary
to that of meat. The ordinary supply of
bread is issued as such, and its quality
depends largely on the capacity of the post baker,
notwithstanding his proneness to credit any defects
in it to the flour, the yeast, the hops, or the oven. The
materials supplied by the government are, with rare
exceptions, excellent, and the failure to produce good
bread is usually to be attributed to either the ignorance,
the carelessness, or the uncleanliness of the baker.
With the proper training of the bakers such failures
will seldom be seen. Company cooks are permitted,
and should be encouraged, to bake biscuit and muffins
occasionally. They are somewhat more difficult of
digestion than good issue bread, but are much liked
and add to the attractiveness of the mess. Stale bread
(that is, more than twenty-four hours old) is somewhat
more digestible than fresh or hot bread ; but during
the process of staling it should be kept covered and
protected from dust, and should not be unnecessarily
handled, nor by any but clean hands ; otherwise bac-
teria and moulds finds lodgment and growth upon it
and may produce disease. Toasting improves some
breads and adds to their digestibility, but it is not
often done in companies.

Pastries and cake are also bread, but are less easily

FOODS AND THEIR PREPARATION 41

digestible than the ordinary forms. They add much to
the attractiveness of a mess and should be served occa-
sionally. The same remarks apply to the various kinds
of batter-cakes.

Comhread also makes a pleasant change from the
monotony of baker's bread, and, as it is cheap, palat-
able, and nourishing, its use is to be encouraged.

Corn-meal mush, with butter or milk, is also relished,
and when cold may be sliced and fried.

Hard bread is issued only for field use. Good teeth
are necessary for its utilization as issued, but it may
be softened in hot water or coffee without impairing
its value.

A measure of economy, sometimes ignored, is the
utilization of crusts and fragments of stale bread in
puddings, as meat-stuffing, and in other ways. Such
practices add to the variety and attractiveness of the
mess, and allow savings to be made in other direc-
tions. To throw away such crusts because sugar and
eggs are necessary in puddings and cost a little extra,
is wasteful and wrong.

Vegetables supply all classes of foods, and are very
important in the soldier's mess for this reason, and
because they serve to impart variety and _-
attractiveness to it. The most important . y^
vegetable issued (except wheat) is the po-
tato^ which consists of almost pure starch. It may be
cooked in a much greater variety of ways than is usual
in most companies, and the company commander should
see that such is the case. In whatever way they are pre-
pared, potatoes should be cooked until soft or mealy,
and should be served hot.

Rice is another valuable starchy food, and in some

42 THE RECRUIT AND HIS ENVIRONMENT

parts o£ the world it is the main article of diet; but in
our country it is much less used and less desired than
bread or potatoes. It is most popular with soldiers as
a pudding, though it may be prepared in a variety of
ways. It should be used to give variety and served in
attractive forms, cooked with tomatoes or something
else to take away its insipidity. Undermilled rice has
a flavor superior to that of the highly milled and is
also preferable, especially when used as a main article
of diet, because of its content of vitamines that ai*e lack-
ing from the latter.

Com is also to be classed as a starchy food. Ripe
corn in the whole or the broken grain, as hominy or
grits, is not so generally liked as the green, but it is
very nutritious, and should be used occasionally as a
principal dish.

Macaroni and other paste preparations are valuable
foods, and admit of a variety of presentations, so that
their use should be encouraged.

Onions are a staple article of issue, and are much
used in the army. Their nutritive value is much less
than that of the articles just discussed, but their flavor
and the variety of ways in which they may be used
make them very valuable. Monotony should be avoided
in their use.

Tomatoes^ likewise, have relatively little food-value,
but stand high for their flavor and the variety they
afford. When they are served cooked, it should often
be with some otherwise insipid food, such as rice, maca-
roni, or stale bread.

Beans andj^eas, though possessing considerable starch,
are the principal sources of vegetable proteid. They
are both very attractive and palatable in the green state,

FOODS AND THEIR PREPARATION 43

and, though less nutritious than when ripe, add much to
the mess. When dried, they are particularly valuable
in making soup (for use in which ham-bones and rinds
should always be saved), and when served boiled or
baked, with bacon.

Beets are another valuable source of food, as they
contain much sugar. They are also cheap, and are
relished by most men.

Most of the common vegetables, as cabbage, greens,
carrots, spinach, radishes, and cucumbers, have little
nutritive value, but they add greatly to the attractive-
ness of the mess and are also valuable in preserving
health and preventing scurvy, and their use should be
encouraged.

Their lack and the consequent occurrence of scurvy
are apt to be matters of vital importance in sieges.

Salads are not used in company messes as much as
they should be. They afford pleasing variety, and may
be made to constitute an important dish, as « , ,
when composed principally of potatoes or
salmon.

As issued in company messes, desserts are nearly al-
ways very simple, and such is necessarily the case.
When practicable, a dessert should be fur-
nished once a day, and it may be made to
use up otherwise unattractive articles, such as rice or
stale bread made into puddings. Pies made of fresh
or dried fruits are easy to make and serve, are inex-
pensive, and well liked.

Milh and its products constitute important articles of
food, though not entering so largely into «-.,.
the soldier's dietary as they might. Milk
contains all classes of food, — proteid, fat, carbohydrate,

44 THE RECRUIT AND HIS ENVIRONMENT

water, and salts, — though not in the proportions desir-
able in maintaining adult life. Fresh milk is both more
palatable and more wholesome than the canned or con-
densed article, if its purity and freedom from disease-
producing germs can be assured, but unfortunately this
is not always the case. It should be borne in mind that
many serious diseases may be conveyed in milk, among
them tuberculosis, typhoid fever, dysentery, diphtheria,
septic sore throat, and scarlet fever, — some of the dis-
eases most dreaded in military life. Milk sickness, a
disease now rarely seen, was also conveyed in that way ;
while for many years the Mediterranean garrisons of
the British army suffered very seriously from Malta
fever, now known to have been transmitted by means
of goats' milk.

In case of epidemic of any of the above-named
diseases, the milk supply should be investigated, and
this is particularly suggested by outbreaks of typhoid
showing an explosive character, that is, epidemics in
which many cases occur almost simultaneously. Because
of this possibility of disease-production, milk whose
origin and condition are not above reproach should be
used in companies and post exchanges only in cooking
or after boiling, and in camp or on the march men
should be cautioned to the same effect, and warned
against purchasing it by the glass from dealers or ped-
dlers. Condensed or evaporated milk is more gener-
ally used in companies than the fresh article, and it is
on the whole probably safer, as the process of conden-
sation and the subsequent prolonged storage tend to
destroy disease-producing organisms. A can of such
milk, when once opened, should either be used promptly
or kept cool and protected from dust until used. Boil-

FOODS AND THEIR PREPARATION 45

ing water should be used to dilute it, to kill germs
that may have settled and grown on it after the open-
ing of the can.

Buttermilk is a valuable and pleasant drink, and
where it can be obtained is much relished by the men.

Good butter is made from good cream and is every-
where highly appreciated ; but unfortunately the good
quality is not always obtainable, and much very poor
butter is used in company messes. Oleomargarine is
little inferior to butter in nutritive qualities and is to be
preferred to poor butter, except that a prejudice exists
against it in this country and men are apt to avoid its
use. It has an advantage over butter in that it is not
so likely to act as a carrier of disease germs.

Both are valuable fat foods as well as relishes, and
should not be regarded merely in the latter light.

Cheeses are very concentrated forms of food, con-
taining about one third proteid and one third fat,
though the different varieties differ in the percentages
of these. They make agreeable and valuable additions
to the mess, but are seldom used in large quantities
because they are apt to be difficult to digest, and to
cause constipation. Ordinarily they are used in compa-
nies rather as a condiment than for their food-values,
though at times they may constitute an important part
of a meal. In cooking, cheese is used principally with
macaroni. Milk and cheese are liable to certain changes
which cause the development of poisons, one of these
known as tyrotoxicon, being very powerful and produc-
ing severe symptoms or death. The ordinary souring of
milk is not in itself dangerous, but may be beneficial
in some respects. The justification for regarding sour
milk with suspicion lies in the fact that the conditions

46 THE RECRUIT AND HIS ENVIRONMENT

favoring the development of the bacteria causing the
souring may also have favored the development of dis-
ease-producing organisms. Milk should be preserved
either by refrigeration, to prevent the growth, or by
heating, to kill, the contained bacteria.

For preserving other foods than meats and milk,
refrigeration, canning, and drying are the three great
commercial methods. Cold storage may pre-
serve fruits and vegetables, as well as meats,
eggs, and milk, practically unchanged for
weeks, and immense quantities are so preserved and
sold. Of even greater importance, however, is the pro-
cess of canning, whereby the articles are cooked, ster-
ilized, and hermetically sealed in cans or jars, to be
preserved for months or years. This industry has in-
creased enormously, and is now applied to almost all
of the articles of food that have been discussed herein,
and to a great number of others not so discussed.

The results obtained are excellent, and such foods
are carried to all parts of the world and enjoyed.

Canned foods pall after a time, though, and should
never, if it can be avoided, be used to the exclusion of
fresh food. Otherwise nutrition may be impaired, and
even scurvy may result. This may be because the heat
necessary to preserve them destroys the vitamine that
prevents scurvy. The fear of metallic poisoning from
canned foods is thought to be exaggerated, and the
probability of such poisoning to be remote, except where
lead is used, and that is infrequent and does not apply
to the great bulk of canned foods used by the soldier.
Drying as a method of preservation is applied to
fruits and vegetables, as well as to meats and fish.
Desiccated vegetables find some use in the army, par-

FOODS AND THEIR PREPARATION 47

ticularly in Alaska, where they constitute a real bless-
ing, but their use is not general.

Dried fruits, however, are everywhere used and with
very general satisfaction. Dried apples, peaches, prunes,
and raisins are issued or sold by the Subsistence De-
partment, and make valuable and pleasing additions to
the mess, where they are served stewed or in puddings
and other desserts.

Sweets are much enjoyed by the men, and are valu-
able for their fuel- value, and also, probably, as lessen-
ing a craving for alcohol. Syrup and jam o-^eetg
are articles of the ration that are much en-
joyed, while the sale of candy by the Quartermaster's
Department shows that its worth is recognized. As
stated before, an excess of sugar causes dyspepsia and
should be guarded against.

Coffee, tea, and cocoa are mild stimulants, but may
almost as well be classed with condiments. Of the three,
coffee is the only one extensively used in 5^^^-.
our service, and it is often poorly made and _ ___
poorly served. The green issue coffee is
of excellent grade, and if properly roasted and ground,
and used fresh, is superior to most higher priced coffees
obtained elsewhere ready roasted. The preparation of
good coffee is simple and easy, but most company cooks
do not practice it. The company commanders should
make sure that, in addition to proper steps in prepara-
tion, the following are observed : —

The coffee must not be long boiled.

The coffee-pot must be emptied and cleaned after
each meal, and no coffee grounds should be used twice.

The sugar and milk, if the latter be served, should
be put in by the user and not served alike to all.

48 THE RECRUIT AND HIS ENVIRONMENT

Enough coffee should be used to give strength and
flavor to the beverage, and then but a moderate amount
of it should be served to each man.

In the field, where the water is of a doubtful char-
acter, the issue of large amounts of weak coffee is justi-
fied, as tending to reduce the amount of unboiled water
used ; but in posts this is not necessary.

Cooks will insist that the men prefer their coffee
weak, long-boiled, and ready sweetened, just as they
will say that they prefer roast beef overcooked, dry, and
swimming in greasy gravy ; but inasmuch as most men
in civil life like to exercise a choice in such matters, it
is thought that a like privilege might be appreciated in
the service.

It is also thought that perhaps the use of tea in the
service might become more general if the beverage were
properly made, and not boiled or steeped until a strong,
black tannin solution results.

The following is a bill of fare for one week, which,
it has been demonstrated, can be supplied with little
extra cost beyond the savings on the ration, provided
that the cook is capable and careful and the mess-ser-
geant intelligent. Slight variations from week to week
and to suit the seasons will permit such a bill of fare
to be used for a long period and give satisfaction.

MONDAY

Breakfast : Stewed Fruit, Fried Eggs, Bacon, Bread,
and Coffee.

Dinner : Roast Beef, Steak, or Meat Balls ; Baked
Potatoes, Squash or Turnips, Stewed Tomatoes ; Pie or
Cake.

FOODS AND THEIR PREPARATION 49

Supper : Cold Sliced Beef, Fried Onions or Toma-
toes, Bread and Jam, Tea or Coffee.

TUESDAY

Breakfast : Bananas or Fresh Fruit, Liver or Kid-
ney with Bacon, Bread, Butter, and Coffee.

Dinner : Beef Steak or Hamburger Steak ; Potatoes,
Radishes, or Onions ; Pudding, Bread, and Coffee.

Supper: Cold Beef, Fried Potatoes, Bread and Jam,
Tea or Coffee.

WEDNESDAY

Breakfast : Stewed Fruit, Fried Mush and Molasses,
Coffee.

Dinner: Boiled Ham; Boiled Potatoes, Boiled Cab-
bage ; Pudding, Bread, and Coffee.

Supper : Cold Boiled Ham, Bread and Jam, Butter,
Tea or Coffee.

THURSDAY

Breakfast : Stewed Fruit, Puffed Rice, Wet Hash
on Toast.

Dinner : Roast Beef, Steak, or Meat Balls ; Baked
Potatoes, Corn, Squash, or Turnips ; Pudding, Bread,
and Coffee.

Supper : Cold Beef or Hash, Bread and Jam, Fried
Onions or Tomatoes, Tea or Coffee.

FRIDAY

Breakfast : Stewed Fruit, Oatmeal with Milk, Bis-
cuits with Syrup and Coffee.

Dinner: Baked Fish with Sauce; Boiled Potatoes
and Onions ; Bread, Butter, and Coffee.

60 THE RECRUIT AND HIS ENVIRONMENT

Supper : Salmon or other Fish Salad, Bread and Jam,
Tea or Coffee.

SATURDAY

Breakfast : Stewed Fruit, Bacon, Rice or Corn Flakes,
Toast, and Coffee.

Dinner : Baked Beans with Pork ; Pickles, Stewed
Tomatoes ; Bread and Coffee.

Supper: Cold Beans or Bean Soup, Pickles, Tomato
Catsup, Bread, Butter, and Coffee.

SUNDAY

Breahfast : Stewed Fruit, Oatmeal with Milk, Hot
Biscuits, Coffee.

Dinner : Roast Pork, Veal, or Mutton ; Browned Po-
tatoes, Baked Squash ; Apple Sauce, Pie or Cake.

Supper : Cold Meat, Bread and Jam, Tea or Coffee.

The Hygiene of the Kitchen
From the hygienic and many other points of view the
company kitchen is one of the most important places
in the post, and the company cook a very important
person.

These two bear a more direct relation to the guard
reports, sick reports, and the general efficiency of the
command than at first appears ; while the subjects of
alcoholism and desertion are especially involved.

It is therefore an important part of the company com-
mander's duties to see that both are as good as can be
obtained. He should see, as stated before, that his cook
is capable of preparing the food in attractive, satisfy-
ing, and digestible forms, that he is economical, a good
manager, and can utilize the ration in a variety of ways
and supplement it judiciously. But the cook may fulfill

FOODS AND THEIR PREPARATION 51

these requirements and still do much harm by causing
or spreading disease. Therefore he and his company
officers should know something of the hygiene of the
kitchen.

The primary and most important rule as to cook,
kitchen, and the contents and surroundings of the latter,
is cleanliness. All parts of the barracks and
all persons therein should be clean, but the
kitchen and the cook should excel. The cook should
bathe often, change his clothing frequently, always
wash his hands after a visit to the toilet, after handling
anything dirty, and before handling foods. He should
always have a clean hand-towel in his kitchen, and not
use for the purpose either a dirty rag or his dish-towels.
He should wear white aprons, caps, and clothing, and
change them when soiled. His finger-nails and his hair
should be kept short and clean, and a nail-brush should
be in the kitchen for use and should be scalded daily.
A cook who has had typhoid fever, or, rarely, one who
does not know that he has had it, may, though appar-
ently in good health, be excreting and distributing
typhoid bacilli ; and a typhoid epidemic limited to a
company should always cause this possibility to be
investigated. Men who are dirty in their habits, who
have syphilis, tuberculosis, or other infectious dis-
eases, or who are persistent in unsanitary or careless
methods of preparing foods, should not be allowed to
cook.

The kitchen should be proof against the most rigid
inspection for dirt. Some disorder and litter necessarily
attend the preparation of food ; but this can usually be
cleared up almost immediately, and it should not remain
any longer than necessary. The meat-block, bread-

62 THE RECRUIT AND HIS ENVIRONMENT

boards, carving-tables, and all utensils should all be in-
spected daily and all kept clean.

The ice-chest and milk-cans should receive special
scrutiny, and should be clean inside and out, as evi-
denced to the eye, the nose, and the white glove.

Foods like cheese, codfish, and bacon, that possess a
strong odor and do not readily spoil, should be kept on
shelves or in boxes, protected by wire gauze, rather than
in the ice-chest. Canned meats, fruit, and vegetables
should be used as soon as possible after they are opened,
or emptied into clean dishes, and not left about in the
cans. All food should be used before it becomes mouldy,
sour, or decomposed, or should be thrown away, though
a slight and recent growth of mould on the surface of
ham, cold-storage beef, bread, jam or other sweets
does not necessarily injure the whole, and may be re-
moved.

The kitchen sinks should always be kept clean, and
should be well trapped. Care should be exercised that
grease, crumbs, and fragments are kept out of them,
that the pipes may not become clogged. Kitchen waste,
the scrapings of food from plates, and unused frag-
ments should be thrown into covered cans, which should
be emptied and cleaned once daily, and should not serve
either as a breeding or a feeding place for flies, roaches,
rats', or other vermin. Particular care should be exer-
cised to exclude all such from the kitchen at all times.
For this purpose cleanliness and screens should suffice,
but if fly-paper, roach-poison, and rat-traps are needed,
they should be supplied.

The kitchen police is usually supplied by roster from
the company, but at times the work is given as a pun-
ishment. This is undesirable. Instead of poor men.

FOODS AND THEIR PREPARATION 53

good ones should be put on kitchen police, and the work
should carry with it immunities and privileges to make
good men desire it.

Men who are sick should be excluded from duty in
the kitchen. In 1909 the writer investigated an epi-
demic of typhoid in a battery of mountain artillery at
Fort D. A. Russell, and found that its spread was due
to the fact that certain men were on duty as kitchen
helpers at the time when they were in the early days of
typhoid attacks. They infected their comrades by han-
dling food that these ate.

CHAPTER IV

THE HYGIENE OP THE BARRACKS

Neither the enlisted man nor his immediate com-
mander has very much choice in the matter of bar-
racks. They are assigned to duty at a post where
certain barracks are provided, and must of necessity
make use of them. In one post the barracks may be
new, large, and built with a view of affording all pos-
sible advantages in the way of comfort, convenience,
and sanitary arrangements. In another post they may
be old, small, and apparently built without a thought
of any of the advantages mentioned. In the one the
capacity of the barracks may greatly exceed the size
of the garrison, in the other, the reverse may obtain ;
but in nearly all instances the conditions are controlled
by military necessity and not by the company com-
manders. It is therefore considered that the proper
scope of this chapter is to indicate what is desirable,
and to assist in making the nearest practicable ap-
proach to it under existing conditions.

The buildings are apt to be of almost any material,

from brick, stone, or concrete, to nipa and thatch.

. Usually they are of substantial materials

and well constructed, unless designed for
ings , . .

merely temporary use m warm countries,

when light board-structures or those of bamboo and

palm are used. In the latter class, cheapness of cost

is always a consideration ; but it is not to be carried

to the extent of making the structures unsanitary. Suf-

THE HYGIENE OF THE BARRACKS 55

ficient room should be provided, adequate and conven-
ient supplies of good water, proper kitchen arrange-
ments, and protection from mosquitoes, flies, and other
insect pests. The structures should be sufficiently raised
above the ground to prevent dampness, if pobsible, and
ample provision should be made for the care of excreta,
garbage, and waste water.

In permanent barracks of the newer type, provision
has usually been made for the sanitary requirements,
and the conditions are satisfactory where overcrowd-
ing does not obtain. Barracks of concrete, stone, brick,
or wood may all be satisfactory if other considerations
are met. One of the first of these is location and ex-
posure, and the desirable locations and facings vary
with climate and local conditions.

In general, it is well to get much exposure to the
sun in cold climates, and this is best accomplished by
having the four corners of the main building point
in the cardinal directions. In such places, however,
the avoidance of prevailing winter winds may be of
even greater importance, and may dictate a location.
In any event, both sun and wind must be considered in
their sanitary as well as their comfort-bearing capacities,
the former as a great aid in cleanliness and disinfec-
tion, the latter as a promoter of ventilation. In any
climate, the structures should be dry as to both site
and walls. Damp cellars and surroundings may be
avoided by selection or by grading and drainage. Damp
walls are avoided by having a damp-proof course, as
of slate or concrete, above the foundations, by double
walls with air-spaces, by good ventilation, and, where
excessive or hard-driven rains obtain, by waterproofing
with paint, etc. If the walls are continuously of porous

56 THE RECRUIT AND HIS ENVIRONMENT

brick or stone to the cellar, or to the surface of the
ground, they will be continuously damp and chilly, in
most climates, and only the insertion of a damp-proof
course will correct the condition. If other considera-
tions, such as size, ventilation, heating, or plumbing,
are unequal, they should be allowed more weight, in
governing the choice of barracks, than the structural
material ; if all other considerations are equal, the
structural feature should govern choice, usually in the
following order : concrete, brick, stone, wood.

The buildings should be sufficiently large to provide
abundant squad room, recreation or day rooms, store-
_- rooms, kitchen, pantry, and dining-rooms,

small rooms for noncommissioned officers,
tailor's, barber's, and cobbler's shops, a workshop for
the mechanics, and ample water-closet and bathing
facilities, unless a part of these are provided else-
where.

The squad-rooms are the matter of greatest consid-
eration, and they should be given first thought in
selecting barracks. They should always be as large as
it is possible to obtain, keep clean, and heat, and
should provide a minimum of six hundred cubic feet
of space and sixty square feet of floor-room for each
man, exclusive of the room occupied by wardrobes and
lockers. They should be well lighted both by windows
and artificial light, preferably electric. The window-
space necessary will vary with climate and location,
but it should insure plenty of breeze in the tropics,
and plenty of light in northern climates. If a good
system of ventilation, other than by windows and doors,
has been installed, so much the better, and it should
be carefully studied until understood, and then kept in

THE HYGIENE OF THE BARRACKS 57

maximum working order. In all barracks, ventilation
and heating are closely related, and should receive the
company commander's personal consideration. If it
be practicable, it is a great help in ventilating most
barracks to have a small open-grate fire going all win-
ter, but there is usually no provision for it. The air ia
the squad-rooms should at all times be sweet and fresh,
and free from the "closeness" and staleness that is
particularly apt to obtain in the early morning hours
of winter nights. The means of insuring this will vary
in different places, but there is always one expedient
that may be resorted to, — raising the lower window-
sashes and fixing boards beneath them, with nails if
necessary, so as to allow the air to enter in an upward
direction between the two sashes. Inspections should
be made occasionally, at the times indicated, to see that
the air is good; while all arrangements to promote
ventilation should be inspected frequently to see that
they are in working order and have not been interfered
with. In case interference is found, it is well to detail
a man in each room to be responsible for their correct
maintenance. All squad-rooms should be opened and
thoroughly aired each day, in addition to the constantly
working arrangements.

Always in the tropics, and during warm weather in
other climates, all windows should be provided with
screens to exclude flies and mosquitoes. If such is not
the case, bed -nets must be used at night.

In cold climates double or storm doors and windows
may be provided. They make the rooms more com-
fortable and easier to heat, but should not be allowed
to impair the ventilation.

Water-closets, bath-rooms, and wash-basins should

58 THE RECRUIT AND HIS ENVIRONMENT

be entirely away from the squad-rooms, in which no
plumbing should show. Articles of food, dirty and wet
clothing, and useless trappings should be excluded as far
as practicable. Floors should be sprinkled frequently
with wet sawdust, and swept so as to create as little dust
as possible; and at least once a week the entire room
and its contents should be so thoroughly cleaned as
to pass the most rigid inspection, no dirt, dust, disorder,
or vermin being anywhere present. This inspection
will be made usually on Saturday, and should be pre-
ceded by an outdoor airing of bedding and change of
bed-linen on Friday. At the inspection all wardrobes,
drawers, lockers, and boxes should be opened, and
their contents exposed to view. The small spaces and
corners about such articles, the space behind or under
radiators, the tops of wardrobes and shelves, should all
be examined, and, if any man seem unclean, his linen
and person. It is not thought wise to subject intelligent
and self-respecting men to such personal inspections
as a matter of routine.

The day-rooms, or recreation-rooms, should be suit-
able for their purpose, should have good light, good
air, comfortable heating, and such provision in the
way of chairs, tables, reading matter, billiard and pool
tables, and other facilities for amusements, as will con-
duce to the interest, instruction, and amusement of the
men, or such, at any rate, as can be obtained.

These rooms should be kept clean and neat at all
times, free from dust, foul air, dirt, and vermin. The
care should be such as to enable them to pass the same
general inspection as squad-rooms. Smoking will be
indulged in, in recreation-rooms, at most times of day,
but the rooms should be opened and aired frequently.

THE HYGIENE OF THE BARRACKS 59

Spitting will also be indulged in, and cuspidors con-
taining water should be provided in sufficient numbers
to prevent spitting on the floor, and any man then
doing so should be punished. The cuspidors should be-
emptied and scrubbed daily.

Pictures and ornaments may be permitted to some
extent, to detract from the bareness and add to the
cheerfulness of the room ; but, in general, unnecessary
dust-collecting articles should be excluded.

The dining or mess room should be sufficiently large
to seat comfortably at table at least ninety per cent of
the command. A certain number of men will necessarily
be absent from each meal, — on guard, in the kitchen,
on pass or furlough, and for other reasons, — but pro-
vision should be made for the maximum number that
may be present. Lighting, heating, ventilation, and
screening are all important here as in other rooms.
Screening, particularly, should be carefully provided,
and every means employed to keep the place free from
flies. The cleanliness of this room should be as nearly
perfect as possible, and while it is permissible to have
the room attractive, dust-gathering trappings should
be excluded. The mess-tables are used uncovered, or
covered with white oil-cloth. The former is the prefer-
able method, as it insures thorough cleaning and scrub-
bing, if the tables look clean. An oil-cloth can be made
to look almost or quite its best by a small amount of
indifferent rubbing, though it really may not be free
from grease and dirt.

As said before, the men should be required to ob-
serve the decencies at table, and they are more apt to
do so if the decencies are observed toward them. The
table should therefore be orderly and attractive, though

60 THE RECRUIT AND HIS ENVIRONMENT

plain, the dishes and utensils should be perfectly clean
and arranged in a proper manner, the food should be
served in an orderly, attractive, and appetizing way, and
with a sense of fitness. While parlor manners may not
be expected in the barracks, gross indecencies of man-
ner, speech, or action should be prevented. The room
and table should be well cleaned after each meal, and
the dishes and utensils should be carefully inspected
daily and their perfect cleanliness assured. Once a
week, or oftener, the tables and floors should be thor-
oughly scrubbed with lye and water, and vinegar-cruets,
salt-cellars, mustard-pots, etc., well washed and filled.
In warm weather, fly-paper and, if necessary, occasional
fumigation with pyrethrum fumes, should be used to
supplement the screens.

No man should be allowed to eat with unclean hands,
and it should soon be a matter of habit for all men to
come to the table clean as to hands and face, and neat
in appearance. Leisurely eating and thorough mastica-
tion should be encouraged.

After the squad-rooms the kitchen is probably the
most important room in the barracks. Its importance
has been discussed elsewhere, but may be emphasized
here. It should if practicable be a large room, well
lighted and well ventilated, opening on a large porch,
and connecting with store-rooms in the cellar or else-
where convenient, and with a roomy pantry, with
abundance of shelving and drawers, also well lighted
and ventilated. Good tables, sinks, running water,
ample drainage, sound and smooth meat-block, an amply
large range, and abundance of good kitchen furniture
and utensils should be provided. A large ice-chest and
some screened shelving should be near at hand. It is

THE HYGIENE OF THE BARRACKS 61

desirable, if practicable, to have a large hood over the
range, to catch and conduct away, through a ventilating
shaft, the odors, vapors, and smoke arising from the
cooking. All of these articles should be frequently in-
spected to make sure that they are always cleaned as
soon as possible after use, and never put away in any
other condition. The cook, above all men in the com-
pany, should live, think, and dream cleanliness, and he
should be held most strictly to account for shortcom-
ings in that line. The kitchen police should be re-
warded for efficiency in such a way as to make the
detail desirable, and in this way the kitchen should be
made an object-lesson and a school of cleanliness. The
inspection of the kitchen should include the pantry
and ice-chest, should take note of, and remedy, waste or
poor management, and should always embrace inquiries
concerning, and search for, flies, roaches, mice, and other
vermin. Cats, dogs, and other pets, as well as men not
tliere on duty, should be excluded at all times. Garbage-
cans should be outside of the kitchen, should be emptied
at least once a day, and then cleaned inside and out ;
otherwise they speedily become a foul nuisance.

The general remarks as to the lighting, heating, ven-
tilation, and cleanliness apply to the offices and the
shop-rooms for the baker, tailor, and cobbler, and the
inspection of these latter should not be omitted, other-
wise they are especially apt to form accumulations of
scraps, dirt, and dust ; and they are especially favorable
distributing points for vermin.

The company barber should be required to keep his
brushes, combs, razors, and utensils thoroughly clean,
and to sterilize them frequently. He should be obliged
to keep an abundance of clean towels and aprons, and

62 THE RECRUIT AND HIS ENVIRONMENT

to be liberal in their use. He is not apt to be so of his
own volition. He should be instructed not to shave or
cut hair for men with skin diseases without first get-
ting the surgeon's assent. Should his own skin or hands
show disease, he should consult the surgeon.

Store-rooms do not need light, air, and heat in such
liberal amounts as do living-rooms, but they should be
dry, free from vermin, and should answer the purposes
for which they are required.

Bath-rooms should be well drained, well ventilated,
and well lighted, and when such is not the case every
effort should be made to correct the condition. Lighting
is facilitated and cleanliness promoted by having walls,
doors, and partitions painted white. Where tubs are
installed, they should be thoroughly washed and cleaned
after each use, and the floor should be kept clean at all
times. Each man should have his own soap and towels,
and should take them to and from the tub with him.
When tubs are not sufficiently numerous to accommo-
date the men as they wish to go, they should be detailed
by roster to bathe, at least once or twice a week, and
as much should always be required of them. Shower-
baths are much more economical of both time and water,
and are installed at most posts. They, as well as tubs,
should have both hot and cold water connections, be
frequently inspected as to condition, and be kept
scrupulously clean. The drain openings should not be
allowed to clog with soap and hairs, and the entire bath-
room should be scrubbed at least once a week, and as
much oftener as is necessary to keep it clean and sweet-
smelling, and free from mustiness. Gratings should be
lifted daily if necessary and the space beneath flushed
and scrubbed. The same general remarks apply to the

THE HYGIENE OF THE BARRACKS 63

bowls for face and hand washing. The stoppers for
these, and the chains holding them, should always be
clean, the outlet openings likewise, and watch should
be kept to prevent the formation of a film or coat of
soap and dirt inside the bowls. The throwing of to-
bacco, paper, cotton, and dressings into bowls, tubs, or
bath compartments should be forbidden and prevented.
The man detailed in charge of the bath-room should be
cleanly and trustworthy, and should have authority to
enforce the rules.

The water-closets are frequently in close proximity
to the bath-room, and if both are kept clean there is no
objection to it. Flush-closets and urinals are installed
in practically all posts now, and where such is not the
case one of the various expedients for disposing of ex-
creta in the field will have to be used, and reference is
made to their description. Flush-closets should be kept
clean at all times, the bowls scoured, and the seats
wiped off occasionally with a damp cloth. The floors
about them should always be clean, and the room should
be free from odor. Standing on the seats, defacing or
defiling them, throwing stiff paper, matches, and other
things likely to cause obstruction, into the bowl, and
writing obscenity on the compartment walls should be
punishable offenses. When a closet gets out of order
in any way, it should be put out of use until repaired.

It is to be borne in mind that the use of carbolic acid
and chloride of lime is but rarely necessary about flush-
closets, and then not for the purpose of destroying odors.

Constant bad odors indicate lack of care or poor
plumbing, or both, and should be corrected. When
concealed by other odors, such as those of chlorine
or carbolic acid, they may not be noticed, but the evil

64 THE RECRUIT AND HIS ENVIRONMENT

condition of which they gave warning is unremedied.
Tissue paper is issued for toilet purposes, and no other
should be permitted to be used, as being apt to scratch
or irritate the anus, and to clog the drain. By signs
in the room, and by verbal instruction, the men should
be taught to wash the hands after every visit to the
closet. It should also become a habit for them to inspect
their feces before flushing the closet, as disorders may
thus be brought to their attention, and remedies sought.
The passage of blood, pus, large amounts of mucus, or
worms should prompt early consultation of the surgeon.
The closet-rooms should be screened, and should be
floored with cement to permit flushing, and to do away
with cracks and crevices. Roaches and flies should be
excluded. Each is indicative of unsatisfactory condi-
tions. Urinals are ordinarily flush-bowls, for use by
one person at a time, and should be sufficiently numer-
ous to meet the demands of early morning and of the
evening. The floor and walls immediately about them
should be of smooth, hard, waterproof material, such as
slate, and should be washed thoroughly each day and
then lightly wiped with a moist rag sprinkled with kero-
sene. Otherwise a crust of urinary salts is apt to form,
and odors of decomposing urine to arise. When proper
care and cleanliness are exercised, neither of these ap-
pear, and the use of deodorants is not necessary. The
flushing of the bowls is usually automatic, and should be
of sufficient frequency to prevent deposition of salts,
though its action should be supplemented by washing
and scrubbing of the bowl. If the outlet of the bowl is
not already screened, a piece of wire gauze should be
placed over it and held in place by a small stone or
other weight, otherwise it may get clogged with bits of

THE HYGIENE OF THE BARRACKS 65

cotton, cigarette-stumps, and other waste thrown into
the bowl. The throwing of such articles into urine bowls
should be punished, if detected, but detection is not
usual.

It is neither desirable nor practical to have the men
do their own laundry- work in barracks, but a couple of
tubs, running water, and scrub-brushes should be pro-
vided, if possible, to enable them to do a certain amount
of emergency work and cleaning. >^

The company commander should familiarize himself
with the system of plumbing in his barracks, with a
view both to detecting leaks and other faults, and to
taking action for the institution of improvements where
indicated, and likewise to fit himself to distinguish
between poor plumbing and inefficient care of good
plumbing.

The water-supply of the barracks should, if possible,
be of water fit for drinking without boiling or other
special preparation. If this is not the case,
the men should be warned and the proper
drinking supply carefully defined and lo- '^^ ^

cated. The general supply should be abundant for all
purposes, and should amount to one hundred gallons per
man per day, though so much need not ordinarily be
used, and the amount really used will depend on a
number of varying factors, such as temperature and
climate, the character of the work done by the men,
the care used, economy exercised, and the condition of
the plumbing.

Where tub-baths are used, the consumption will
be greater than if showers are used. While care
should be exercised to prevent wastP, it is usually
false ecopomy to Jiiu^er any reasonable use of water,

66 THE RECRUIT AND HIS ENVIRONMENT

as in bathing, scrubbing, watering plants or grass, or
laying dust.

The water should be piped to the kitchen, the bath-
rooms, water-closets, urinals, wash-basins, furnace-room,
and to such places in and about the building as may be
necessary for police purposes or fire protection. All
faucets, exposed pipes and fire-plugs, and other parts
of the water-supply apparatus, should be frequently in-
spected for leakage and as to their working condition.

Except in the ways indicated above, the water-sup-
ply in barracks is not usually controlled by the com-
pany commander.

Good plumbing presupposes good materials, and such
are usually furnished. Iron pipe should conduct the
-J. , water-supply, and all joints should be tight.

. Faucets are usually of brass, and with pro-

per usage rarely need repairs, except new
washers. Lead pipe is objectionable as being liable to
cause lead-poisoning. Some water after a time will cause
the pipes to fill partially or entirely with a deposit of
mineral salts, or a growth of low vegetable forms, with
a consequent lessening of the size of the stream. Such
conditions, as well as advanced erosion, may necessitate
renewal of the pipe. Kitchen sinks and wash-bowls
should have their outlet-pipes and traps exposed and
open to inspection, not closed in to become musty
hiding-places for roaches. Kitchen sinks are usually
made of galvanized or enameled iron or zinc, wash-
bowls of enameled iron or porcelain. In any event,
the surface should be smooth and capable of complete
cleaning.

All should be effectively trapped to prevent the re-
gurgitation of air or gas from the drains. Sinks should

THE HYGIENE OF THE BARRACKS 67

preferably have grease-traps, which should be easy to
open and clean.

All bath-tubs should be of enameled or porcelain-
lined iron or of zinc, and closet and urinal bowls of
enameled iron or porcelain. All should be thoroughly
trapped, and ventilated on the ground side of the trap,
by communicating with the ventilating pipe. No odor
should come from them, and they should flush freely
and effectively on all occasions. Whenever one of them
is found at all out of order, flushing poorly or imper-
fectly, or emptying slowly, it should be put out of use
until the fault is corrected. Such trouble, more often
than not, comes from the use of newspaper as toilet-
paper, or the throwing of matches and other improper
objects into the bowls. Any leaking from a closet,
urinal, or drain should be immediately corrected, as
especially apt to cause disease. The maintenance of
thorough cleanliness in the closet is incidentally the
most ready way of learning of such defects, while the
faults arising from its neglect are at times unjustly at-
tributed to the plumbing.

Of the various systems of lighting in use in our bar-
racks, electricity is by far the best. Both oil and gas
consume and contaminate the air, produce - . , ^
dirt and much heat, may be blown out, and
give relatively poor light. Electric lighting produces
no dirt, neither consumes the oxygen nor adds to the
combustion products in the rooms, produces very little
heat, cannot be blown out, and gives a brilliant, steady
light that is very much better than either of the others.
The danger of explosion is absent, and that from fires
is reduced to a minimum by proper wiring. The lights
should be suf&ciently numerous to illuminate well ail

68 THE RECRUIT AND HIS ENVIRONMENT

parts of the building, while in the reading and recrea-
tion-rooms they should be numerous enough and placed
low enough to make reading and writing practically as
easy as in the daytime. A particularly satisfactory
arrangement of electric lights is one whereby the source
of light is hidden, the light being reflected up to and
back from a white ceiling, giving an even, steady
glow without glare. ^ Dull and flickering light, such
as is often produced by gas or oil, is very trying to the
eyes, and causes strain and fatigue ; while the vitiation
of the air by the combustion of these substances neces-
sitates much more liberal ventilation, or causes suffer-
ing. Economy in lighting should be practiced by ex-
tinguishing lights when the necessity for their use has
passed, as in the dining-room and kitchen after they
are cleaned, in the squad-room late in the evening, thus
having more for use in recreation-rooms.

^ " The fonr types of lighting systems in common use to-day are : day-
light, direct lighting systems, indirect lighting systems, and semidirect
systems. The evenness of illumination and the proper diff useness of the
light, with exclusion of all extremes of surface brightness, are ideal con-
ditions best realized at present in the proper illumination of a room by
daylight. As Ferree points out, before it reaches our windows or sky-
lights, daylight has been rendered widely diffuse by innumerable re-
flections ; and the windows and skylights themselves, acting as sources,
have a broad area and low intrinsic brilliancy, all of which features
contribute toward giving the ideal conditions of distribution stated
above. The best distribution effects given by artificial lighting are
obtained with the indirect systems in which the source is concealed
from the eye and the light is thrown against the ceiling or some other
diffusely reflecting surface. In the direct systems the tendency is to
concentrate the light on the object viewed, and too often the eye is
not properly shielded from the source of light. The semidirect systems
represent a compromise in which a part of the light is transmitted
directly to the eye through a translucent reflector, and a part reflected
to the ceiling. Like most other compromises, this one is not ideal." —
Journal of the American Medical Association.

THE HYGIENE OF THE BARRACKS 69

As stated earlier, the subjects of ventilation and heat-
ing are so intimately connected that no consideration
of the one is complete unless it includes _,
the other. This is so for the reason that ^

gravity is the most important factor in ventilation, and
the weight of a given volume of air is less or greater as
it is warm or cold. In other words, we influence or con-
trol gravity by means of artificial heat. The same force
is the principal factor concerned in the diffusion of
heat and heated air throughout barracks.

In summer, doors and windows can be kept open, and
ventilation is seldom a very serious problem ; but in
winter or very cold weather, when doors and windows
are closed and all the outside air is so cold that its im-
pact causes discomfort, the case is different.

Open fires are suitable for heating single, small
rooms, but not large ones, though the presence of an
open-air fire aids in the ventilation of the latter as well
as adds its cheer.

Stoves give more heat and less ventilation, for the
same amount of fuel used, than do open fires. They
may be made to promote ventilation greatly by being
surrounded by a sheet-iron cylinder or jacket, into
which a fresh-air shaft empties at the bottom. The
air is warmed as it enters, and rises into the room
through the top of the cylinder, and later escapes by
way of stove-door, window-cracks, and sundry other
outlets, including outlet-shafts, if such are provided.

The inlet should be screened to keep out dust and
dirt, and the top of the stove or of the cylinder should
always be provided with an open vessel of water, to
moisten the air by its evaporation.

Cast-iron stoves give off carbon monoxide, a poison-

70 THE RECRUIT AND HIS ENVIRONMENT

ous gas, when red-hot, and may so do harm. The air
used in the combustion of fuel is taken from the room
and passes up the chimney, fresh air replacing it from
the outside, and quite satisfactory ventilation may at
times be so maintained, even with unjacketed stoves,
but it is not wise to rely on such means alone, especially
in crowded barracks. Slow-burning stoves, such as an-
thracite base-burners, exercise much less influence in
this way than rapid-burning wood or soft-coal stoves.

Hot-air furnaces operate by heating fresh air, which
is brought to them through a ventilating shaft from the
outside, and which, when heated, rises through the
tubes and passages to the registers, whence it passes
into the rooms. One advantage of this method of heat-
ing is that, with increased heat, in very cold weather
it sends up an increased amount of fresh air. This air,
though, is usually very dry if the water-pan of the
furnace is not carefully watched and kept filled. This
is due to the fact that air doubles its capacity for ab-
sorbing moisture with each increase of 15° C. in its
temperature ; so that outside air which at zero C. does
not seem dry is excessively so when raised to 25° C.
For this reason all systems of artificial heating should
make some provision for moistening the heated air ;
which otherwise causes discomfort and harm.

The method of heating just described is not very much
used in our barracks, being regarded less favorably
than the steam and hot-water systems.

Steam-heating is very satisfactory and is much used.
In this system the heat from the fire is transmitted
to water, which is made to boil, under pressure if neces-
sary, and the heat is carried throughout the building
by the steam, which travels through tight iron pipes

THE HYGIENE OF THE BARRACKS 71

that expand into radiators in the various rooms. It is
a rapid method of heating, and one easily controlled by
an intelligent man, and such a man should be detailed
in charge of it. He should maintain an even, steady
fire, enough steam to make the rooms comfortable, and
keep the water in the boilers at a constant and proper
level. Such plants usually show their maximum effi-
ciency when a steam pressure of one or two pounds is
maintained.

Water should be kept evaporating from the radi-
ators, or, with a good man in charge of the system,
steam may be allowed to escape from them to moisten
the air.

Hot-water Keating is somewhat similar, but the pipes
are filled with water instead of steam. It is a very steady
method of heating, but slower in either heating or cool-
ing than steam. High and low pressure systems are
used, only the latter in our service.

The air heated by the radiators is dried thereby, and
provision should be made for moistening it.

When steam and hot-water heating are used, they are
made to promote ventilation by having the fresh air
enter the rooms through or under the radiators. It is
thereby warmed and made lighter, and at once rises, to
be later distributed through the room by gravity, con-
vection, and diffusion. In order that it may not again be
drawn through the radiators and redistributed, a line of
less resistance should be created for it by ventilating
shafts opening near the floor and leading to the roof, or
by an open fire-place to answer the same purpose.

As there is also danger of fire in and about barracks,
and as that danger is increased in cold weather, all
chimneys, flues, shafts, stoves, furnaces, etc., should be

72 THE RECRUIT AND HIS ENVIRONMENT

thoroughly inspected and put into first-class condition
in the late summer or early fall, before fires are started.
Competent men only should be detailed in charge of
fires, fire-drill should be held sufficiently often to famil-
iarize the men with their duties in case of conflagration,
and fire-buckets filled with water should be distributed
about the buildings. As a matter of cleanliness, and still
more as a matter of hygiene, and especially in the trop-
ics, this water should be renewed once or twice weekly,
to prevent its serving as a breeding-place for mosqui-
toes. Frequent inspections should verify the thorough-
ness and effectiveness of this measure.

The avoidance of mosquitoes, flies, roaches, lice, and

other vermin has already been shown to be principally

. a matter of screening, cleanliness, and po-

lice ; but if an old barracks is infested with

bed-buffS or fleas, it is often a most difficult matter to

get rid of them.

The most effective way to do so is to give the build-
ing and furniture a thorough overhauling, scalding out
cracks and crannies of beds, floors, and walls, with boil-
ing water, washing them with jive per cent carbolic
solution, then closing all cracks with putty or strips of
board, and painting over all. Infested clothing or bed-
ding should be washed or steamed.

Frequent inspections should be made for the early
detection of any recurrence or reintroduction of the
pests, when their eradication from one room, or even
from one bed, may suffice to end the trouble.

CHAPTER V

CAMPS

The soldier's time is partly spent in camps, and occa*
sionally the periods so spent may extend to many months.
The conditions of camp-life are in many respects radi-
cally different from those in barracks ; the old sanitary
problems may have to be met in very different ways,
while new ones arise, and sickness once started has
opportunities to spread that differ somewhat from those
in barracks. Our own unfortunate experiences in the
camps of concentration in 1898 clearly show that the
assemblage of large bodies of raw troops into great
camps is in itself a dangerous matter, and that, if wise
care founded on knowledge is not used to prevent it,
diseases in epidemic form may create greater havoc
than the enemy in arms. On the other hand, the ex-
cellent sanitary and health conditions maintained for
long periods in the camps on the Mexican border, as
well as in numerous other camps of the last few years,
show clearly that the intelligent and earnest application
of our present knowledge suffices to prevent such con-
ditions in time of peace. Whether or not the knowledge
we have can be effectively applied on the vast battle-
fields of Europe is now in process of demonstration.

The medical department must and does take the in-
itiative in sanitary matters, and it naturally finds much
satisfaction in the excellent recent results, but it is only
by having the interested and intelligent cooperation of
the line that such results are attainable.

74 THE RECRUIT AND HIS ENVIRONMENT

At times the choice of the camp-site will devolve upon
the company commander, at other times a site is assigned
_ to him by higher authority, and he has no

choice in the matter. It is, however, usually
within his power to improve a poor site, or to impair
or destroy the value of a good one ; and whether he is
more likely to do the one thing or the other depends
largely upon his knowledge of military hygiene. The
general principles regarding the selection, arrangement,
and care of camps, as laid down in the Field Service
Regulations, are to be observed, though they can at
times be improved upon, and when such is the case it
should be done. Let it be remembered that from a
sanitary standpoint the important desiderata are: first,
that the site should be clean and healthful ; second,
that it should be kept clean and free from infection
during its occupancy ; third, that it should be left so
after the departure of the troops.

The consideration of the site of a camp must include
an investigation of the healthfulness of the surrounding
country, and in certain instances a very desirable site is
wisely abandoned for one apparently less so, because the
health conditions may be known to be better in the lat-
ter. For example, in the Bitter Root valley in western
Montana there occurs during the spring months a fatal
fever, which is conveyed by the bites of infected ticks.
These are found principally on the west bank of the
stream, the eastern side being almost free from the
disease. It would be wise, in that territory and at such
a season, to forego considerable advantages that might
be found on the western side, and to take the trouble of
crossing the stream, rather than to rim the greater risk
of infection with the " tick fever." A somewhat similar

CAMPS 75

disease occurs in certain river-bottoms in Japan, and
in that case the camp could be safely placed on the
infected side of the stream, above all levels sulked to
fioodinrj^ as the infected insects are met with only at
such levels. Oroya fever occurs only in certain narrow
Andean valleys high above sea level. Kala-azar is
found especially in old and infected coolie lines and
houses, and in Africa sleeping sickness is transmitted
by a fly that is found only in or about thick underbrush
close to water, and relapsing fever by infected ticks that
appear principally in regular rest-places or camps.

The qualities desirable in a camp-site vary somewhat
with the season, breeze and shade, for instance, being
desirable in summer and undesirable in winter. The site
should have a natural slope, to insure the speedy disap-
pearance of rain-water from tents and streets. The sur-
face should be as regular and smooth as can be obtained,
free from numerous rocks and hollows. Stumps and
trees are at times objectionable, particularly if numerous
and close set, but at other times they can be put to a
surprising number of uses, and those that are most in
the way will disappear in a short time after the camp is
made. The inequalities of surface due to numerous large
roots or lightly covered rocks are, however, harder to
overcome.

The soil of the camp-site should be dry and firm, so
as not to give rise to a great amount of dust in dry, or
mud in wet, weather. Sandy or very soft loam is
undesirable, and, in very windy seasons or neighbor-
hoods, the dust it gives rise to may be a plague. A
surface well set with grass is good, if not damp ; but
the grass will soon die in tents and be tram}^>ed to
pieces in the streets, and should be well cleaned up.

76 THE RECRUIT AND HIS ENVIRONMENT

The neighborhood of marshes or standing water should,
if possible, be avoided, principally because they are
apt to be infested with mosquitoes, but also because
the ground may be wet. Ordinarily, high-ground
water (shown by its nearness to the surface in wells
or pits) makes for insalubrious conditions, much as
do marshes.

Winds may be desirable or the reverse, according to
circumstances. In regions where mosquitoes are abun-
dant, a prevailing wind blowing them away from the
camp is a great comfort, one in the opposite direction
a great nuisance. However, certain observations in the
Canal Zone have led excellent observers to believe that
mosquitoes, especially certain species oi Anopheles, may
and do fly considerable distances, even up to a mile or
more, against the wind to get to towns and camps, ap-
parently attracted by the odor.

In wintry weather a strong wind always produces
discomfort, and in summer it may do so because of the
dust and dirt it blows, and in such circumstances shelter
from it should be sought.

As sites are unhealthful or infected, in most in-
stances, either because of the presence of disease-carry-
ing and infected insects, such as mosquitoes or ticks,
or because of their previous infection from human oc-
cupancy, old camps, marshy grounds, and places apt
to present the conditions mentioned, should be avoided.
While the avoidance of malarious swamps and of such
disease-centres as have been mentioned above is of the
greatest importance in regard to certain diseases, espe-
cially those that are insect-borne, it is usually camp
diarrhoea, dysentery, typhoid, and other infections dis-
seminated largely by man himself that create the

CAMPS 77

greatest havoc in camps. The danger from these usu-
ally increases with the length of time the camps are
occupied, and with the increased opportunity for their
defilement. This being so, bivouacs, temporary and per-
manent camps are apt to be defiled in an increasingly
dangerous degree in the order named. Even a dirty
bivouac-ground may constitute a menace to the inhab-
itants of the region, to other troops later following the
same route, or to the command leaving it, on its return
that way.

The danger of infectious diseases is lessened by at-
tention to the following points : —

The ordinary shelter of the camp is furnished by
tents, which may be of any of the varieties issued for
the service, though the shelter-tent is only _
exceptionally used, in one camp, for more
than a few days at a time. All tents are apt to be hot
in summer and cold in winter, objections partly met
by the proper use of tent-flies. All are liable to be
crowded, and the air to contain many micro-organisms
when they are kept closed. This can be met by thor-
ough sunning and ventilation, with walls raised, for a
part of each day when the weather permits, and by the
frequent removal, cleaning, and airing of all blankets,
clothing, and accoutrements to which the moulds and
other organisms adhere, and the exclusion of articles
in or on which they may grow, such as food, dirty
straw, trampled grass, empty but unclean bottles, cans,
and boxes. All tents are apt to be damp in rainy or
wet weather, and to lessen this they should be well
ditched, so that all water from the tent-walls and the
surrounding ground is carried away and the tent-floor
kept dry. If the camp is to be occupied for any con-

78 THE RECRUIT AND HIS ENVIRONMENT

siderable length of time, board floors should be fur-
nished, or the interior be filled with fine gravel and
rammed, while company streets should be raised and
made hard and smooth by pounding or rolling; they
can be much improved by sprinkling and treatment
with crude oil, especially an oil that contains a large
amount of asphalt base, as most California oil does.
.If floors are used, they should be raised occasionally
and the space beneath thoroughly cleaned and aired. The
general tent ventilation is also important in promoting
dryness. Because of the dampness, men should always
try to sleep off of the ground. In permanent camps they
may have cots. Straw sacks are helpful, but they also
should be raised if practicable. Cots or beds may be
improvised from timber, or easily from bamboo, in a
country where that abounds. Small branches of pine or
other evergreen boughs serve to make a well-ventilated
and comfortable bed where they are found. Boughs,
cornstalks, loose straw, moss or dry leaves may be avail-
able in bivouacs. In other camps than bivouacs these
materials should be stirred up and aired daily and
renewed before they become mouldy or much broken up.
Owing to the crowding in camps and the frequently
poor bathing facilities, the opportunities for the spread
of body- verm in are unusually good, and all precau-
tions as to cleanliness, clothes-washing, and steriliza-
tion, if necessary, should be exercised to prevent their
introduction and dissemination. Dogs, cats, and other
pets should be excluded from tents and usually from
camps. Mosquitoes are to be avoided by means to be
considered later, but if they are present, nets must
be used. Flies, roaches, rats, and mice are best kept
down by the maintenance of such good police that they

CAMPS 79

find no breeding-places, and no access to food in or
about the tents ; hence the exclusion of food, boxes,
cans, etc. In some places the camp is very apt to be full
of fleas, and, as these insects do not stay long on their
hosts and breed in the sand, floors, or bedding, cleanli-
ness of tents, floors, and surroundings is most impor-
tant, as the young live on decomposing animal and
vegetable matters found there.

Because of ignorance, laziness, or viciousness, men at
times urinate in or near tents instead of seeking urinals.
The offense may not be readily detected, but it is none
the less filthy and dangerous, and should be severely
punished when detected.

Huts^ cabins, and dugouts may be used instead of
tents in long-established camps, particularly in cold
climates or seasons. Because they are not so accessible
to light, ventilation, or cleaning as are tents, even closer
and more frequent inspections and greater care in clean-
ing are necessary, and particularly so in the prevention
or elimination of vermin. At least once a week all
clothing, bedding, accoutrements, and other accumula-
tions of personal belongings should be moved outside
and the places thoroughly inspected and cleaned. Such
places as well as tents will require heating in cold
weather, but as long as proper precautions are taken
against fire and to provide for the escape of combustion
products, this is desirable, as promoting dryness and
ventilation, as well as comfort. Dryness of shelters and
abundance of fresh air should be assured by all possible
means, and to every man. All should work out-of-doors
a part of each day. Wet clothes should be dried and
dirty ones washed outside of the shelter, if it be at all
practicable. Men with clothing or shoes wet from rain,

80 THE RECRUIT AND HIS ENVIRONMENT

snow, or slush should change them for dry at the first
opportunity, and before lying down to rest or sleep. So
far as military necessities permit, men, even those on
guard, should be allowed to shelter themselves from
inclemencies of the weather.

The water-supply to permanent or semi-permanent
camps may be piped throughout them and delivered
__ from stand-pipes conveniently placed. In

other instances, it will have to be hauled or
carried from wells, cisterns, streams, and other sources
of supply, to the place of consumption. If it is known
to be good and free from infection, it may be drunk as
delivered ; but when doubt exists as to its purity, and
such will most often be the case, it must be boiled or
filtered before use. Boiling destroys all disease-produc-
ing organisms that are found in water, and renders
it safe. Prolonged boiling makes assurance doubly
sure, but if fuel or time is precious, making certain
that the water comes to the boiling-point once may
suffice, as that will destroy the organisms of typhoid,
cholera, and dysentery. But it is at best a time-con-
suming process, and if the water is not well cooled it is
not so refreshing, and men seek it from other sources.
Other methods of purification are therefore resorted
to, and among these are filtration and treatment with
chemicals. The Darnall filter, the efficacy of which de-
pends largely on the precipitation of suspended matters
before the filtration, and filters of the Berkefeld or
Chamberland types, that are efficient by virtue of the
fineness of their pores, are of great value, though the
former type shows erratic action at times and the others
are apt to be broken or get out of order on field service.

Chemical treatment of suspected or contaminated

CAMPS 81

waters is now used by many large cities, and gives very
good results. In its simplest form, in a camp, it would
ordinarily consist in adding one part of " chloride of
lime " to about 600,000 parts of the water. For small
quantities of water this may be measured as follows :
Take a level teaspoonf ul of chloride of lime and dis-
solve it in four pints of water. Of this add one tea-
spoonful to a gallon of the water to be purified, or one
tablespoonful to four gallons, or ten tablespoonf uls to
a barrel of water, and allow it to stand for at least half
an hour before use. The ordinary amount used by city
water purification plants is one part to a million, or even
less, but one part in half a million does not affect the
taste or smell of water, is harmless, and is necessary in
water containing much organic matter, so that the use
of that strength or double it is advised for the field. ^

However purified, the drinking water should be kept
pure and protected from all sorts of contamination until
used. This is provided for in the directions accompany-
ing the Darnall filter, but special arrangement has to be
made in other cases. A simple and effective way of doing
it is to have one drinking-place for each company, and
to have at that place two or three barrels or large cans
fitted with covers and with faucets near the bottoms.
Water should be boiled, or otherwise purified, and run
into one of these, covered, and allowed to cool. When
cool it is marked as ready for use, and the water is drawn
off through the faucet as needed. Meanwhile the next
canful is cooling. When the first can is emptied, it is
rinsed out with boiling water and refilled, to cool while

^ Should one have occasion to install a simple and cheap chlorine
purification plant at a post, a good description of one may be found in
U. S. Public Health Report, October 9, 1914.

82 THE RECRUIT AND HIS ENVIRONMENT

the second is in use, and so on. The barrels or cans
should be elevated on a platform so that the faucet
may be convenient, and a soakage-pit should be dug be-
neath the drip and filled with small stones or gravel
to prevent the formation of a mud-puddle. Waste of
the water should be discouraged, but if it amounts to
more than can be cared for by the pit, which should be
about one foot deep by two to three feet square, outlets
a foot wide and six inches deep, and of such length as
necessary, may be made and filled with stones or gravel,
to lead away the excess and permit of its absorption.

Outside contamination is prevented by the use of
the tight-fitting cover. If faucets are not to be had,
siphons may be improvised, if rubber-tubing is avail-
able. Otherwise, the water will have to be dipped. If
so, a clean dipper should be provided for the purpose,
and the water emptied from it into the drinking ves-
sels. No cup should be dipped in the water after it
has been contaminated by hands or mouth. The dipper
should be scalded from time to time, and should be
kept clean in every way. If reliably clean ice is obtain-
able, it may be added to the water. If its quality is
doubtful, it may be packed around vessels of water,
but should not be put into them. The general care of
the water-supply as prescribed in Field Service Regula-
tions should be observed.

There are no tests that can be quickly applied that
will enable a medical officer to pronounce a given
water-supply safe. He may form an opinion to that
effect from a consideration of the source and surround-
ings of the supply, but any idea that he can, by a
simple and quick chemical test, or a microscopic ex-
amination of it, gain positive knowledge that it is pure

CAMPS 83

and safe is fallacious, and should not be entertained.
If the supply probably receives seepage from privies,
stables, or homes, or washings from the same, or drain-
age from near-by cities or towns, it must be regarded
as unsafe ; and in other cases, where sources of con-
tamination are not so evident, it is wisely precaution-
ary to take the same view. In fixed camps there may
be opportunities for the full and careful examination
of water-supplies ; but even when such is the case, and
the water is found satisfactory, the condition may
change in a day because of some accident or the care-
lessness of one or a few men. Boiled water should
be used for many kitchen purposes, such as washing
food-receptacles and such foods as are eaten raw. Boiled
or actually boiling water should be furnished the men
for washing their mess-kits. A good arrangement is to
have for each company a box, a row of large kettles of
hot water, at least one of them actually boiling, and
a small mop or scrub-Jbrush. As a man finishes a
meal, he takes his mess-pan and implements to the
place where these are, scrapes any food-remnants into
the box, rinses the articles clean in the first kettle,
passes to the second and there scrubs them with the
brush, and then scalds them in the boiling water of the
third kettle. Proper provision should be made, by
means of a trough-container or otherwise, to prevent
soiling of the ground with bits of food or greasy water.
The water-supply should be sufficient to provide
baths for the men. If the camp be situated on a stream
or other body of water, it may afford proper .

facilities in warm weather. Where such is °

not the case, and in cold weather, special provision will
need to be made. Such provision will include a proper

84 THE RECRUIT AND HIS ENVIRONMENT

supply of water, sheltered and warm bathing-places,
and a proper disposal of the dirty water.

The supply of water may be piped to the bathing-
place, or it may have to be carried there. The former
condition need not, ordinarily, concern the company
officer, except that, if the water as delivered is very
cold, most of his men will not bathe in it in cold
weather. In case it has to be carried, each man should
carry for his own use, and economy will then be exer-
cised. The most effective use is then made of the
water if the bather first scrubs himself from a basin,
usiug soap and a rough cloth, and later rinses off the
soap with a shower, which may be improvised by
means of a large tin can and a piece of rope. Warm
water should always be available, and may be kept so
if a large can of water be kept over a fire near the
bathing-place, and any man desiring to bathe be al-
lowed to take from it, replacing an equal amount of
cold water. A sheltered and warm bathing-place may
consist of a room in a convenient building, of a special
house, shed, or tent, heated, if necessary, by a stove, an
extemporized brick oven, or other means. The floor
should be hard and dry, or should be covered with
wooden gratings to lift one above the waste water. If
for lack of time or other reason a suitable bathing-
place has not been prepared, and if it be cold weather,
hot water may be furnished and men allowed to take
baths in their tents. In such cases they should be
careful not to spill water.

If bathing is possible only at the cost of considerable
labor or inconvenience, a proportion of the men will
neglect it, and it is therefore desirable that a proper
place be provided and the men required to bathe at

CAMPS 85

least once a week ; while the feet, face, and hands should
be bathed oftener, and facilities should be provided for
that. These may be just outside or inside the tents.
The disposal of waste water is at times as great a
problem as the procuring of the fresh supply, and it
will have to be solved in different ways under different
circumstances. In large or permanent camps under-
ground drains may lead it away ; at other times trenches
may conduct it to a near-by stream or to dry wells or
pits, and occasionally it may be necessary to collect it
in barrels and haul it away. Always, care should be
exercised that it does not flow or soak to the source of
supply and contaminate that, and that it does not form
breeding-places for mosquitoes. Where other provision
is not made, fairly satisfactory results may usually be
obtained as follows: A suitable space inside of a tent,
say five or six feet square, is dug to a depth of four
inches, and filled with gravel or fine stone, which is
rammed. Over this a wooden grating is placed, and
on the grating the men bathe. From the lower side of
the space, trenches four inches deep and a foot wide are
dug and filled with gravel or stones, and they conduct
the water downhill to an open trench that leads it
away, or to a soakage-pit about a yard square and
deep, or larger if necessary, that is filled with large
rocks, whence it soaks into the ground. Such pits, if
in porous soil or gravel, will dispose of a great amount
of water in a day. If in clay or close-grained soil, their
working is not so satisfactory, and it may do better to
run the water out in numerous, shallow surface-trenches
from which it can evaporate. Similar precautions may
be taken to provide for the waste water from drinking-
troughs for animals.

86 THE RECRUIT AND HIS ENVIRONMENT

Facilities for washing clothing should be provided
in each company, though they need not be more elabo-
rate than a supply of good, and preferably warm, water,
a board, and a scrubbing-brush and soap, The waste
water may be disposed of as indicated for bath-water.
If a boiler can be provided for clothes, it is desirable
to have it. In rainy weather a heated tent should be
furnished in which to dry them, but at most times they
can dry in the open.

As in barracks, so in camp, the kitchen is one of the
most important parts of the command, and on its proper
administration depends much of the cheer-
fulness, health, and efficiency of the men.
The food should be abundant and good, and its prepa-
ration such that the men will be nourished and satisfied
by it, and not under the temptation to gorge themselves
with pies, milk, and soft drinks of doubtful character
from outside sources.

The mess in fixed camps may be made quite as good
as in barracks, and, except in rare emergencies, the
articles of the ration are both good and abundant. As
the problem of cooking is presented somewhat dif-
ferently in the field and in barracks, the company com-
mander, the mess-sergeant, and the cooks should all study
the best methods for field service. Some excellent gar-
rison cooks are not nearly so good in the field, while
others excel there. Economy, good management, and
cleanliness are as important in the field as elsewhere,
while, owing to the outdoor life and active exercise, the
appetite is usually increased and more food required.
Owing to the liability of chilling, exposure to wet,
and the greater opportunities for intestinal infection,
irritating, indigestible, and slightly nourishing foods,

CAMPS 87

such as green corn and boiled cabbage, should be used
sparingly, while green or overripe fruits should be for-
bidden. In the presence of epidemics of intestinal
diseases, it makes for safety if only cooked food is
eaten. Underdone cereals or vegetables are apt to cause
indigestion, and as they are more difficult to cook
thoroughly in the field because of the trouble with
fires, wind, etc., particular attention should be paid to
them. Rice, beans, hominy, oatmeal, and potatoes are
probably most apt to be underdone. The methods of
cooking in camp are various, the facilities ranging from
the most simple and crude to the quite elaborate. Soup-
carts, baking-ovens, and so-called fireless cookers may
solve some of the problems; but the knowledge, in-
dustry, and management of the company commander,
mess-sergeant, and cooks must be relied on to solve
most of them. They must utilize to the utmost the ar-
ticles of the ration, and such other good food-supplies
as they can obtain, and the equipment furnished for
cooking and such additions to it as they have or can
prepare ; and must put to use or minimize the harm of
natural factors, such as wind, rain, snow, or poor fuel.
It is the ability to do this last that enables some men
who are not very good cooks in garrison to excel in the
field. While a man knowing more of cookery may let a
meal be spoiled or uncooked because of poor fuel, rain,
and adverse winds, another man may have an excellent
fire and a well-cooked meal in spite of all three. Camp
craft results from experience and ingenuity, and the
one should be furnished by manoeuvre-camps and prac-
tice-marches, and the other encouraged by observant
company commanders when it manifests itself. The
man possessing these qualities will get the most from

88 THE RECRUIT AND HIS ENVIRONMENT

his utensils and his fire, whether he has a fully equipped
camp-stove, a spider and pots, or merely a trench of
his own digging.

As far as possible, men coming in from a march or
a guard should be supplied with hot food at once, and
when camp is changed an effort should be made to
supply a hot meal as soon as the regular meal-time
comes. This means the use of kitchen carts or fireless
cookers, or the early establishment of the kitchen and
the use of food that can be quickly cooked.

As in garrison so in camp, cleanliness of cooks,
kitchen, and food are secondary only to the actual sup-
ply of food, and the lack of it will do more harm than
partial starvation. Flies have greater opportunities to
breed in camps than in garrison, dust is more abun-
dant and blows about more freely, fecal contamination
of hands, shoes, and clothing occurs more readily, and
the facilities for storing food so as to protect it from all
these are poorer. Consequently, the amount of care to
be exercised is greater, and the necessity for minute and
thorough cleanliness more urgent. The hands, persons,
and clothing of the cooks and assistants should receive
the greatest care. Tables, benches, blocks, cooking
utensils, and everything about the kitchen should be
cleaned as soon as used, and scalded, if it be possible,
with boiling water. Boxes and bags containing food
should be frequently inspected inside and out, and their
positions shifted, in order that insects may not gather
in or about them. They should always be kept clean.
Kitchen floors and surroundings should be raked, swept,
or scrubbed after each meal, so that all particles of food
and everything that might attract flies will be removed.
Slop-buckets and garbage-cans should be washed after

CAMPS 89

each emptying, and not allowed to become crusted with
a greasy coat of filth. At least once a day a rigid in-
spection of the kitchen should be made and all points
of kitchen police investigated. Reliable men should be
put on this duty and rewarded for its proper perform-
ance. Mosquito netting or wire-gauze covers should
be provided for the protection of food while it is await-
ing preparation or serving. Sheeting or boxes should
protect it from dust.

It is questionable whether screening the entire kitchen
is always advisable. Cleanliness is necessary in keeping
down flies, and if a kitchen is screened all around it is
darker and has more angles and comers in which dirt
and scraps may collect to attract them. As the door is
of necessity frequently opened, they enter and are then
kept in by the screening. Screening is an aid in pre-
serving the food uncontaminated, but it does not justify
even the partial neglect of the more important matter
of scrupulous cleanliness.

The kitchen fire should constitute a small crematory
for kitchen-waste, and the cook should endeavor to be
as independent as he can of civilian scavengers and
fatigue parties. Nearly all scraps and solid waste that
are to be thrown away can be burned by him, and at
times he can take care of most or all of his dirty water
by devices to be described later. Every tin can that is
emptied should be thrown into the fire and all organic
matter in or on it destroyed. Later it may be hauled
away or buried.

The Arnold pit has been much used for some years
and has often given great satisfaction. It is prepared
as follows : A pit is dug about 60 inches long, 30 inches
wide, 48 inches deep at one end, and 36 inches deep at

90 THE RECRUIT AND HIS ENVIRONMENT

the other. It is filled loosely with stones to a height a
few inches above the general ground-level, and is banked
on all sides to protect it from surface-water. The kitchen
fire is built on these stones, and is inclosed on the sides,
but the ends of the trough thus made are left open. All
watery material, such as waste coffee and dish-water, is
poured on the stones at the shallow end of the pit. The
heat of the stones evaporates it. All solid waste, includ-
ing tin cans, is burned in the fire. The ashes and debris
are removed as often as it becomes necessary. This ar-
rangement is improved by having the liquid waste first
strained by passing it through a layer of straw or ex-
celsior six inches deep, which would catch much of the
fine solids and grease in it. The straw should then be
burned and fresh supplied once or twice daily. It might
be placed in the bottom of a large tin or other box, or
in a shallow pit that drained into the larger one. At
other times, when the particular conditions would war-
rant it, the water could be led away to a stream by such
a filled trench as was described for the bath-water,
provided it were first strained through straw. Otherwise
the trench would soon become foul with a deposit of
soap, grease, and food-particles. When garbage and
waste water are hauled away for disposal elsewhere, the
matter of emptying them from cans and loading them
into wagons should be carefully done under the super-
vision of a responsible man, with a view to the preven-
tion of spilling and the immediate cleaning up of any
that may occur. Receptacles should be washed inside
and out immediately after emptying, and should at all
other times be kept tightly covered. Lime-washing the
outsides of cans and the stands on which they rest
renders the detection of dirt easier and is recommended.

CAMPS 91

If abundance of good food is provided in the messes,
the men have no proper excuse for indulging in im-
proper food obtained from peddlers, and such persons
should be excluded from the camp and its environs.

Papers, sweepings, and other ordinary camp litter, as
well as horse-manure and stable-dirt, should be burned,
and such disposal of it is easy and conven-
ient. If not so disposed of, it is apt to become ^

scattered, create a nuisance, and, particu-
larly, to do harm as affording breeding-
places for flies. A crematory may readily be impro-
vised, and if a good draught is furnished, it may be
kept burning continually with waste as fuel. Three
forms of pit or crematory are as follows, and any one
of them may be easily and quickly constructed : —

1. A circular pit with a cone of stones, around which
the fire is built, piled up in the middle.

2. A horseshoe-shaped mound of earth, or a niche
dug in a bank, or a trench open at one end.

3. A cylindrical crematory, which may vary in size
according to the size of the command and the amount
of material to be burned. It may be made of mud,
stones, brick, corrugated iron roofing, old garbage cans,
or whatever is available and suitable. In general, its
height should equal or exceed its diameter ; it should
have three or four openings, each eight to twelve inches
square, placed at equal intervals around the bottom as
air inlets. If iron bars are available they may be built
into the cylinder to form a grate above the level of the
air inlets. In rainy seasons a roof or other covering
should be provided. The writer has seen excellent
results from all the following types of cylindrical
crematory : —

92 THE RECRUIT AND HIS ENVIRONMENT

(a) One built of mud plastered thick around a bar-
rel. Inlets are provided and the fire lighted. As the
barrel burns out the mud bakes. This size will suffice
for a company.

(b) One made from three widths of corrugated iron
roofing, each three or four feet long and each having
a square measuring eight or ten inches cut from one
corner of it. The three pieces are hooked together with
wire in such a manner as to distribute openings left by
the missing squares at equal intervals around the bot-
tom of the cylinder. When set up this cylinder should
be braced and steadied by piling mud or sod about it.
It should suffice for two companies and has the ad-
vantage of being transportable in very small space if
the sheets are merely unhooked and laid flat one on
another.

(c) Any size at all may be made from stone or
bricks plastered with mud. One having the inside di-
ameter of three or four feet at the top and a height of
five feet or more should dispose of all the refuse of a
regiment. One such in a camp of the 6th California
Infantry in 1910 one day sei-ved to cremate a horse and
another day a cow, in addition to the regimental refuse.

Like all other types of incinerator this requires mod-
erately intelligent handling, as it is of course possible
to smother almost any fire. The proper method, in case
there is no grate to the incinerator, is to place large
stones or, preferably, empty cans loosely in the bottom,
so that air may pass among them freely. On these, or
on the grate, place a little wood and the dryest refuse
and light it. Then place some wetter refuse, then dry,
and so on until the mass is well lighted. Continue to
put on small amounts of refuse at a time, not filling the

CAMPS 93

cylinder but placing the material against the side toward
which the wind is blowing. At evening the incinerator
may be filled and allowed to smoulder all night. Next
morning it should be started again with wood.

Other forms of incinerator may be improvised to suit
conditions, and bits of stove-pipe or other means of im-
proving the draft or protecting the fire from rain can
be utilized. These pits must be cleaned as necessary,
and the ashes and unconsumed matters, such as tia
cans, placed where they cannot constitute a nuisance.

The proper disposal of the products of human waste,
feces and urine, so that they may not create a nuisance
or constitute a source of danger, is one of „

FCCGS

the most important problems of camp sani- _ ,_ .

tation. ihe methods available are incmer-
ation, water carriage, various forms of carriage on land,
and disposal in the soil. Considering these in turn it
may be said of incineration that it possesses the advan-
tage of safe and sanitary disposal with sterilization, it
does not attract and breed flies and does not contami-
nate the soil or the water supply. On the other hand,
the first cost of the incinerator is large, the cost of up-
keep and fuel excessive, carelessness in handling leads
to the development of bad odors, and the equipment
necessary constitutes such a mass of impedimenta as to
make its removal ordinarily impracticable when the
troops are moved. The method may therefore be con-
sidered in most instances an unattainable ideal.

Water cai'riage is in some exceptional instances an
excellent method of disposal. The conditions under
which this is true, however, are relatively few. It may
be applicable if the camp is known to be permanent or
semipermanent in character and is situated on or close

94 THE RECRUIT AND HIS ENVIRONMENT

to tidal water or a stream not used for drinking pur-
poses, that will remove the excreta promptly or at short
intervals. It may also be used in camps of very tempo-
rary character if they are so situated in regard to tidal
or running water as to make its utilization for the pur-
pose both simple and inexpensive, for instance, the
building of seats out over the water. In the former case
the installation may be anything from a complete sew-
erage and water closet system to one as simple as in the
latter case. Of intermediate arrangements a good one
is the use of troughs of the Reed trough type, connected
at their lower ends with drains of glazed tile that are
laid with a good fall. The outlet of the trough may be
closed by a hollow cylinder open at the level at which
it is desired that the water should stand, say twelve
inches from the bottom. Through this the accumulating
fluid finds exit, and once a day or oftener the whole
trough is flushed by simple removal of the cylinder.

Another plan, that has been found to afford a certain
amount of satisfaction in a permanent camp emptying
its waste into a small stream, includes large closed
boxes or tanks made of concrete, though wood might
be used, into and through which the sewage flows and
in which enough sedimentation and disintegration oc-
cur to make the outflow a pale, opalescent fluid almost
free from odor and easily visible particles. It is not
contended or thought that the sewage is thus purified,
but the plan has two distinct advantages in that it al-
most does away with bad odor, and it offers no encour-
agement for the breeding of flies. Despite its advantages
at times, water carriage of excreta is rarely applicable
in camps, especially in campaign.

Disposal by what may be called " land carriage " in-

CAMPS 95

eludes those methods that necessitate carrying or haul-
ing the excreta through or about the camp, among
them the pail system, the dry earth closet, carts, and
Reed troughs. They all have the common fault that,
while they provide for the reception of the excreta as
passed from the man, the matter of its ultimate dispo-
sition remains to be solved, and a satisfactory solution
is always dijB&cult and at times impossible. Among the
expedients resorted to have been burial, burning, dump-
ing at a distance from camp, dumping into water, and
disposal in large pits. All are imperfect, laborious, ex-
pensive, and unsatisfactory, they are apt to constitute
nuisances, to attract and breed flies, to pollute water
supplies, and in many instances to pollute the surface
of the ground. Within the writer's experience one of
the most satisfactory of these methods has been the dis-
position of the contents of Reed troughs into large pits
where the surface of the refuse was kept covered with
a layer of crude petroleum. This resulted in absence
of odor and of flies, but the labor involved in handling
excreta from troughs was considerable, that in digging
pits more, and accidents occasionally happened which
resulted in pollution of the ground in camp. Such acci-
dents are liable to occur with any system that requires
the handling or carrying of dejecta through camp. In
addition each method has inherent objectionable fea-
tures. Pails and boxes require much labor to clean them
and much supervision is necessary to see that the clean-
ing is thorough and that covers are kept on in intervals
of use, otherwise bad odors and flies abound. Dry earth
closets are often not to be used properly because of lack
of dry earth, the impracticability of separating feces
and urine, the consequent mass of feces and mud to be

96 THE RECRUIT AND HIS ENVIRONMENT

handled, and the impossibility of keeping flies away
from such a mixture. Like pails and boxes, earth closets
are not easily moved with the troops. Latrine carts are
highly expensive because of the transportation and
labor they monopolize. Reed troughs also demand large
expenditure in money, labor, and transportation, and in
addition, if used with lime in accordance with the War
Department order prescribing their use, they neither
sufficiently repel flies nor do away with bad odor. It
may be said though, that both of these objections may
be met by the use of crude petroleum instead of lime.
The objections set forth above will in most camps, es-
pecially of mobile troops, be sufficient to prevent the
use of any method of disposal calling for transportation
of excreta by land, and it therefore happens that we
still resort to those ancient methods that have at other
times been so faulty that all of these we have been con-
sidering were evolved as substitutes for or improve-
ments upon them, namely, disposal on or in the soil.

Of these methods there are three principal ones : —

Disposal on the surface of the ground with little or
no covering.

Shallow burial.

Deep burial.

The first named method usually merits only condem-
nation, as leading to contamination of soil, persons,
water and flies, though it occasionally happens that
circumstances will justify it. In a certain camp near
San Diego, for instance, "hardpan" as hard as most
sandstones was found at or within a foot or two of the
surface. The digging of deep trenches was impossible,
as picks and crows were soon blunted and rendered
useless, and when a trench was cu^ out to a depth of

CAMPS 9T

two and a half feet the soil was so non-absorbent that
urine quickly filled it. In the neighborhood were some
small areas where the overlying soil was deep enough
to permit of plowing, and this had been done. A con-
stant wind was blowing, and it was found that urine
and strained kitchen water when thrown on this plowed
ground to the leeward of camp was absorbed by the
loose soil and held until wind and sun completed its
speedy evaporation. Such a method of urine disposal is
certainly not ordinarily desirable, but in the case in
question it was the best and safest available method,
and military hygiene must in practice consist largely of
doing the best thing possible at the time and place.

The second method of soil disposal, burial in shallow
trenches, seems to have had considerable use in the
British and Indian services, but it should not be used
in camps of more than a few (lays' duration, unless
special circumstances make it appear the safest or only
available plan. Its most obvious faults are that flies
can breed in feces exposed to them and then buried to
a depth of only six to ten inches, that a relatively large
amount of ground is necessary, that soiling of the feet
with fecal matter is rendered more probable, that soiled
paper is apt to be blown about camp, that a relatively
light rain, especially in the tropics, will flood such shal-
low pits and diffuse their contents. When used the
system calls for the constant presence of a sufficient
guard to see that each man covers his own dejecta, that
toilet paper is properly enclosed, weighted, or (after
use) covered, and to attend to the final filling, packing,
and turfing of each trench at the proper time. The use
of crude petroleum in the trench and as a partial cov-
ering for the fecal matter wqu14 lessen odor and flies.

98 THE RECRUIT AND HIS ENVIRONMENT

The de&p trench latrine is the form used in our camps
of concentration in 1898, and it was condemned then
and many times since as a contaminator of persons,
soil, and water, a breeder of flies and of smells, and a
constant source of supply where flies might and did
load up with typhoid bacilli before visiting the kitchen
and mess tents. All of this was true, but more recently,
since the importance of preventing pollution of the sur-
face of the ground and of preventing access of flies has
been appreciated, and since actual and extensive prac-
tice has demonstrated the feasibility and value of such
precautions, it need be true no more. The danger to
be feared from a proper use of deep trench latrines is
pollution of the ground water, but as the introduction
of a good supply of drinking water from outside the
camp is nearly always resorted to anyhow, that is not
a vital objection, and ease of construction and sim-
plicity make it certain that this form of disposal will
long be used. When used though, the trench should be
properly constructed and cared for if the evils above
enumerated are to be avoided. First of all it should be
dug to a suitable depth, usually six feet or more, and
protected from rain, washings, and caving. Then it
should be covered with a box seat with hole covers that
close automatically, and all cracks and crevices closed
in such a manner that the pit is made quite dark and
fly proof. Separate urinals of tin or tarred paper fun-
nels opening into the pit by small angular tunnels
should be placed at each end. They may be made im-
passable to flies by stuffing them lightly, toward the
bottom, with grass or straw, although painting them
inside each day with crude petroleum suffices for this
and keeps down odor.

CAMPS 99

Various improvisations of pit covers can be made
that will require relatively little lumber, if tarred pa-
per, burlap, or cheap muslin be substituted for it on
the sides and ends of the box and for seat covers. By
keeping in mind the requirements of making the pit
dark and fly proof the resourceful officer can nearly
always devise a satisfactory cover.

As to the subsequent care of the pits, it is thought
that crude petroleum has advantages that put it in a
class by itself as a pit dressing. It keeps down bad
odors to a remarkable degree, is repellent to flies, does
away with the use of earth or lime in pits, and indefi-
nitely prolongs their usefulness in absorbent soils ; it is
easily handled and transported, and is of great value
for many other sanitary purposes about camp. It should
be used to paint the insides of urinal funnels and to
sprinkle over the surface of the pit contents each day.

Crude petroleum appears to owe its value as a pre-
ventive of fly breeding mainly to the fact that it is
repellent to adult flies. If maggots once hatch in a
petroleum-treated pit they are apt to develop about as
usual, despite the daily sprinkling with oil. Neverthe-
less, the treatment is still worth while, as, if continued
regularly, it keeps egg-laying adult flies away and limits
the output of the pit to the one crop of flies. Without
the treatment numerous crops would appear.

Other methods of caring for pits are also in use but
are not so satisfactory. Earth and lime are sometimes
used to cover each day's dejecta. They do not keep
down odors or prevent fly breeding as well as the oil
does, and they rapidly fill the pit and lessen its period
of usefulness and necessitate extra labor to dig others.
The burning out of pits has also been much used and

100 THE RECRUIT AND HIS ENVIRONMENT

has usually given satisfaction. The results are about
the same as from the above described use of oil, and
when that is the case it seems a waste of labor to over-
turn each pit cover and replace it each day, not to men-
tion the waste of fuel and the sometimes disagreeable
features attending the burning.

The Jepson latrine and kitchen pits were among the
earlier successful types of dark and fly proof pits, and
excellent results have been reported from their use in
proper soils. They differ from other pits in that they
are dug with a post hole auger and are small in diam-
eter, but deep. They are to be covered in and made
fly proof.

Urinals should always be provided in camp, so that
the men will neither need to urinate promiscuously
through the camp nor to wet and soil the latrine seats.
The day urinal may be a trough or a funnel of wood,
tin plate, or tarred paper, that conducts the urine to a
dark and preferably fly proof soakage pit. The funnel
or trough should be painted with crude oil each day, if
possible, and great care should be taken to insure a8
far as possible that the men do not urinate on the
ground near the urinal and so make a muddy and foul
place. In case oil is not available for troughs and fun-
nels, fairly satisfactory urinals may be made by dig-
ging pits and filling them with stones, or they may be
filled with sawdust, or barrels or boxes with both ends
knocked out may be half buried and similarly filled.
Pine needles and sawdust are reputed to be especially
valuable for filling because they minimize or prevent
the odor of decomposed urine.

Night urinals consist of large cans or half barrels,
to be placed in the company streets at night, and to be

CAMPS 101

carried away and emptied and washed in the morning.
If one emptying does not suffice to prevent overflow or
spilling, they should be emptied also at ten o'clock at
night. They should be marked at night with lanterns,
so that they may be located easily. During the day,
when not in use, they should be kept clean and dry and
exposed to the sun.

The general interest of officers in the prevention of
disease and their knowledge of the subject has increased
so much in recent years that they usually show them-
selves efficient in maintaining good conditions. Never-
theless, they as well as the medical officer would be
greatly helped if each company had an enlisted man
whose duty it was to study and look after sanitary con-
ditions. Army experience had convinced the writer of
this, and his experience on the Canal Zone, where non-
medical men who were formerly carpenters, railroad
men, engineers, foremen, soldiers, and so forth, have
been trained by working experience to become sanitary
inspectors and have rendered service of the highest
value, has strengthened the conviction. Such a trained
man in each company would be of the greatest value
to the organization and to the surgeon. Having ac-
quired his training and demonstrated his value he
should have non-commissioned rank and pay.

Camp sanitary work may at times need to extend
beyond the camp and may include the improvement or
protection of a water supply, the search for and elim-
ination of mosquito breeding in large areas, the drain-
ing of swamps, petrolizing of pools, grading and ditch-
ing of ground, the clearing of brush, and the regulation
or control of traffic in food stuffs. Under certain condi-
tions it may include a quarantine system, a war on rats.

102 THE RECRUIT AND HIS ENVIRONMENT

a house-to-house inspection of civilians, the control of
epidemics, or the sanitation of entire towns or districts.
In all of these cases trained men are of especial value
to the sanitary officials as well as to the company,
though their value to the latter is constant.

CHAPTER VI

THE HYGIENE OF MOVING TROOPS

The march, the battlefield, changes by ship and rail,
all present their special problems of sanitation, neglect
of which may result in disaster to the careless command
or to its friends and allies. Many men and some offi-
cers are apt to ignore the latter phase of the question
and to think that when they have avoided harm to
themselves and their companies they have performed
their full duty in sanitary matters. Nowhere is a man
his brother's keeper to a greater degree than in an
army, and it is hoped that the fact may become more
fully appreciated.

Article V of the Field Service Regulations deals well
with the subject of marches ; but the rules there given
should be applied with discretion. It must ^,
be remembered that the various possible
states of weather, roads, and personnel may result in
an almost infinite variety of circumstances, all of
which could not possibly be considered in any set of
printed rules. Much must depend on the judgment
of the commanding officer, in sanitary as in tactical
matters, and his knowledge or lack of knowledge of
sanitation may determine the success or failure of a
movement. If good judgment is used in adapting the
regulations to the circumstances, the rules laid down
therein will constitute a reliable general guide. The
length and speed of the march, for instance, must be
materially influenced by climate, weather, roads, water,

104 THE RECRUIT AND HIS ENVIRONMENT

transportation, weight carried, amount and character
of sickness in the command, the rations, character
and state of the clothing, the spirits of the command,
the objective, temperance in the use of intoxicants, and
other factors.

The length and frequency of rests must be influenced
by much the same factors, and the commander who
sets a pace and determines the frequency and duration
of rests without regard to these influences is not doing
justice to his men. The time of day during which the
march is to be made will also influence the length,
speed, and rests, and the choice of it must in turn be
influenced by diverse considerations. Thus the temper-
ature may make daytime marching very trying, yet
the state of the roads, the possibility of malarial or
other infections, the presence of sick, and other consid-
erations, may make it appear the lesser of evils. It is
always well, therefoi'e, to consider these various influ-
ences and to bear in mind that the command brought
into camp in good spirits and good condition after
what may be a relatively short march, is in better con-
dition for large accomplishments on the morrow, than
another command that has marched five miles farther,
but has reached camp with the men footsore, weary,
discouraged, and with their vital resistance so lowered
as to be ready to yield to the inroads of any chance
infection. The influence of climate and weather is so
quickly manifested on the men, and in such obvious
and well-known ways, as not to need much discussion,
and a moderate amount of common sense and consider-
ation for his men should cause an officer to make allow-
ances for them. Heat, wind, snow, rain, fog, slush,
glare, mugginess, all tire, discourage, and tend to

THE HYGIENE OF MOVING TROOPS 105

sicken the men, shorten the march, and increase the
rests.

Closely related to these is the state of the roads.
Mud, excessive dust, loose sand or gravel, very rough
and uneven roads, all increase delay, vexation, and
fatigue, and, even when weather conditions are good,
may cut the march to a fraction of what is desired.
Not to be separated from the question of roads is that
of transportation. If the former are good, abundant
wagon transportation may be used, if available, lessen-
ing the loads of the men, supplying them with abundant
food, tentage, and other necessities and comforts. If
they are bad, transportation facilities may be much
limited in consequence, or, if furnished, may prove a
source of vexation and weariness, the men having to
spend hours of toil extricating mired animals or wag-
ons, in unloading, loading, and carrying freight. Such
trials of body and spirit react on the health, and when,
in addition, because of failure of the transport wagons,
men have to lie down supperless and without proper
shelter, the question of transportation has assumed a
sanitary importance of magnitude.

Intimately related to the question of transportation
is that of the weight carried by the men, and the at-
tempt is wisely made to reduce this to a minimum ;
yet under some conditions, and generally they are those
in which men should have to carry the least, as in bad
weather, over bad roads, on forced marches, after very
trying campaigns that sicken man and beast, trans-
portation may fail and the men have to carry extra
ammunition, food, and clothing. If this is a necessity
the best should be made of it and the load carried,
but the march should, as far as possible, be regulated

106 THE RECRUIT AND HIS ENVIRONMENT

to suit the altered conditions. We are not able to breed
or buy men as we do horses, with a view to their
strength, speed, endurance, or spirit, though we do
attempt to select them with a view to these qualities.
Nevertheless, each organization will have its strong and
its weak men, its fast and its slow, its cheerful and
its despondent, and it is the less desirable of these that
must be most considered under trying conditions. The
weak man must not be overloaded, the lame man over-
marched, because the more able men can march far-
ther or carry more. Otherwise they will become sick,
and the problem is worse complicated than before.
Disregard of this simple fact has been known to re-
sult in most serious consequences. Whatever the
weight carried, it should be so disposed on the person
as to carry as comfortably as possible, and not constrict
or compress the chest. As stated before, it is on the
free play and efficient working of the heart and lungs
that strength and endurance depend. If the chest is
compressed and its mobility lessened by tight clothing,
crossed straps, or other cause, that free and efficient
working are impossible, and the man becomes exhausted
under a load that might not greatly inconvenience him
if it were more wisely disposed. Experiments have de-
monstrated that inhalations of oxygen enable athletes
to run farther and faster, and with less inconvenience,
than is the case without such inhalations. When the
action of either the lungs or heart is interfered with,
the oxygenation of the blood is hindered and early
tiring, weakness, and exhaustion follow. These con-
ditions constitute not only disturbing and delaying
factors of a temporary nature, but also weaken the re-
sistance to disease and prepare the way for infections.

THE HYGIENE OF MOVING TROOPS 107

Sickness in the command that is moving always
occasions delay, often very much extra work, and, quite
as often, danger of epidemics. All sick should there-
fore be left behind, if possible, when the march begins;
all hygienic measures should be employed to prevent
other men becoming sick; all who do become so should
report to the medical officer as soon as practicable so
as to get the benefit of early observation, treatment,
and care, and all who do not favorably and quickly re-
spond to such early care should, if possible, be provided
for on the way, in houses, camps, or hospitals, or sent
back, and not allowed to hamper and constitute a dan-
ger to the entire command. The Field Service Regu-
lations prescribe that the sick shall be eliminated before
the start is made, but in practice certain classes of
sick are not always eliminated and later give much
trouble. Among these are venereal cases. Many such do
not appear on sick report unless frequent inspections are
made and they are ordered to report. These men, though
doing full garrison duty and feeling well, are likely to
develop buboes on the march and be unfitted for either
walking or horseback riding.

Men recently discharged from treatment in hospital
for malaria, dysentery, and other debilitating diseases
are apt to become exhausted or to have recurrences of
their sickness when subjected to hard marches.

Weak hearts and weak feet are liable to break down
under similar conditions, and men known to suffer from
either should be excluded. Not only should sick men
be excluded from the march, but well men should be
taught and, if necessary, compelled, to conduct them-
selves in such a way as to maintain their efficiency and
strength. Alcoholism, particularly, should be discour-

108 THE RECRUIT AND HIS ENVIRONMENT

aged, and all straggling to get alcohol and all drinking
in ranks should be punished ; for not only does the in-
dulgence lead to inefficiency from drunkenness, but it
predisposes to exhaustion, infections, injuries, to heat-
stroke in hot weather and freezing in cold. While only
harmful and not to be encouraged in camp, drinking,
if not carried to excess and not prolonged into the
hours belonging to sleep, is then less directly harmful
than on the march.

Cheerfulness and bright hopes are powerful stimu-
lants to accomplishment, and it should be the aim of
the company commander to keep his men in such a
state of mind. Difficulties may often be laughed away,
while if given too much thought or gloomily dwelt upon
they readily become insurmountable. One of the great
items in Napoleon's success was his faculty of having
his men accomplish the impossible.

Hardships may be magnified in retrospect; on the
march they should be minimized and belittled, if un-
avoidable.

Another occasional cause of exhaustion is said to be
the reckless and excessive indulgence in water. The
.^, Field Service Regulations state that under

"ordinary conditions a canteen of water
should last a man a day." Ordinary conditions in the
field are, however, hard to define, and the amount of
water needed under varying conditions and by differ-
ent men varies greatly. There is no doubt that many
men do use water injudiciously, and that, by training
or habit, they may teach themselves such moderation
and restraint as to be enabled to make the contents of
one canteen last them through any ordinary day's
march. As the canteen holds two and one-half pints

THE HYGIENE OF MOVING TROOPS 109

and the march rarely covers more than eight or ten
hours, it may be seen that this should not involve any
hardship for a well and fit man. It is, however, a well-
recognized fact that men who begin a march with the
consumption of large amounts of water, and who early
exhaust their canteens, are very apt to become ex-
hausted or to fall out before the march is completed.
The consumption of the water is not always the sole
cause of such exhaustion, but both may be the effect of
a common cause, such as sickness, diarrhoea, alcoholic
indulgence, excessive smoking, or injudicious eating the
night before. By the avoidance of such indiscretions the
moderate use of water is made easy ; but if a man has
spent a part of the night in alcoholic indulgence, smok-
ing, and eating cheese and salt herring, his system is so
loaded with poisonous waste-products that he needs a
large amount of water to dilute and remove them, and
depriving him of it will not improve his condition in
any way. Aside from such indiscretions, more water is
required by men whose food is very salty or very dry ;
by those marching in a hot sun or losing much water in
the form of perspiration, or those marching in dust, as
at the rear of a column. Thus we see that while "ex-
cessive " use of water is harmful, its liberal use is not.
On the other hand, insufficiency of water is harmful,
even when not causing suffering through thirst, in hot
weather as predisposing to sunstroke, and as causing
such concentration of the urine as to cause very severe
bladder irritation, with burning and pain that occasion
great suffering and alarm. It is nevertheless highly
desirable that men should so conduct and so train
themselves that they can be able to get through the
marching hours without using more than one canteen-

110 THE RECRUIT AND HIS ENVIRONMENT

fill of water; and if for any reason they cannot do so,
it is usually better that they should go thirsty than that
they should drink water from unknown sources or of
doubtful character, as a few hours of discomfort from
thirst, or an attack of pain in the bladder, are to be
preferred to an attack of typhoid, cholera, dysentery, or
parasitic infestation. Sunstroke, however, may be as
fatal as any of these, and if symptoms of it appear,
water must be used, under the direction of the surgeon,
if one be present.

The water problem should be handled as follows : —
Before the march is begun, an abundant quantity of
good water, boiled, filtered, or purified chemically, if
necessary, should be supplied. If the water is boiled,
that should have been done the night before, in order
to have it cool in the morning. If other vessels are not
available, it may be put in the canteens the night before
and allowed to cool in them. Each man should drink
what he wants before starting, using his cup for the
purpose, and have his canteen filled from the good
supply. Except rarely, he cannot know that the water
he sees later in the day will be suitable for drinking,
and he should therefore drink then only from his can-
teen, and, in order that it may suffice, exercise great
care and moderation in the use of that supply. As soon
as camp is reached in the evening, the preparation of
a fresh supply should be begun, and, if boiling is the
form of purification used, the first drink furnished may
be tea or coffee. Reckless or careless indulgence in
water from supplies of unknown character may have
the most disastrous results.

Field Service Regulations say that " sources of water
supply are examined by experts and marked good or

THE HYGIENE OF MOVING TROOPS 111

had.''^ It is a difficult matter and a time-consuming proc-
ess for an expert to determine whether or not a water
supply is good or bad, and on the march a medical
officer can only base his opinion on the source and sur-
roundings of the supply as he can see them or learn of
them from others. The appearance, odor, taste, and such
other tests as he is able to apply under the circumstances
can in no wise assure him that the water is fit to drink.
It is therefore usually desirable that all water from
sources not well known to be good should be purified
by heat or otherwise before use for drinking.

Smoking is apt to increase thirst and should there-
fore be discouraged on the march, particularly if the
water supply be small in amount or of poor character.
The use of chewing gum tends to lessen the urgency
of the desire for smoking and also to lessen thirst, and
may be regarded as helpful for those reasons. It is
sometimes urged that cold weak tea or coffee be carried
in the canteen and drunk on the march, in order to as-
sure the use of boiled water. Aside from the possibility
of their being diluted with unboiled water, and of tea
being made with cold and unboiled water, these drinks
are not so refreshing and thirst-satisfying between meals,
to most Americans, as plain water, and it is not thought
that they are as good for use on the march as the latter,
provided that it is properly purified or sterilized.

The food-supply on the march, as elsewhere, is very
important. Because of the greater amount of work per-
formed, and the increased tissue-changes
due to the outdoor life, the amount of food
required on the march exceeds that required in garrison ;
while because of the few and imperfect kitchen facilities,
the new and strange environment, the absence of water-

112 THE RECRUIT AND HIS ENVIRONMENT

closets, and for other reasons, food infection is more
apt to occur, and every effort should be made to obtain
cleanliness and to serve all food sterile, rendered so
by heat. Because of the exposure to which the men
are subjected, diarrhoeal troubles are readily induced,
and instating foods should be avoided. Except in rare
instances it should be possible to furnish two hot and
substantial meals a day to the marching column, and
that should be done. A hot breakfast should be served
before the march is begun, and it should be a substan-
tial meal, such as one of meat, potatoes, bread, and coffee.
Eggs and similar articles, if obtainable, may be used.
The noon meal, also, should be prepared and issued to
the men before starting, and should embrace much
nutriment in relatively small bulk. Fried bacon, cheese,
sliced meat, and bread meet the requirements well, while
a pickle, a bit of fruit, or jam adds to the enjoyment
of it. In the evening, after the hard work of the march
is ended, the men should have another hot meal, and as
they will have leisure to digest it, it should be more
bulky than the other meals. Stews, if well made, answer
admirably, and may be supplemented with such addi-
tions as are obtainable. Because of lack of fuel, delay
in the arrival of company wagons, the necessity of start-
ing fires and doing the cooking after the halt is made,
the evening meal is often late ; and if they can obtain
other food many men eat it, often with little regard to
its suitability. It is hoped that soup-carts, ambulance
kitchens, and fireless cookers will correct this by having
a ready cooked and hot meal prepared when the halt is
made. Because of their portability, canned and pre-
served foods are much used on marches, and the usual
precautions are necessary to see that no spoiled cans are

THE HYGIENE OF MOVING TROOPS 113

used. If this be done, they constitute fairly pleasant and
very wholesome food-supplies, but they should be sup-
plemented with fresh articles when these are obtainable.
The general care in the preparation of foods that has
been indicated as desirable in camps should be exercised
in the short camps made by marching troops.

The government provides suitable clothing for all
varieties of climate and weather, and the company com-
mander should see that his men are pro- niothinff
vided with the proper kinds and amounts to
meet the probable needs of the march. Flannel shirts
should be worn even in tropical climates, as they pre-
vent too rapid cooling of the body and afford protection
from the night chill. Blouses or coats are rather an
impediment than a help in the tropics, if flannel shirts
are worn, though more useful and comfortable than a
sweater in cold weather, especially cold, windy weather.

The poncho should always be carried and the blanket
nearly always, even in hot seasons, as the night chill
is often penetrating and is accentuated if the clothing
or the ground be wet. The mosquito net, while not an
article of clothing, may be mentioned here as most im-
portant in tropical countries, or hot weather. It is the
soldier's most important protection against yellow fever,
malaria, and dengue; while it may be quite as efficient
in protecting him from tick-bites, from the flies that
infest with screw-worms, from poisonous insects and
reptiles. Its use, though the importance of it has long
been recognized, is apt to be neglected on marches.

It is not considered necessary to discuss in detail the
various articles and kinds of clothing to be worn, but
some few articles need discussion. The drill regulations
allow the marching soldier three pairs of socks, one pair

114 THE RECRUIT AND HIS ENVIRONMENT

on liis feet, one in his blanket-roll, and one in his surplus
kit on the company wagon. In order to keep his feet in
good condition he should begin each day's march with
clean feet in clean socks, and must always have a dry
and clean pair of socks for emergencies, such as the
accidental falling into mud-puddles or streams. It is
therefore necessary that he should wash his feet and
one pair of socks each night, and the company com-
mander should make sure that he does so, and that, if
possible, he then has facilities, such as a fire, for drying
the socks. The socks should not only be clean and dry,
but they should fit properly. If too long, they fold or
wrinkle and make pi*essure or rub. If too short, they
cramp the toes and may be as important in causing or
aggravating corns, bunions, foot-cramp, and ingrowing
toe-nails as poorly fitting shoes. They should be of such
weight as is suited to the individual man, in general
being rather light for foot-troops so as not to cause
excessive sweating or burning of the feet. Any disorders
arising from the use of improper socks or from other
cause should at once be reported to the surgeon, who,
by timely advice or treatment, may be able to avert
lameness or disability.

Shoes likewise are frequent causes of lameness, and
in many instances the company officer is to blame for
not seeing that his men get proper sizes and fits. At
other times the quartermaster's department is at fault
in not having proper sizes for issue. In such event the
man chooses a shoe of improper size, or buys them of
improper shape and material from civilian dealers. The
footgear of the army has improved in quality of late
years, however, and most of the shoes now issued are
excellent, both in shape and material. A proper shoe

THE HYGIENE OF MOVING TROOPS 115

should be sufficiently long and broad, so that the toes
are not crowded even after a long march. It should not
make painful pressure on any place, but should fit
snugly and evenly over the instep and about the heel,
to prevent rubbing or forward slipping of the foot. The
heel should be broad and low. Two pairs of shoes are
allowed, one pair on the feet and one pair in the surplus
kit. If practicable, the day's march should always be
begun in a clean and dry pair, and it is therefore im-
portant that a part of each evening's work should be
the cleaning, drying, and oiling of one pair. For the
last-named purpose, a piece of fat meat will answer if
other oil is not obtainable. Shoes left wet and dirty
soon become hard, wrinkled, and uncomfortable, and
" run over " and break more readily than those kept
clean and supple.

Two suits of underclothing are allowed, one on the
person and one in the surplus kit. As underclothing
is even more important as a protection from dirt than
from cold, these will also require frequent washing.
Neglect of this may result in attacks of boils, ringworms,
and other skin infections. When a day in camp permits
it, and coffee tins or other receptacles are available for
the purpose, underclothing should be boiled.

The towel,, but one being authorized, will require
frequent washing.

For general purposes and use in all climates, the
campaign hat is very satisfactory, though discomfort
and complaint have been caused by the stiff brim that
has been used for some time past. With a soft brim it
is unexcelled for general use, though in the tropics
a cork or pith helmet and in arctic weather a fur cap
excel it for seasonal wear.

116 THE RECRUIT AND HIS ENVIRONMENT

There is no evidence of any advantage in red or
orange hat linings.

The general rules for camp police should be applied
to marches as far as practicable, and they can be ap-
plied to a far greater extent than is ordi-
narily the case. In order to do this, proper
instructions should be given in advance, and each com-
pany should have, as in camp, at least one man on
sanitary police duty, whose business it would be to see
to the proper disposal of waste matters, to prevent the
careless and indiscriminate soiling of halting-places, to
assist in preventing the use of improper water, and to
do such other work of a similar character as the cir^
cumstances necessitate or the medical officer recom-
mends. Men should not, except in urgent cases, be
allowed to fall out except at regular halts. If the halt
is a short one, the company commander indicates to the
sanitary soldier a suitable spot for urine and feces. The
man goes to that spot and marks it. All men needing
to fall out go there and use the place indicated, after-
ward covering their dejecta with earth. If the halt is
longer, half an hour or more, the sanitary soldier re-
pairs at once to the designated spot and digs a shallow
trench for feces and a shallow pit for urine. All men
should be instructed to use these places only, and the
trench and pit should be filled in again before the
march is resumed. In case a man, from urgent neces-
sity, does fall out on the march, he should be instructed
to cover his feces with earth, using his bayonet, if
necessary, for the purpose. Similar rules should apply
to men on outpost or picket duty, and in this way
much may be done to prevent the surroundings of a
camp from becoming an ill-smelling, fly-breeding nui-

THE HYGIENE OF MOVING TROOPS 117

sance. Scraps of food, greasy papers, and other articles
thrown away by the men at the halting-place should
be thrown into one pit and burned or buried.

On arrival at camp, the sanitary soldier should im-
mediately begin shallow trenches in a proper place
selected by the medical officer, and men should be
punished for urinating or defecating elsewhere. After
that, the other business of making camp may proceed.
Without it, the camp should not be made, as its site
will almost certainly be defiled.

In bivouac, or while actually marching, the men
should take all possible precautions to protect them-
selves from, or to rid themselves of, vermin and insects,
and in warm weather the use of the mosquito net should
not be neglected.

The hygiene of the battlefield has been largely set
forth in the consideration of the camp and the march.
All the general principles there set down battle,
hold good and should be observed as far ^.i ^
as possible. Often, however, the military „ o->na
necessities allow no time to be devoted to
sanitary matters ; but even so, the soldier who has been
well trained to a realization of the importance of such
matters will be able to take better care of himself and
to do less harm to his comrades than the man not so
trained.

The man going into battle should, if possible, ob-
serve all of the following rules in addition to the gen-
eral care outlined above : —

1. Make sure that you have a first-aid packet, that
it is in good condition, and that you know how to
use it.

2. Have your cauteen full of boiled water.

118 THE RECRUIT AND HIS ENVIRONMENT

3. Be clean in person and clothing, be bathed, and
have on fresh underclothing.

4. Have your bowels and bladder empty.

6. Eat only good, nourishing, and digestible food.

All of these rules have an important hygienic bear-
ing in case he should be wounded. The introduction of
the first-aid packet in its present form was one of the
greatest improvements in military hygiene ever con-
summated, and it has prevented an immense amount
of suffering, mutilation, and death. For a large pro-
portion of wounds, a properly applied first-aid dressing
constitutes the most important part of the treatment,
and, in many cases, the whole of it. W ith such a dress-
ing at hand and a knowledge as to how to apply it, the
use of water on wounds is very rarely necessary. But
if water is used, it is most important that it should have
been boiled. Otherwise it may infect the wound most
seriously. Cleanliness of person and clothing are very
important for the same reason, to prevent infections.
Most infections of wounds are caused by bacteria de-
rived from the skin or its coverings, and by simple
cleanliness of these, surgeons are daily able to, and do,
make extensive wounds that heal without a trace of
infection. The importance of having the bowels and
bladder empty, or relatively so, lies in the fact that
wounds of these viscera are exceedingly dangerous, but
that the danger is directly lessened with the chances of
excremental soiling of the tissues. For this reason,
eating, drinking, and moving, all of which increase or
facilitate the escape of intestinal or bladder contents,
are to be avoided in the case of belly wounds, and for
the man so wounded we may formulate another rule :

6. If wounded in the belly, lie down in the most

THE HYGIENE OF MOVING TROOPS 119

comfortable position, eat nothing, drink little or no-
thing, do not move, do not get excited or restless. If
overlooked or forgotten, you may be better off than if
foimd and transported.

The sanitary disadvantages under which men travel
on our army transports are numerous, but they are
mostly beyond the company officer's power
to remedy. The transport regulations pro- . ^
vide for such sanitary measures and daily *^

inspections as would seem to assure good conditions,
and the conditions are such that with the aid derived
from sea air and changes of scene the health of the
men is usually well preserved or improved. Over-crowd-
ing is an evil frequently encountered on transports,
and one from which others flow. The company com-
mander is quite powerless to prevent this, but he
should lessen the evils of it by having his quarters as
freely ventilated as possible, having them policed each
day, and vacated by both men and their belongings
when opportunity offers. He should see that his men
bathe frequently and have frequent changes of under-
clothing, and that they get suitable opportunities for
clothes- washing.

Transports are not infrequently infested with bed-
bugs. The company officer can only partially correct
this evil by the police and cleanliness of his quarters,
and, at times, by bed-bug hunts and the use of insect-
icides. In Canal Zone barracks, which are provided
with bunks similar to those on transports, bugs are
destroyed by boiling the canvas and its stretcher frame
and flaming the upright supports with a gasoline torch.

The food on transports is usually of good quality
and VQry nourishing, but the methods of cooking and

120 THE RECRUIT AND HIS ENVIRONMENT

serving it are almost always monotonous and unat-
tractive, and result in unnecessary waste, improper
methods of eating, and some disgust with the food. The
company officer should try to influence these condi-
tions for the better, so far as he can do so. Owing to
the long confinement in exceedingly narrow limits dur-
ing the trans-Pacific voyage, unremitting attention to
all sanitary details is urgently demanded. All cases of
sickness or disease of any kind should be reported to
the surgeon early, in order that he may isolate conta-
gious diseases, as well as give treatment. The two ills
from which a majority of men suffer are sea-sickness
and constipation, the former at the beginning of the
voyage, the latter throughout it. The tendency to sea-
sickness is lessened if the man goes aboard the boat in
good general condition, with his bowels cleaned out and
his system free from the poisons produced by over-
eating, alcoholism, and other excesses. Constipation
should be prevented, if possible, by the use of rather
bulky foods, such as oatmeal, fruits, and vegetables, by
daily exercise and a well-maintained habit of visiting
the closet regularly and making the effort to defecate.
Under varying conditions, troop trains may be com-
posed of any kinds of cars that are in use. The gen-

eral principles of troop hygiene should be
. *^ applied as far as practicable, whatever the

accommodations. The most common faults
in troop trains in time of peace are poor policing and
dirty cars, and an insufficiency of water for drinking
and cleaning purposes. Both of these faults are usu-
ally attributable to the railway officials, but the troops
are partly to blame in that they are sometimes care-
less and wasteful of the water, and make very little

THE HYGIENE OF MOVING TROOPS 121

effort to keep the cars clean. The company commander
can therefore partially control the evils. He should also
make it his particular care to see that the car closets
are well supplied with water for flushing purposes, and
that the supply is replenished as opportunity offers.

CHAPTER VII

THE HYGIENE OF HOT AND COLD CLIMATES

The general principles of hygiene are the same the
world over and may be applied in any climate. They
aim to keep the body strong, sound, free from infection,
and at its maximum efficiency. Inasmuch, though, as the
dangers of infection as well as of injury from extremes
of temperature are somewhat different in the tropics
and the arctics, it is well to give these conditions sepa-
rate consideration.

Hot Countries
The danger to life and health is greater in nearly
all tropical countries than in those that are temper-
ate. This is due to a number of causes, among which
we may note the almost total neglect or ignorance of
sanitation among tropical peoples, the high, even, and
often moist, temperature in which disease-producing
organisms flourish and multiply, the great abundance
and variety of insect-life, the common pollution of
water-supplies, the habits of dress, and the heat itself.
It is sometimes said that the safest procedure in matters
of hygiene in strange countries or climates is to con-
form to the habits of the natives, but this is often a
very serious error, and it has undoubtedly cost many
lives. It is faulty habits in the natives that help to keep
alive, in the tropics, many diseases that have long since
almost or entirely disappeared from temperate climes,
while the people sicken and die of preventable infec-

HYGIENE OF HOT AND COLD CLIMATES 123

tious diseases in far greater numbers than should be
the case.

The native of the tropics is very apt to suffer from
water-borne diseases, and cholera and dysentery, al-
though not limited to tropical climates, are
so much less prevalent elsewhere as to be
relatively rare, even if not unknown. The native is in-
fluenced in his choice of a water-supply by convenience,
superstition, habit, and the fact that his ancestors did
certain things, but not often by sanitary considerations.
For this reason he suffers from the diseases mentioned,
and partly for this reason he practically always harbors
one or more varieties of intestinal worms. The only
safe rule for general application to drinking-water in
the tropics is that it should be sterilized by boiling,
distillation, filtration, or chemical treatment. But
this alone is not sufficient. The water must be kept
sterile until consumed, by being put in sterile contain-
ers and closed against all possible contaminations. Both
Filipino and Chinese servants in the Philippines are so
entirely ignorant of the very meaning of sanitary pre-
cautions, that they are continually giiilty of such action
as stoppering bottles of distilled water with corks they
have held in their mouths, wiping out a drinking-glass
with a dirty rag or paper picked from the floor, drink-
ing direct from bottles, and bottling unboiled water
rather than take the trouble of boiling it, and it is feared
that not all soldiers are free from some of these faults.

It is generally asserted, and is theoretically true,
that less food is required in the tropics than in colder
climates, and that the fats and proteids i^i .« ,
particular should be considerably reduced.
This may be admitted, but we must also admit that

124 THE RECRUIT AND HIS ENVIRONMENT

lifelong habits, exercise, and temperament exert an
influence that cannot be ignored, and any arbitrary
attempt to put American soldiers, especially if they be
doing field-work, on a ration approaching the rice-and-
fish diet on which many natives of the tropics live,
will result not only in discontent, but also in impaired
nutrition and in clandestine indulgence in food or drink
of improper character. The present army ration is
thought to be excellent for the tropics, as for home,
provided that the men work and exercise as at home.
If such is not the case, the ration is too heavy and
should be reduced as indicated. The sugars and starches
are well borne in the tropics, are not such " heating "
food as fat and proteid, and do not tend, in the same
way and same degree, to cast an excessive amount of
work on the liver and kidneys. Neither do they offer
opportunities for such harmful forms of intestinal putre-
faction. Organic acids, such as fruit- juices, are espe-
cially valuable and important, as well as agreeable, in
the tropics.

Care must be exercised in the use of fresh fruits and
green vegetables, not because they are in themselves
harmful, but because they are apt to be contaminated,
from unclean water or from fecal manuring, with the
parasites causing intestinal diseases. The only safe
plan in using them in countries where dysentery, chol-
era, and intestinal worms abound is to have them
sterilized : the green vegetables and some fruits by
cooking ; bananas, mangoes, oranges, and similar thick-
skinned fruits, by thorough washing in boiled water.
A large part of the food consumed by white people
in the tropics is preserved by refrigeration or by can-
ning. It is as good there as elsewhere, but is apt to

HYGIENE OF HOT AND COLD CLIMATES 125

decompose rapidly after exposure to the ordinary tem-
perature and atmospheric conditions, and should there-
fore be used promptly after such exposure.

Owing to the facility with which potatoes and similar
vegetables spoil, the tropical resident should early ac-
custom himself to the use of rice, yams, and similar
products. The use of condiments and spices is gener-
ally more liberal in the tropics than elsewhere. This
is, partly at least, a matter of custom, but it may have
a physiological basis in that these articles are stimu-
lant to the alimentary tract. They are not known to
do harm.

Alcohol is quite as much abused by northern peoples
in the tropics as in their own homes, or more so. In
real moderation, that is, in the amounts
that can be completely oxidized in the body •'^^conoi
and used as food, it is not known tiiat alcohol is more
harmful in the tropics than elsewhere. In greater
amount it is so, for the reason that alcohol in excess is
in all climates an irritant to the liver, and in the tropics
the liver is already hard-worked, irritated, " sluggish,"
and subject to congestions, — conditions aggravated by
the irritation from the alcohol. Like the proteins and
fats it does less harm if plenty of exercise is taken to
promote its oxidation and the elimination of the com-
bustion-products. As in other climates, its use is only
infrequently indicated, and abstinence from it is advis-
able. Its very general, and often excessive, use among
soldiers proceeds not so much from any needs of the
system as from idleness, vacancy of mind, evil exam-
ples or careless associations, laxity of public opinion
on such matters, and absence of such restraining influ-
ences as home-life and respectable female society. It

126 THE RECRUIT AND HIS ENVIRONMENT

would therefore seem that the company officer can best
combat the evil by attention to these points. Heat-
stroke and heat-exhaustion are much more apt to occur
in a man who is drinking, and to be more severe when
they do occur. All drinking to excess is debilitating
and probably lessens the resistance to infections. Re-
currences of malaria and dysentery are not infrequently
brought on by drinking-bouts or sprees. Alcohol also
predisposes in more indirect ways to disease-infections,
as by rendering a man neglectful of the quality of his
food or the use of his mosquito net, and because he
may use impure water with his drink, erroneously
trusting to the alcohol to sterilize it.

In general terms, the dress should be adapted to the
climate and to insure comfort and protection. The
clothing issued to the army fulfills these
° requirements, allowing variations in the
underclothing to suit individual tastes and require-
ments. The cotton service cloth for outer dress is
cheap, strong, durable, fairly cool, and easily washed.
The flannel shirt for the field and those of cotton for
barracks meet the requirements. British writers lay
some emphasis on the desijability of always wearing
woolen clothing in order to protect from chill, and
much has been said as to the value of the woolen
belly-band or abdominal binder. The writer's personal
experience, and observations as to the general American
experience, in the tropics do not indicate that this is a
rule of general application. As stated before, most
tropical diseases are infectious in nature, and if proper
precautions be taken to avoid the infections, it is not
thought that the discomfort produced by too great
warmth of body, excessive perspiration, and prickly

HYGIENE OF HOT AND COLD CLIMATES 127

heat is apt to offer additional protection. In the field,
where the chill of night air is more keenly felt and
where wetting may occur from rain or from fording
streams, the flannel shirt should be worn, and it and
the blanket meet the requirements. There is no objec-
tion to the use of light flannels by men who find them
comfortable, while in the cold season and in high lands,
as at Baguio in Luzon, they may be much needed ; but
for most of the service to which our men have been
subjected in the tropics they are a source of harm
rather than of good. Light-weight cotton undershirts,
with short sleeves, and muslin drawers not coming
much below the knees are preferred. The clothing
worn in the tropics requires frequent washing and fre-
quent changing, and a good-sized laundry bill is a
necessity. The clothing is usually sun-dried, and that
is an important aid in destroying germs on it. Most
native wash-men do not boil it, but, if feasible, they
should be required to do so.

The campaign hat, as previously stated, is an excel-
lent article for field use, but it should be well ventilated
by openings in the sides, and should be worn in such a
manner as to preserve a large air-space above the head.

The service cap offers very little protection from either
heat or light, and is an unsuitable form of headgear for
the tropics. It should be superseded for garrison use
there by the campaign hat or a helmet, the latter of pith
or cork and with a ventilated sweatband and crown.
Much has been said and written about the value of pro-
tection from the actinic or invisible rays of the sun, and
helmets with an interlining of metal foil, and hat lin-
ings, underclothing, and spine-protectors of black, red,
or orange material have been advocated as means of

128 THE RECRUIT AND HIS ENVIRONMENT

protection from them. Observation and experiment
indicate that the main causes, other than infectious
diseases, of tropical invalidism and discomfort are heat
and humidity, and that, with due care in regard to these,
the effects of actinic rays are practically negligible.
In fact, it is the writer's opinion and observation that
persons much in the sun are apt to fare better, except
as regards infectious diseases, than those who remain
much indoors, possibly because the former get more
exercise.

The evil effects ascribed to the actinic rays are prin-
cipally those manifesting themselves as functional nerv-
ous disorders. Such disorders are notoriously hard to
trace to a definite cause, and, on the other hand, the
sufferers from them are the most favorable subjects for
treatment by mental suggestion. Therefore, the fact
that a number of such sufferers are benefited by the
use of red underclothing is not conclusive evidence
that their ills were caused by actinic rays.

Shoes should always be worn in the tropics as a pro-
tection against infections. Comfort and fit should be
considered as elsewhere, but because it is comfortable
to go barefooted is not sufficient reason for doing it.
One of the greatest causes of sickness and debility in
the tropics is the hookworm, and as it usually gains
entrance to the body through the skin of the feet, the
general use of shoes is looked upon as an important
method of protection against it. Plague infection usu-
ally occurs through flea-bites on the feet and legs. Other
infections occur in the same way ; and the subject will
be discussed at greater length in another chapter. Shoes
and leggings also protect against leeches, ticks, mosqui-
toes, and other insects.

HYGIENE OF HOT AND COLD CLIMATES 129

Because of the heat, the relative cheapness of native

servants, and his comparative wealth, the American is

apt to nefflect outdoor exercise in the trop- _

• T. 11111 Exercise

les. It IS very important that he should not

do this, as abundant experience has shown that exercise
lessens the liability to the nervous breakdowns that con-
stitute one of the chief causes of invaliding from the
tropics. It is desirable that the glare and heat of midday
be avoided as times for such exercise, the early morning or
the evening being preferred. The exercise should be
incidental to interesting work or play. Tennis, polo,
football, horseback-riding, and hunting are excellent
forms. Marching is also good if the men are interested
and cheerful. After the exercise, which should be suffi-
ciently violent to produce a good sweat, the body should
be bathed, well rubbed down, and dry clothing put on.
Swimming is also a good form of exercise and one that
should be encouraged, as every soldier should be a good
swimmer.

With proper precautions as to exposure to the sun,
the prevention of chill from wet clothing, and the
avoidance of great fatigue, it is thought that exercise
will do only good. Many white men in the tropics suffer
from lack of it, very few, and they are usually persons
already diseased, from excess. Its value lies in the pro-
motion of the active functioning of the skin, liver, and
other organs of waste elimination, and the resulting
improved nervous control, rather than in increase of
muscular strength. Without exercise, alcohol, tobacco,
and excesses in food are all doubly harmful.

Because of the freer perspiration and the greater lia-
bility to skin diseases in the tropics, more frequent
baths and changes of clothing are necessary than in

130 THE RECRUIT AND HIS ENVIRONMENT

temperate regions. The bath water should not be suffi-
ciently cold to produce shock or chill, but as such water
cannot usually be obtained in the tropics,
° that feature need not require much con-
sideration. Persons who have suffered from malaria or
dysentery or other intestinal troubles should use tepid
or warm water. It should be remembered that typhoid,
dysentery, cholera, and certain infestations with animal
parasites may be contracted by bathing in polluted
streams or ponds, and such places should therefore be
avoided. Whatever the source of the water, care should
be taken that it does not get into the mouth and so
carry infection. After the bath the body should be
thoroughly dried, particular attention being paid to the
arm-pits, crotch, and groins, and, if these parts sweat
profusely, it is well to dabble them with some antisep-
tic solution and then dry them again, after which they
may be dusted with talcum powder. Fresh and dry
underclothing must be then donned. If prickly-heat
eruptions are present or appear easily, a weak formalin
solution, about one teaspoonful of formalin to a pint or
a quart of water, may be used to sponge the body after
it is washed and before drying. It is thought that the
measures here advised are as good as are known for
the prevention of the prickly heat, small boils, chafing,
and " dhobie itch " or ringworms that cause so much
annoyance and irritation in the tropics. In addition, it
should be remembered that some of these affections
are contagious, and contact with persons having them
should be avoided. Soldiers occasionally borrow articles
of clothing from one another, and that is another
method of spreading skin diseases. In Japan it is still
a rather common custom for many people to bathe in

HYGIENE OF HOT AND COLD CLIMATES 131

the same tub or tankful of water, and that probably
accounts for much of the abundant skin disease seen
in that country. Such a practice, though economical of
fuel and water, is to be avoided.

The heat, the bright light, the new and strange en-
vironment, the native habits of both dress and conduct,
unite to stimulate and excite the sexual de- ^
sires of the new-comer in the tropics, while
his money and the native habits, poverty, ^°
and views of morality, constitute a set of circumstances
enabling him to gratify them. In consequence he is apt
to indulge in such sexual excesses as impair his nervous
control, unless, as is frequently the case, he is soon or
often checked by venereal disease. Later, when he be-
comes debilitated by his excesses or by other causes,
his sexual vigor fails and he begins to worry about
that, thus aggravating and accentuating his trouble.
Nothing that is equally harmless so profoundly affects
the mind of the average young man as the loss, even
though it be temporary, of his sexual vigor, and nothing
so prolongs and aggravates that loss as continual brood-
ing over it ; so in this combination we have the making
of neurasthenia and melancholia. Each man should
know that his sexual needs are not greater in the
tropics than elsewhere, that sexual or other excesses
may bring about nervous exhaustion and temporary
loss of sexual power, and that the best rules in the
tropics, as elsewhere, are: 1. Sexual continence; 2.
Avoidance of obscenity and indecency ; 3. Cleanliness
of the genitals ; 4. Complete avoidance of thought or
handling of them, except for legitimate and proper
purposes.

The necessity for thorough policing and cleanliness

132 THE RECRUIT AND HIS ENVIRONMENT

of houses and grounds is even more important in the

tropics than elsewhere, because of the greater prev-

alence of vermin and of vermin -borne

diseases. Malaria, yellow fever, dengue,

.. plague, and other insect-borne diseases,

occur principally in the tropics, and are

best avoided by such methods of policing

as do away with the feeding or breeding places of the

insects carrying them. In addition, roaches and ants

abound in numbers and with a persistency not seen

elsewhere, and, as they run impartially in water-closets

and food-chests, it is easily conceivable that they may

transmit disease. Rate and mice constitute not only

an annoyance but also a great and positive source of

danger, because it is among them that epidemics of

plague begin, and it is from such rat epidemics that

those among people take their origin. Parasitic skin

affections prevail very widely among persons, domestic

animals, and fowls, and it is partly by cleanliness of

habitation that we escape them.

All the usual sanitary precautions as to cleanliness,
plumbing, and good policing are to be observed in the
tropics as elsewhere ; but additional care must be given
to all standing water both inside the house and out, to
prevent mosquitoes breeding in it. Such collections
should not be allowed if they can be avoided. If allowed
to exist, the water should be completely emptied and
renewed once in four or five days at most, or should be
kept covered with a film of mineral oil, which can be
renewed at like intervals. Ponds or other large collec-
tions should be stocked with fish, and the general pre-
cautions against mosquitoes, to be outlined later, should
be observed. Mosquito-proof houses have proved of

HYGIENE OF HOT AND COLD CLIMATES 133

great benefit in the prevention of mosquito-bome dis-
eases in the Canal Zone, as well as adding very greatly
to the comfort of life there. That they are not univer-
sally used in malarious countries is a misfortune where
it is not a reproach.

Very Cold Climates

The principal sanitary dangers menacing the dwellers
in very cold climates, aside from lack of food and other
things outside of our present consideration, arise from
exposure to cold, resulting in frost-bite or freezing, from
poor ventilation, from too intimate association with
diseased persons or animals, from improper food or
lack of fresh food. Infectious diseases are less numerous
than elsewhere, as their germs do not find such favor-
able surroundings in which to grow, and there are fewer
persons to harbor and distribute them.

The outdoor air of arctic regions is purer and freer
from disease-producing organisms than that of other
regions. Man-polluted air is as dangerous
there, however, as elsewhere. As ventilation
and heating are, from a sanitary standpoint, insepara-
ble, and, as free ventilation makes heating more diffi-
cult because of the greater volume of air that must be
warmed, it may be understood at once that the natural
tendency in an arctic climate is to have poor ventilation.
Every increase in ventilation lets in cold and allows
heat to escape, and the discomfort of this is more
acutely and keenly felt than that due to foul air ; so the
effort to keep warm may cause the air to become vile.
As animal heat helps materially to warm a crowded
space, and as crowding lessens the consumption of fuel,
man and dogs, sick and well, are thrown into close con-

134 THE RECRUIT AND HIS ENVIRONMENT

tact. If one man in a crowded, ill- ventilated room has
tuberculosis, diphtheria, tonsillitis, measles, smallpox,
or other contagious malady, the contagium or poison is
so concentrated as to make all present unusually liable
to contract the disease.

Ventilation, therefore, should be as free as possible,
care being taken to warm the incoming air, as by al-
lowing the air to enter through a tube or tunnel open-
ing under or about the stove. Should the air enter
unwarmed it will cause such condensation of moisture
as to make the hut damp. Crowding should be avoided,
and as much time as possible be spent in the open.
Particularly should intimate association in crowded
rooms with sick persons be avoided. The intimate con-
tact with sick and with animals is also productive of
disease in other ways than that indicated above. A
man having gonorrhcea or syphilis is in such circum-
stances much more apt to infect innocently and un-
knowingly those about him than he would be under
other conditions. Echinococcus disease, due to infesta-
tion with a certain dog tapeworm, is almost limited to
persons brought into such intimate contact with dogs
as is here mentioned. Cleanliness is almost impossible
under such conditions, and wounds are thereby very apt
to become infected.

A pure water-supply is not such a rarity in the arctics
as in the tropics, both because pathogenic germs do not

^ _.,_,, flourish in arctic temperatures and because

vvater ■, c u

men are less numerous as sources oi pollu-
tion. The danger of pollution of a supply is greatest in
the spring and summer, when melting snow may wash
into it the excrement that was scattered in the neigh-
borhood during the very cold weather. Excrement is

HYGIENE OF HOT AND COLD CLIMATES 135

apt to be so scattered, for the reasons that other disposal
may be more troublesome and that snow and freezing
prevent its constituting a nuisance to the nose and eyes.
Especial care should be exercised to prevent anything
of the kind, and drinking water should always be taken
from points above any possibility of such contamination.
Attempts should not be made, particularly on marches,
to quench thirst with snow or ice, as they detract from
the local and general heat of the body, and are liable
to iri'itate the mouth and throat. Snow and ice may fur-
nish the water-supply, but they must be melted and the
water heated, when it may be profitably used in making
tea, which is then refreshing, comforting, and stimulat-
ing, and adds to the warmth of the body.

The food -supply of the arctics consists largely of
canned goods, and may be quite generous. Every effort
should be made to supplement that diet
with fresh articles, whether of animal or
vegetable origin, as scurvy is otherwise apt to make its
appearance. This disease is due to the deficiency of
some principle or " vitamine " contained in both meats
and vegetables, which is destroyed by overheating, by
long storage or by ripening and drying of the vegeta-
bles. For instance, it can be caused in guinea pigs by
a diet of bread and dried mongo beans, while a diet of
bread and sprouted mongo beans protects them from it.
The Scott Antarctic expedition avoided scurvy by the
abundant use of the fresh or frozen meat of gulls, pen-
guins, and seals, and the surgeon especially praises seal
meat as an antiscorbutic.

Because of the necessity of greater bodily heat-pro-
duction in the arctics, more food is required, and, as
meat and fat give rise to more heat during their oxi-

136 THE RECRUIT AND HIS ENVIRONMENT

dation, and as they are also more readily obtained, it is
in them that the increase should be made. This need
is recognized by the government, and is met by an
increase in the ration for troops serving in Alaska.
Where game or fish are obtainable they should be used
to supplement the ration. The methods of preparing
the food are not essentially different from those used
elsewhere. Foods should be served hot, and the heat
of the body so conserved.

Alcohol should not be used in the arctics except as a
drug, as it increases heat-radiation and loss. Particular
care should be takeu that it is not used
during the period of exposure to cold, as
that is the time when loss of heat is to be especially
avoided. If used at all, it should be after the period of
exposure, when the body is chilled and the surround-
ings warm and comfortable. In such circumstances it
may be of considerable value, but its routine use should
not be practiced.

Fur, feathers, and wool as conservators of heat, and
canvas and leather as protection from wind, constitute
the main clothing-supply and bodily pro-
° tection in the arctics. Fur, leather, and
canvas, with the exception of shoes, are for use out-of-
doors only, wool for general wear both indoors and out,
while feathers or down are used in bedding. Extreme
cold is nearly always dry, and may therefore cause less
suffering than higher temperatures when the air is
moist. Wind of course greatly increases the suffering
and the danger from either dry or wet cold. The reason
that fur, feathers, and wool make such warm clothing is
twofohl ; they are themselves poor conductors of heat,
and they contain in their interstices a large amount of

HYGIENE OF HOT AND COLD CLIMATES 137

air, another poor conductor. For the latter reason a
multiplicity of light garments is warmer than the same
amount of material woven into one heavy garment, and
cotton or silk wadding may be used also with good re-
sults. It is because they prevent the displacement of
the warmed non-conducting layer of air within the
clothing that leather or close-woven canvas affords such
excellent protection against wind.

Fur caps and gloves, blanket-lined canvas boots, can-
vas overcoats lined with blanket or sheepskin, woolen
outer and under clothing, woolen socks, oiled shoes, felt
overshoes, and canvas leggings are issued for very cold
service, and in a few far northern posts buffalo coats are
furnished for use by men on guard. By proper use, these
articles can be made to furnish adequate protection
against any cold that is likely to be encountered. The
parts most apt to suffer from cold are those most ex-
posed and having the weakest circulation, such as the
nose and cheeks, the ears, hands, and feet. The fur cap
protects the head and ears, but not the neck and face.
It should therefore be used with the overcoat collar
turned up, or with the hood of the coat, in very cold
weather. The blanket-lined canvas hood covers the neck
and part of the face and therefore affords better pro-
tection. A veil or a strip of cloth may also be worn
across the lower part of the face if necessary. The fur
gloves adequately protect the hands except in the most
extreme cold or in cases of long exposure. If necessary,
woolen gloves may be worn beneath them. When, in
spite of them, the hands become numb and cold, they
should be beaten or exercised to warm them. For work
not requiring the use of individual fingers, woolen mit-
tens under canvas afford good protection for the hands.

138 THE RECRUIT AND HIS ENVIRONMENT

Care should be exercised about removing the warm
hand from its glove to do delicate work in the cold. A
soldier has been known to have both hands frost-bitten
because he removed his gloves in the wind and in a tem-
perature of 40° below zero F. long enough to adjust his
saddle. The feet are easily kept warm during walking
if the government issues of footwear are properly used ;
but when men are riding and not using the feet, or when
snowshoeing and the feet are bound so tightly that the
circulation is interfered with, the problem is more diffi-
cult. Except in wet weather, the foot-covering should
not be impermeable, as the feet when comfortably
warm are apt to perspire, and such a covering as a
rubber shoe causes the perspiration to condense against
it and to be frozen there, so that the foot is almost or
actually in contact with ice. An oiled shoe is less ob-
jectionable, as it does permit the vapor to escape, in
part at least. In very dry cold, however, a felt shoe, or
two or more pairs of woolen socks with canvas or soft
leather moccasins, may be better still. Fur-lined boots
or stockings are very warm. Surgeon Atkinson, of the
Scott expedition, says : " It was essential each night on
camping to change the footgear immediately, the socks
having become saturated with perspiration. Special
socks of very thick woolen texture were kept for sleep-
ing in, and they remained practically dry. Over them
was worn a loose fitting bag of some fur. On changing
the socks they were pinned together with a safety pin
and hung outside. If there was a good sun, by next
morning they were completely dry and comfortable."
The remainder of this chapter is made up of extracts
from Surjjeon Atkinson's account of the antarctic ex*
periences of the Soott expedition.

HYGIENE OF HOT AND COLD CLIMATES 139

" Frost-bite varied in degree from the loss of a super-
ficial patch of skin to the loss of parts of _ ^
limbs.'' ^'°«*"

" Frost-hites of First Degree. — In the
open, it was quite a common and even laughable ex-
perience to see one's companion's nose or cheek with a
patch of white upon it. He, at the time, was quite un-
conscious that anything was wrong. When warned, he
removed the warm can from his mit and placed it upon
the offending part. At the same time, if there was any
wind, he would turn away from it. After a minute or
so, with a slight tingling sensation, the circulation re-
turned to the part, and in the course of a day or so there
was a very small loss of quite superficial skin. Parts
which had been attacked by frost-bite became necessa-
rily more subject and also, luckily, gave warning. If a
wind sprang up, one felt a sting like that of a bee, and
knew immediately that the nose or cheek was attacked,
and took measures to bring the circulation back."

" Frost-bites of Second Degree. — Frost-bite of the
second degree caused blisters, varjdng depths of sub-
stance being implicated. It was quite common after any
cold sledging trip for one's fingers to be bulbous at the
end. This was due to blisters of varying sizes, and was
caused by exposure to cold, and also by handling cold
metal objects, like the cooker and Primus. These blis-
ters were of no importance, and on return they were
pricked ; after some time the skin was replaced and the
fingers became normal again. . . . Another effect of
continually touching cold metal objects was that the
fingers never quite reached the stage of blistering, but
the skin became hard and thickened, so much so that
one was unable to appreciate such an object as a match

140 THE RECRUIT AND HIS ENVIRONMENT

between the fingers. The hardened skin always peeled
off after we had been back in the hut for a time."

" Frost-bites of Third Degree. — This degree, be-
sides causing blisters, caused actual loss of substance
by gangrene. After exposure the onset of gangrene
came on at a varying period. It was never immediate,
and varied from a fortnight to three weeks. The blister
contained an evil-smelling, sanguineous fluid, and be-
neath it was a dark, f ungating patch. A line of de-
marcation formed after a varying period, and then
sloughing of the affected part followed. . . . The only
treatment that the majority of frost-bites needed was
the application of a warm hand to the affected part.
The application of snow is probably of use in temperate
climates, but where the snow is at the same temperature
as the air it is impossible to do this. Also, the snow in
the Antarctic is composed of hard, sugary grains, and
the effect of rubbing this upon the affected parts would
probably be more serious than the frost-bite itself. It
was always as well to be certain that one had no frost-
bites before returning to the warm hut."

" The effect of food upon the circulation was very
well marked. After one had been under way pulling a
sledge for four or five hours, if there was any wind,
one started feeling cold, and then began to be frost-
bitten. On camping and having something hot to drink
the effect was immediate. One felt the heart begin to
beat strongly and powerfully, and gradually a glow
spread downward into one's feet and generally over
one's body. On cold days, when the temperature was
below -40° F., if the air were still one was not at all
subject to frost-bite, but immediately a slight or strong
breeze sprang up with a rise of temperature one's face

HYGIENE OF HOT AND OOLD CLIMATES 141

became affected. The amount of evaporation on a windy
day compared with that of a still day is about the pro-
portion of five to one. After washing and removing fatty
substances from the face one was more susceptible to
frost-bite."

" Effect of Concentrated Food after Man-hauling
for more than Two Months. — All parties noticed after
being out for more than two months man-hauling that
they got practically no satisfaction from the concen-
trated food. One became exactly like a machine. With
a certain quality of food it was possible to go on for a
certain time and do a certain amount of work. With a
little extra food a little more work could be done. With
the ration that was provided, after a time one started
feeding on one's tissues. Emaciation was extreme on
the return from the Southern journey, and the effects
of cold were naturally much more severe in this state.
Owing to the fatty nature of the food defecation was
extremely easy, and one reacted in this way immedi-
ately to any increase of food."

" The monotony of travelling over a dead white sur-
face on overcast days, when no horizon was visible, was
extremely marked. It can only be likened to intellectual
starvation.

" The effect of a cold trip upon the constitution was
extremely well marked, though with nothing definite.
In any trip extending up to a week, where the tempera-
ture was continuously below -40° F., the men returned
in an extremely low state. During this time one never,
while in the sleeping bag, got any conscious sleep, and
once or twice there were well marked cases of men
sleeping while actually under way. This want of sleep
caused a general lowering of the constitution, and the

142 THE RECRUIT AND HIS ENVIRONMENT

lassitude after a cold sledging journey is a thing always
to be remembered."

" Snow-hlindness on Bright Days. — If one did not
wear glasses, even for so short a time as half an hour,
on those bright days, one was practically
' certain to have an attack of snow-blind-
ness. The eye felt perfectly well while at
work in the open, but the initial symptom was always
noticed upon entering a tent where a Primus stove was
alight. The attack began with a feeling of grains of
sand in the eye. There was marked spasm, conjunctiv-
itis, and weeping. Photophobia was well marked. This
lasted for a varying period, the eye being irritable for
as long as two days, even with treatment. The conjunc-
tiva was congested and swollen, and the condition one
of extreme discomfort. It was a pure conjunctivitis and
due entirely to the sti'ength of the illumination. . . .
When away sledging the tea leaves used to be saved
after luncheon and, made into a rough poultice, were
worn over the affected eye under the snow goggles. This
always produced a greater degree of comfort and was
beneficial."

" Snow-hlindness on Overcast Days with Strong and
Diffused Light. — On these days there was want of
contrast, and the diffusion of light was caused by re-
fraction and reflection of light from the surfaces of
minute ice crystals, which were continuously falling.
The light therefore came from all directions equally.
It was impossible to distinguish the difference between
foreground and horizon. One's appreciation of where-
abouts was practically limited to the skis on one's feet.
Contrast was entirely absent because of want of shadow,
and, as an instance, it was possible to be standing within

HYGIENE OF HOT AND COLD CLIMATES 143

arm's length of a snow cairn 9 feet high, and for the
cairn to be invisible. Eye-strain was continuous, the eye
striving to make out whether the foot was being placed
on an even surface. It was impossible to appreciate any
inequalities, such as sastrugi. At the same time the illu-
mination was intense. The result of these two conditions
was to cause conjunctivitis plus diplopia from the tir-
ing of the eye muscles. The diplopia was exceedingly
marked, and lasted for some considerable time. It was
impossible to accommodate for any object, and it was
only on going into the tent or seeking any dark object
near that the diplopia was realized."

" Snow-blindness on Dull, Overcast Days. — On such
days the effect was entirely one of eye-strain. Although
the eyeball was congested to a varying degree, the main
effect was due to eye-strain, and diplopia was much
more marked. The want of contrast was the same, but
the intensity of illumination was absent.

" The deductions from the above are that snow-blind-
ness is in part eye-strain, and in part due to the actual
effect of light."

For the prevention of snow-blindness, leather goggles
with amber glasses are recommended. Care must be
taken that no metal comes in contact with the skin, that
the glass is well away from the eye, and that the entrance
of light from the sides is excluded. Eskimo " snow-eyes,"
or wooden spectacles with slit-like openings for vision,
are said to be excellent. The use of veiling across the
eyes, and the practice of marching with the eyes fixed
on the back of the man ahead, the leader being changed
at short intervals, are at times helpf uL

PART II

THE CAUSES OF DISEASE

•' He discovereth deep things out of darknejs, and bringeth otU to
light the shadow of death."

Job 12 : 22.

CHAPTER VIII

THE REMOTE OR PREDISPOSING CAUSES OP DISEASE

For our purposes it may be assumed that most of the
diseases with which we are concerned are due to animal
or vegetable parasites ; but not every man exposed to
infection by such parasites contracts the diseases caused
by them. A special predisposition or liability is neces-
sary, otherwise everybody would have tuberculosis, the
entire army at Chickamauga in 1898 would have had
typhoid fever, and all physicians would die of infectious
diseases within a short time after entering upon their
profession. This matter of liability or immunity to
diseases is one of the most interesting, complicated,
and important in the whole realm of medicine, and
many of the world's greatest thinkers and investi-
gators find it worthy of their highest efforts and con-
stant attention. It is the purpose of this chapter to deal
with these questions in some elementary aspects that
should be known by the company officer, in a practical
and simple way, without technicalities.

One of the most important of the factors concerned
in predisposition to disease is heredity. Every man
inherits from his ancestry something that
renders him liable to tuberculosis, but im- ■*

mune to rinderpest and chicken-cholera. He possesses
in a degree not possessed by any other known creature
a liability to malaria, syphilis, gonorrhoea, yellow fever,
cholera, smallpox, and other diseases, while he shares
with many other animals his susceptibility to tubercu-
losis, suppuration, plague, and anthrax, and at the same

148 THE CAUSES OF DISEASE

time he is not at all subject to some diseases that are
very fatal to his domestic animals.

In addition to its influence in this general sense, he-
redity has long been credited with great influence in
predisposing certain families or individuals to certain
diseases. Consumption was long looked upon as a hered-
itary disease, but, with our more complete knowledge
as to its nature, the tendency is now to regard its ap-
pearance and persistence in families as an evidence of
familial contagion rather than of heredity. In the case
of cancer, another disease prone to " run in families,"
the same explanation is now frequently advanced,
though no germ-cause is known for the disease. The
influence of heredity, though still considered weighty,
is not now so much emphasized as formerly as a
cause of insanity. In all these diseases, however, it is
still contended that a predisposition, a type of tissues
endowed with resisting powers below the normal, is in-
herited, even if the disease has an extraneous cause.
Disease can at times be born with the child, and not
manifest itself until later, the actual disease germ
being present in the body all the time. Syphilis is
the ailment most often showing this. Other diseases,
such as typhoid and smallpox, may be contracted in the
uterus, and the child may be born sick. It is probable
that sometimes disease may be suffered and recovered
from in the mother's womb, and the attack confer im-
munity through later life.

Certain persons appear to possess all their lives an
immunity to certain diseases, never contracting them in
spite of frequent and direct exposure.*

^ Captain C. F. Craig and the •writer were quite unable to infect cer-
tain indiyiduals, who volunteered for the purpose, with dengue, using
methods usually successful and injecting doses of infected blood many
times as great as would be received in natural infections.

PREDISPOSING CAUSES OF DISEASE 149

Certain nervous affections have no known cause but
heredity, the disease appearing in the affected family
with great regularity. "Bleeders," persons who bleed
excessively or fatally from very trifling injuries, in most
instances inherit the tendency, and in a curious way, as it
usually descends only through females to manifest itself
in males. The drink habit is often spoken of as inher-
ited, but this is probably not the case. An unstable
nervous system, which allows its possessor to fall more
readily a victim to drink or other excesses, is inherited.
It is common observation that types of body are in-
herited, that children look and are built like their
parents, and it is but natural that they should be pre-
disposed to the same diseases, so far as bodily conforma-
tion exercises any influence.

That this does exercise an influence is indicated by
the table quoted on page 5, as well as by popular
belief. The common remark that such a
man looks as though he might have apo- _ ^
plexy any day, or such another man will ^

probably die of consumption, are based on facts long
noted by physicians and the public. It is partly for the
purpose of eliminating persons so predisposed to disease
that the government demands not only that each man
shall be in good health at the time of his enlistment,
but that he shall also conform to certain standards not
having much bearing on his present efficiency.

Certain diseases are known generally as those of
childhood, as they are so rarely seen in persons beyond
that age. Scarlet fever, measles, whooping-
cough, and diphtheria may all occur at °
other stages of life, but it is with ever-decreasing fre-
quency that they do so, and the phrase is, in general,

150 THE CAUSES OF DISEASE

correct. On the other hand, cancer, apoplexy, cataract,
and several other troubles are so nearly confined to
aged persons that they may be called diseases of old
age. Certain infections are seen principally in early
adult life, so that it is the young soldier that usually
shows them in the military service. Among them we
may mention typhoid, gonorrhoea, syphilis. The ques-
tion of age is related to that of recklessness and folly,
and it is partly for this reason that the young are in
general more disposed than the old to infectious dis-
eases. The prospects of recovery from an illness are
also influenced by age. Pneumonia and injuries are
much more serious in an old than in a young man. On
the other hand, diabetes and epilepsy are not usually
60 serious in elderly persons as in children.

Certain persons are born with peculiarities of person
that render them particularly liable to certain diseases,

_ , and no adequate explanation can be offered

Personal /.to n ^

_ for them, oome persona cannot eat nsh,

others strawberries, others eggs, without

becoming sick. A large number of persons

have such a susceptibility to the effects of certain

pollens that they must leave their homes when these

pollens are ripe, or suffer from hay fever. Some men

suffer from asthma if they go about a stable or ride

behind a horse, others are made sick or faint by the

presence of a cat or the odor of its urine. Of two healthy

men, one may suffer great discomfort after taking a

tenth of a grain of iodide of potash, while the other

can take three hundred times as much and not suffer

at all. Many of these peculiarities are now believed

to be examples of anaphylaxis, of which mention will be

made in the next chapter. It is quite probable that re-

PREDISPOSING CAUSES OF DISEASE 151

lated phenomena influence the development and course
of infectious diseases.

Worry, fear, and homesickness strongly predispose
to, if they do not actually cause, mental and nervous
diseases. They also appear to predispose __ .
to infectious diseases, possibly by lowering
the general resisting powers and influenc-
ing the circulation.

The aphorisms of all languages recognize the value
of training in almost any occupation or pursuit in life.
Military authorities recognize it by the fact _ . .
that they require the soldier to spend years °

in training. It is not less valuable in sanitary matters
than elsewhere. The child or the man who is trained to
reason, to obey, and to conduct himself properly, is in
much less danger from infectious diseases in camp or
elsewhere than is the reckless, disobedient, or head-
strons: individual who knows no law but his own will
and appetite. It is the latter who drinks bad water,
eats poor food, contracts venereal disease at each op-
portunity, urinates and defecates in forbidden places,
avoids vaccination, seeks alcoholic indulgence, sleeps
without his mosquito-net, spits on the floor, and is
otherwise a source of much worry and mischief. It is
because of this lack of training in hygiene that re-
cruits are so apt to become sick when brought into
camp, and, what is worse, to scatter their sickness in
all directions. As training in hygiene increases among
officers and men with increase of knowledge, the results
show in the sick report, and it is not probable that tlie
evil conditions of the camps of 1898 will ever be re-
peated in camps of the regular army. Whether or not
they will be repeated in large camps of volunteers

152 THE CAUSES OF DISEASE

remains to be seen, but it is improbable, as we know
how to prevent them and hope to be able to do so.

Lack of training on the part of troops is the most
important predisposing cause of disease in armies. It
is the duty of all officers, of whatever rank or branch
of the service, to endeavor to overcome this defect, for
which they are mainly responsible. The fact that a man
is ignorant or headstrong at the time of his enlistment
does not justify his being so a year or three years later.
Medical officers should be required to give lectures or
other instruction, but the company officer should see
that example and wise precept are so constantly before
the minds of his men that hygienic living becomes a
matter of habit.

Aside from habit in the large sense just used, many
small and unimportant personal customs have an influ-
ence in predisposing to disease. Eating raw
meat predisposes to infestation with tri-
chinaB or with tapeworms, carelessness in hand-washing
increases the liability to many infections and poisonings.
The habit of going barefooted may be of very great
importance in predisposing to plague and hookworm
disease. Careless habits in the disposal of waste are
responsible for so many sanitary ills as to make it evi-
dent that the main purpose of sanitary training is the
establishment of proper habits.

The influence of race as a predisposing factor of dis-
ease is closely related to that of heredity, habits, and
environment, but race in itself exercises
some influence. The reason for this is not
always known, but in some instances it is probably due
to long racial exposure to certain diseases, whereby
only the more resistant strains or families survive. At

PREDISPOSING CAUSES OF DISEASE 153

other times it is probably the case that the disease in
question may be uniformly incurred in childhood, and
so confer protection through later life. Whatever the
reason, Cubans and West African natives are less sus-
ceptible to yellow fever than Americans and Europeans.
Jews are especially subject to diabetes, and negroes are
much more apt than other peoples to suffer from keloid,
a form of tumor.

Exposure to inclemencies of weather predisposes to
numerous diseases. Tonsillitis, pneumonia, rheumatism,
and influenza are all germ-diseases, yet the _,

frequency with which they are ascribed to ^

• siiiro

wetting or cold shows that these influences

are not without effect. The germs causing pneumonia,
diphtheria, spinal meningitis, and tonsillitis may be
present in the mouths or noses of healthy people and
produce no symptoms, yet after exposure the person
may sicken. Similarly, a person may carry the organisms
of malaria or dysentery, and only become conscious that
he is ill after a wetting or chilling. There is a growing
belief that nearly all tuberculosis infections are received
in early life, and that the appearance of the disease only
at a later period is due to a lowering of resistance at
that time, whether by an attack of typhoid or measles,
by hard work, poor food, exposure, or other cause.

Injury predisposes to very many diseases. Pneu-
monia, meningitis, and typhoid, of general diseases,
may follow injuries in such a manner as _ .
to appear related to them. Abscesses, kid- ^

ney and liver troubles, and tumors may follow injuries
that do not break the skin, while anthrax, erysipelas,
most suppurations, " blood-poisoning," hospital gan-
grene, lockjaw, hydrophobia, and some other affections

154 THE CAUSES OF DISEASE

are preceded by breaks in the skin in nearly all in-
stances, though these may be so small as not to be
noticed at the time. It is through the wounds that the
disease-producing organisms gain entrance to the body.
In the strict sense it is also through wounds — insect
bites — that malaria, yellow fever, plague, and sleeping
sickness are transmitted. The great class of suppura-
tions, however, are the principal diseases following in-
jury, and the proper use of the first-aid packet for the
purpose of preventing them has almost done away with
one of the greatest horrors of war.

Injury may also act as a means of diffusing and gen-
eralizing an affection previously isolated and relatively
harmless. It may rupture an abscess due to appendi-
citis, and so give rise to general and fatal peritonitis,
or it may loosen the infected clot in an inflamed vein,
and cause acute general " blood-poisoning."

As is shown in Part I of this book, the soldier's
environment includes so much that it must exercise an
. influence in predisposing hira to, or pro-

tecting him against, nearly all sorts of dis-
eases. It is so large a matter that it cannot
be adequately mentioned in a paragraph, and the whole
subject of hygiene touches on it. The consideration of
some phases of it occupies the remainder of this chapter.

There are quite a number of " occupation diseases,"
so called because their development depends on injury
_ due to the employment of the individuals.

4. ^ Among such diseases may be mentioned
writer's cramp, painter's colic, chimney-
sweep's scrotum, housemaid's knee, and many others.
During and after the Civil War a certain type of
dilated and irritable heart was known as soldier's heart,

PREDISPOSING CAUSES OF DISEASE 155

and In the stress of a hard campaign many more cases
may develop. In the early months of 1899, when the
State troops were doing much hard marching in the
Philippines, many such cases were seen. Occupation
has a great effect, however, in other and less obvious
ways. Thus it may expose a soldier to mosquito bites
and so predispose him to malaria, yellow fever, or
dengue; it may put him on guard in a prison, where
he will contract typhus or relapsing fever. Men work-
ing about stables are more apt than others to suffer
from lockjaw after wounds, as the germ occurs in
horse-manure. Occupations involving the breathing of
much dust, such as marble-cutting, scissors-grinding,
and some weaving, predispose to tuberculosis. Seden-
tary occupations may impair digestion, allow muscles
to atrophy, and cause hemorrhoids. Callings involving
great strains or exertion predispose to diseases of the
heart and blood-vessels. It is stated that the majority
of Japanese jinricksha men are dead or invalids from
circulatory diseases before they attain the age of forty.
Occupations causing much worry or nervous strain
predispose to nervous exhaustion. Overwork in almost
any calling may predispose to disease, either by lower-
ing or exhausting the general resisting powers of the
body, or by exhausting the nervous supply.

The quality of the air-supply is very important as
predisposing to disease, by its temperature, dryness, or
purity. Too great heat, especially if moist, .
causes much discomfort and may result in
heat-exhaustion, heat-stroke, and death. Rooms that
are too hot cause the men to sweat and to expose them-
selves unduly to cold or draughts, which may result in
congestions of the lungs or kidneys. Booms that are

156 THE CAUSES OF DISEASE

too cold allow the body to become chilled on the sur-
face and congested internally, making easy the devel-
opment of coughs, sore throat, and other troubles. In
barracks, however, such troubles are usually more closely
related to foulness and contamination of the air than
to its temperature. One case of sore throat in a squad-
room may sufi&ce to contaminate the air and expose
every man in the room to disease if the ventilation is
poor. This condition is aggravated with every increase
in crowding. Carbon dioxide and other waste-products
of the body may also make the air poisonous without
considering infection.

Foggy or damp air predisposes somewhat to rheu-
matism. That which is too dry causes dryness and
irritation of the respiratory surfaces. Dusty air intro-
duces many infections, among them tuberculosis, and
it is for this reason that spitting on floors or streets is
very dangerous. The spit dries and is pulverized, and
eventually becomes dust, in which condition it may be
blown or inhaled into sound noses or throats, carrying
with it the disease-producing germs. Dust-laden air is
responsible for many more " colds " than is cold itself.

The use of contaminated water predisposes, of course,
to water-borne infections. In addition, the use of very

hard water or of water containing chemi-

cals may so disturb the digestive organs as
to make infection easier. Excessive water-drinking dis-
turbs the digestion and causes unnecessarily profuse
sweating and urination ; deficiency of it causes irrita-
tion of the kidneys and bladder, constipation, and
general insufficiency of waste elimination. Greater in-
sufficiency of course causes direct suffering from thirst.

Aside from the very numerous infections conveyed

PREDISPOSING CAUSES OF DISEASE 157

by uncooked or improperly cooked foods, the kind,
amount, and preparation of the articles used have so
great an influence on health as to make the _

subjects of catering and cookery worthy of
the company officer's best thought. He should learn
what foods are good, their digestibility, food-values,
cost, and the amounts to be furnished. The method of
preparation should be such as to make them attractive
and digestible. The ration forms an excellent basis.

Excess of food predisposes to stomach and intestinal
disorders, to gout, obesity, vascular and kidney diseases,
and to various forms of auto-intoxication, or self-poison-
ing by waste products. Insufficiency of proper food leads
to weakness, loss of flesh and a lessened resistance, that
renders infections more easy. Great epidemics of typhus
and relapsing fever have followed famine and depriva-
tion so many times as to earn for them the title of
famine fevers, and our present knowledge that they are
louse-borne enables us to appreciate the influence of
misery in lowering physical and moral tone.

Alcohol is the direct cause of such diseases as delirium
tremens, alcoholic neuritis, and gastric catarrh ; but it ia
also a predisposing cause of many other
diseases, — of the blood-vessels, heart, kid-
neys, and brain. It also predisposes to infections, both
by making its user careless in regard to them and by
lowering the resisting powers. Drunkards are especially
subject to pneumonia, and are also especially un-
favorable subjects for that disease. The chronic gastric
catarrh of the old alcoholic may make him an easy
victim for cholera or typhoid. Alcohol predisposes
to heat-exhaustion in hot and to freezing in cold
climates.

158 THE CAUSES OF DISEASE

Insufficient or excessive clothing may predispose to
disease as do heat and cold. Insufficient covering in the
tropics may lead to severe sunburn, or, if
° of the head or spine, predispose to heat-
stroke. Lack of foot-covering not only leads to injury
of the feet, but predisposes to diseases that usually enter
through the skin of the feet, including hookworm dis-
ease, chiggers, Guinea worm, and plague. Insufficient
clothing may also predispose to mosquito-borne diseases.
Excessive clothing may predispose to heat-stroke, ex-
haustion, and diarrhoea, and this is especially true when
men are turned out for inspection or drill in too heavy
uniforms.

Warm baths, if followed by exposure or chilling, may
predispose to disease, as may cold ones in persons who
do not react promptly. Insufficient bathing
° predisposes to skin diseases, especially in
hot countries ; bathing in polluted waters, to water-
borne infections. In addition to typhoid, dysentery,
cholera, and common intestinal worms, there is reason
to believe that schistosomum disease — infestation with
a worm that lives in the veins of the liver, and causes
bleeding and other serious bowel and bladder symp-
toms— may occur during bathing, the young parasites
entering through the skin. This disease is widespread
in Africa, and varieties of it are seen in the West Indies
and the Philippines, so that it may yet assume impor-
tance with us.

The use of dirty water also predisposes to skin dis-
eases, as noted in regard to the oft-bathing Japanese.
The exposure incident to bathing in streams may in-
crease the liability to diseases conveyed by mosquitoes
and other insects.

PREDISPOSING CAUSES OF DISEASE 159

Natural sleep in proper amounts is an important
factor in the prevention of disease ; the lack of it causes
weakness, exhaustion, and depression that
render infection and injury easy matters. °

Insufficient sleep for a long period of time causes ner-
vous disorders and predisposes to insanity. Sleeping in
improper surroundings may greatly increase the liability
to disease through chilling, wetting, exposure to mos-
quito bites, and in other ways. Sleeping in close contact
with persons suffering from certain contagious diseases
would strongly predispose to them, as would sleeping
in the beds or clothing of such persons.

Poor sanitary police is a feature of poor military
training, and predisposes to all of the epidemic forms
of infectious diseases. It does this by allow-
ing infected dust and papers to blow about
and pollute the air, by allowing soil and water con-
tamination, by leaving or providing breeding-places and
food for flies, fleas, mosquitoes, rats, and other vermin,
and by failure to remove sources of infection. In these
ways it encourages the development of typhoid, cholera,
dysentery, yellow fever, plague, pneumonia, influenza,
tuberculosis, and other diseases.

By attention to police and general cleanliness of per-
sons, houses, and neighborhoods some diseases that for-
merly occurred in great epidemics have been almost ban-
ished from civilized countries, and even famine does not
bring them forth as in earlier times. Typhus and relaps-
ing fevers are striking examples. Tuberculosis and other
diseases have been reduced in part by similar measures.

As the best police is possible only when all unite in
striving for it, it is essential that line officers and en-
listed men should become interested in the sanitary

160 THE CAUSES OF DISEASE

importance of the question, and should look on good
policing as a source of pride, comfort, safety, and effi-
ciency.

A poor camp-site may constitute a predisposing cause
to many kinds of disease. It may expose the men to fog,
unnecessary dampness, wind and cold, or to
*^" dust and heat, to mosquitoes, flies, fleas, bad
water, or contaminated soil, and through
these factors promote the development of the worst
camp-diseases. While it is highly desirable, therefore,
to select as good camp-sites as can be obtained, it must
ever be borne in mind that proper sanitary precautions
may nullify the evil effects of a bad site, and that
neglect of them is almost certain to destroy the value
of a good one. Polluted sites, those that have been
much used by troops, and those that expose the men to
bad water and disease-bearing insects are particularly
to be avoided, as these factors predispose so strongly
to various diseases that only the best trained and disci-
plined troops may come off unharmed.

Practically every case of infectious disease is derived
from some other one, and it is therefore obvious that
^ the existence of one case constitutes a f ac-

FfOSGXlCO

tor predisposing to more. One man with
typhoid, cholera, smallpox, or plague, in a
camp, constitutes a danger to the entire command, and
this fact is so well recognized in these and other dis-
eases that it forms the basis of the entire system of
quarantine and isolation. The origin of individual cases
of infectious diseases may be difficult to trace, the ty-
phoid-carrier, the unsuspected syphilitic, or the man
with a slight diphtheria, not even realizing that he is
sick, and unknowingly spreading disease broadcast. One

PREDISPOSING CAUSES OF DISEASE 161

disease may predispose to the development of another
or to new manifestations that are spoken of as new
diseases. Thus blood-poisoning, gonorrhoea, typhoid,
and, more particularly, acute articular rheumatism,
predispose to valvular heart-disease, syphilis to cer-
tain affections of the nervous system and to aneurysm,
diphtheria to varying forms of paralysis, and amoebic
dysentery to abscess of the liver.

CHAPTER IX

THE IMMEDIATE OR EXCITING CAUSES OF DISEASE

The immediate or exciting causes of some diseases,
among which may be mentioned such important ones as
scarlet fever, measles, yellow fever, and typhus, are un-
known, but those that are known are so numerous and
of such varied character that they could not possibly
be discussed in this chapter, even if it were desirable
that they should be. We will therefore omit all discus-
sion of the causes of large and important groups of
diseases, and consider only briefly the various classes
of disease-producing factors which it seems it would
be interesting or profitable for the company officer to
know. Numerous as they are, such factors may be
gathered into a few groups.

Of these groups, the first to be considered is that of
mechanical causes, and, of such, traumatism or violence
is probably the most important. Like the
other components of this group, it may pre-
dispose to disease, but it is also the direct
or exciting cause of many ills, among which we may
class practically all varieties and instances of wounds,
from the slightest abrasion to the most extensive shell-
wound, fractures, dislocations, and bruises. Concussion,
laceration, or rupture of internal organs, such as the
brain, spinal cord, liver, kidneys, stomach, intestines,
or bladder, may result from blows or other injuries that
cause no break in the skin, or even, in rare instances,
leave no external mark. At times the violence may be

EXCITING CAUSES OF DISEASE 163

slight in degree, and apparently out of all proportion
to the resulting damage. Thus, a relatively slight blow
on the chin may be so directly transmitted to the brain,
and so jar and shake it, as to cause immediate and
deep unconsciousness; or a blow over a distended
stomach or bladder may rupture it and cause death, to
the great surprise of all witnesses. Or the evil effects
of the injury may not be manifested at once. A knee
or hip, for instance, may be injured and give rise to no
symptoms at the time, but later cause prolonged suffer-
ing or lameness ; or a man may receive a severe blow
on the head or the abdomen, and continue at his work
all day, yet he may have received an injury from which
he will die in a few days. Officers should, therefore,
exercise much care and forbearance before they pro-
nounce a man a malingerer because some accident from
which he suffered appeared trivial or harmless. Vio-
lence may be so transmitted as to manifest its effects
on a distant part. Thus a man may fall from a height
and land on his feet, and yet fracture his skull ; or he
may fall on his hands and fracture his collar-bone ; or
he may receive a blow on the right side of the head
and suffer a laceration of the left side of the brain. As
the manifestations of violence may be almost infinite
in variety, so may its effects. Pressure may also cause
disease in a variety of ways. Applied to the feet it
may cause deformity, bunions, or corns ; to the waist,
displacement of internal organs ; to a nerve, as by a
bullet or a bone-fragment, paralysis or great pain;
applied to a blood-vessel, it may cause ulceration and
rupture, with fatal bleeding, or it may cut off the blood-
supply of the part to which the vessel runs, and cause
gangrene or death.

164 THE CAUSES OF DISEASE

Heat and cold^ besides predisposing to disease, aa
shown in the preceding chapter, may directly cause
injuries varying from the slight reddening of the mild-
est burn or chilblain to the loss of entire limbs, or of
life itself. They, as well as violence and pressure, in
addition to the immediate damage done, may cause life-
long suffering or deformity, from the formation or
contraction of large scars, or by means of secondary
infections.

Increase or diminution of atmospheric pressure may
cause disease or death, the former in divers or caisson-
workers, the latter in mountain-climbers or balloonists.
In the case of increased pressure, the trouble most
often comes from too sudden return to normal pressure,
which allows the liberation of nitrogen gas in the blood.

Electricity may cause disorders varying from slight
pain or nervous disturbance to deep burning or sudden
death.

Mechanical injuries not usually thought of as such
are exemplified by the rashes or irritations due to han-
dling or contact with some caterpillars or moths, and are
caused by the introduction and retention in the skin of
the minute barbed hairs that partly cover the creatures.

The group of chemicals that cause disease or death

is very large and embraces practically all poisons. They

, may occur in any form, gaseous, liquid, or

solid, and may enter the body in any way,

as by inhalation, by mouth, by the rectum, through the

skin, or through wounds.

Gaseous poisons usually enter the system by inhala-
tion. Those most commonly causing trouble are carbon
dioxide, water gas, coal or charcoal gas, or carbon
monoxide. These and other gases may produce death

EXCITING CAUSES OF DISEASE 165

without occasioning great suffering. Another group, in-
cluding formalin, ammonia, chlorine, and sulphurous
fumes, cause marked irritation of the respiratory tract
and excite efforts at escape, so that they are, in that
respect, less dangerous. Certain others, such as some
compounds of arsenic or phosphorus, may cause poison-
ing by inhalation in small amounts, and be very diffi-
cult to trace. Chloroform and ether usually, and wood-
alcohol and some other liquids occasionally, enter the
body in a vaporous or gaseous form. Gases may produce
death in any one of several ways : by acting mechan-
ically to exclude oxygen, and so cause suffocation, as in
the case of nitrogen ; by forming combinations with the
blood to prevent its taking up oxygen, even if it has
the opportunity, as in the case of charcoal gas ; by caus-
ing paralysis, or change of nerve-tissue, as in the case
of chloroform or wood alcohol ; by causing such irri-
tation of the glottis as to close it by swelling, and so
induce suffocation, as does ammonia.

Liqvid poisons may also cause injury or death in a
great variety of ways. The group includes a large
number of substances. Some of them, such as sulphuric
and nitric acid^ do injury by their strong corrosive
properties ; others, as alcohol, act on the nerves. They
usually enter the body by way of the mouth, but, as in
the case of the acids, they may act on the surface, or
enter through wounds.

The poisons occurring in solid form are even more
numerous than the others, and they enter the body in
the greatest diversity of ways, and produce manifold
symptoms. General poisons include a great variety of
substances, such as arsenic, phosphorus, antimony, mer-
cury, lead, and a great many more. They may be taken

166 THE CAUSES OF DISEASE

knowingly with good or evil intent, or in ways not
known at the time, and often difficult to trace. The
amount taken at one time may be almost infinitely
small, yet its frequent repetition may result in poison-
ing. Thus, a painter may contract lead-poisoning from
the minute amounts of lead getting on his food from
unwashed hands, a beer-drinker from the lead taken
into solution from lead pipes through which the beer is
drawn.

Alkalies, such as caustic potash, caustic soda, lye,
and quicklime are powerful irritants or caustics.

Vegetable poisons include substances producing dis-
ease or death in a great variety of ways. Some of the
most common and familiar of these are opium, strych-
nine, cocaine, and jimpson weed. Most of the enslaving
drugs — alcohol, opium, cocaine, and others — are of
vegetable origin. Habitual users of them may get to
using enormous doses, some of them several times the
amount that would be fatal to persons not so habitu-
ated. Some vegetable poisons are very irritating to the
skin and cause marked eruptions. Croton oil causes
pustules that resemble those of smallpox. Poison ivy
owes its evil qualities to an oil that occurs in and on the
leaves and that causes the well-known inflammation of
the skin.

Many of the chemical poisons are the products of
germ action. Alcohol, the best known, results from the
action of yeast cells on sugar. Ptomaines result from
the action of germs on meats, fish, milk, and other food-
stuffs. There are a great many of them, and their effects
vary greatly. Some of them resemble drugs, such as
morphine, strychnine, or atropine, in their action, and,
as their presence may not be suspected at the time they

EXCITING CAUSES OF DISEASE 167

are taken into the system, the symptoms produced by
them may prove very puzzling. It should be borne in
mind that ptomaines may not be destroyed by boiling,
and cooking should therefore not be depended upon to
render partially decomposed meat safe. Many of them
are harmless, but neither can that fact be depended
upon to show that a given article of food is wholesome.
Their poisonous character depends on the type of organ-
ism producing them, rather than on the stage of decom-
position. Thus one piece of meat may be quite rotten,
and yet not poisonous, while another that is free from
odor and presents a fairly good appearance may be very
dangerous.

The foods that most often give rise to ptomaine poi-
soning are those that have been preserved imperfectly,
such as beef or fish in cans that have become perfo-
rated or blown, cold-storage beef that is not well frozen
or chilled, poultry imperfectly chilled, especially if it be
undrawn, and imperfectly cured hams and sausages.
The symptoms vary considerably, depending on the
source, character, and amount of the poison ingested,
but in most instances they include evidence of marked
gastro-intestinal and nervous disturbances, such as vom-
iting, diarrhoea, headache, dizziness, and cramps. Self-
poisoning or auto-intoxication may be due to ptomaines
or other decomposition products resulting from the
putrefaction of food, occurring in the stomach or bowels,
or to simple retention and absorption of poisonous pro-
ducts which would ordinarily be eliminated, but which,
because of constipation, kidney disease, or for some
similar reason, remain in the body. Such poisonings are
promoted by overeating, lack of exercise, and by ex-
cessive drinking or smoking, as well as by diseases.

168 THE CAUSES OF DISEASE

Certain small organs of the body, known as the duct-
less glands or glands of internal secretion, have a tre-
_ . mendous influence on development and wel-

- . fare, and their injury or destruction may

It fll cause grave disease. Among such disturb-
„ ances are exophthalmic goitre, due to excess

. . of secretion of the thyroid gland, and myx-

oedema and cretinism, the latter a form of
idiocy, due to its absence. The most familiar instance*
of the influence of internal secretion are seen in the
absence of the usual sex characters in animals castrated
or spayed wlien young, the absence of testicular or ova-
rian internal secretion being responsible. The differ-
ences shown in the development of a stallion and that
of a gelding, of a bull and a steer, a ram and a wether,
a normal bitch and a spayed one, are obvious to all.

Animal poisons^ in addition to the products of animal
waste to which reference has just been made, include
such substances as snake-venoms and those of stinging
insects and spiders. These vary greatly in their com-
position, and their effects range from the slight itching
and burning of a mosquito bite to the agonizing deaths
following some snake bites. The venoms are introduced
through wounds, many of them being harmless if applied
to the unbroken skin or even if taken by mouth.

Deprivation diseases have been discussed in the
chapter on foods.

The most important group of the larger animal

parasites that infest man is that of the

.° intestinal worms. Their distribution is

. world-wide, and in some places they are so

prevalent and their effects so serious, that

they exercise very important influences on the mor-

EXCITING CAUSES OF DISEASE 169

bidity and mortality rates. They may be grouped in
three classes: the flukes or sucking-worms, the tape-
worms, and the roundworms.

Flukes or sucking-worms are not common parasites
of man in our own country, but in some parts of the
world they are very prevalent and cause serious illness.
Several varieties occur in the Philippine Islands, and
some of them cause death. One variety occurs in the
lungs, and causes blood-spitting and cough that may
lead to the belief that tuberculosis is present ; or it may
lodge in the brain and cause paralysis or other cerebral
symptoms. Other varieties live in the veins of the liver
and may produce disease of that organ, while their sharp-
pointed eggs lodge in or perforate blood-vessels of the
bowels or bladder and cause bleeding, irritation, and
other symptoms. This is a type of the schistosomum
disease mentioned in the preceding chapter. Although it
is claimed that this particular class of flukes may enter
the body through the skin, th© usual history of the flukes
is that they pass a part of their lives in the bodies of
snails or other small water-animals,^ and enter the hu-
man body only by way of the mouth. Even though both
methods of infection be possible, the obvious means of
prevention are, first, to prevent infected or egg-bearing
feces or urine from reaching water ; second, to boil or
otherwise sterilize the drinking water ; third, to abstain
from bathing in infected water unless it also be boiled
or filtered ; fourth, to avoid the use of uncooked foods
that may have been contaminated by bad water.

The tapeworms are better and more widely kn^wn

^ Flukes in general, so far as their life-history is understood, have at
different times four forms or stages and two or three methods of mol-
tiplication.

170 THE CAUSES OF DISEASE

as human parasites. There are many varieties of them,
but the best known are those large species ingested
with beef and pork, though others are important, and
some of these, such as the broad tapeworm from fish,
may be very important in places. The life history of
tapeworms, while not so complicated as that of flukes,
involves, in most instances, residence in two animals,
and knowledge of it enables us to understand the man-
ner in which infestation occurs, and the method of
avoiding it. Life begins in the eggs, which are passed
from the worm into the bowel-contents of its host, and
thence to the outer world. Here they may fall into water
or on vegetation, or the excrement itself may be ingested
by animals. At any rate, the eggs must, in one way or
another, get admission to the alimentary canal of the
second host, for which purpose a particular species of
animal is necessary. In the case of the beef tapeworm,
this host is the ox, in that of the pork tapeworm, the
pig. Rarely this development may occur in other ani-
mals, or in man himself, but ordinarily development will
not occur in any but the usual host. Having reached
the stomach of this host, the embryo is set free when
its enveloping shell is dissolved, and penetrates the wall
of the stomach, whence it passes by the blood vessels to
the liver, muscles, brain, or other part of the body,
where, after undergoing some further development, it
becomes the head and neck of a future worm, inclosed
in a small bladder, like cyst or measle, from one fourth
to three foui'ths of an inch in length and about one third
of an inch in diameter in the case of the pork measle,
and somewhat smaller in the case of the beef measle. If
now the flesh of the infected pig or ox be eaten raw, or
not cooked sufficiently to kill the worm, it may pass un-

EXCITING CAUSES OF DISEASE 171

harmed to the bowel of man and there attach itself and
grow. The head and neck as ingested are very small,
bearing comparison in size to a small pinhead and a
piece of fine twine. From this head and neck the rest of
the worm develops in the bowel. The part so developing
consists of a great number of segments, at times hun-
dreds, each flat and white, so joined together as to form
a long flat ribbon that may attain a length of thirty or
more feet, each segment having a nervous and alimen-
tary system and male and female generative organs, and
each developing, fertilizing, and discharging eggs, so
that each tapeworm, though an individual, may be said
to be also a community. It may be readily understood
from the above that allowing pigs to act as scavengers of
human ordure, as is often the case in the tropics, is not
a wise sanitary measure. It was stated above that man
might rarely be the measly host. In such cases he might
become infected with eggs by means of contaminated
water, or of lettuce or other green vegetables manured
with human feces, by getting the minute eggs on his
hands in water-closets or from his own stool, or by
having them pass from the bowel to the stomach during
vomiting. Several other varieties of tapeworms may
infect man, — one of the most dangerous, and one for
which man may shelter the cystic stage with fatal re-
sults, being derived from the dog, and another danger-
ous one possibly being derived from the rat, which may
deposit the eggs on food articles with its feces.

Many varieties of roundworms infest man, and their
life-histories vary greatly. A few varieties will be briefly
discussed in order to indicate more clearly the neces-
sity of certain sanitary precautions. Those most com-
monly inhabiting the human intestine — thelarge^wJiite

172 THE CAUSES OF DISEASE

roundworm^ the loJilpworm^ and the pimoorm or seat-
worm — require no other host, and infection occurs,
directly or indirectly, from man to man. The egg9 are
laid in the feces and pass from the anus, whence they
may get on the hands, into drinking water, or on green
vegetables, and so obtain entrance to the mouth and
stomach of the same or another person. The embryos
are set free in the stomach or intestine and develop
into adults. Probably the most common method of in-
fection is by means of polluted water. Children and
adults who are infested with seat- worms may reinfect
themselves many times, by reason of the fact that these
worms often crawl from the anus and give rise to most
intense itching, in the efforts to relieve which the
hands and nails pick up many of the microscopic eggs,
which may later be transferred to the nose or mouth.

The hookworms are probably the most important of
all the worms infesting man, both because they may
and do infect the great majority of the inhabitants in
some tropical countries, and because they so seriously
reduce health and strength. In Porto Rico, the Philip-
pines, and our own Southern States, infestation with
these worms is common, and thousands and thousands
of persons are debilitated or incapacitated, and have
their resistance to other disease reduced by it, with
the result that industrial progress is delayed and physi-
cal degeneracy and high sickness and death-rates pro-
moted. Formerly it was believed that infestation with
this parasite occurred in the same manner as with those
just described, but it is now generally admitted that it
usually, if not always, occurs in another way. The usual
history is about as follows : The adult female pro-
duces a great number of eggs that pass out from the

EXCITING CAUSES OF DISEASE 173

host with his feces. If passed on moist, warm earth,
the eggs hatch and liberate microscopic embryonic
worms which eat feces or other organic matter, live
and grow in the moist earth, and eventually, if fortu-
nate, find an opportunity to get on the bare feet or
other skin-surface of a person, penetrate the hair fol-
licles and tlie true skin, producing itching and irrita-
tion, and causing "ground itch," gain access to the
lymph or blood-vessels, and are carried, by way of these
channels, to the lungs. Here they leave the blood and
pass out on the mucous membrane, crawl up the wind-
pipe to the throat, from there down to the stomach,
and then to the small intestine, where they take up
their abode, reach adult life and a length of one third
or one half an inch, and in turn produce eggs to infect
more polluted soil. In addition to this, they produce
a very serious anaemia or thinning of the blood, which
gives rise to weakness, shortness of breath, dropsy,
mental dullness, and, in children, checked develop-
ment and stunted physique and mentality. Such con-
ditions impair the body's resisting powers, and the vic-
tims more readily succumb to malaria, dysentery, and
other diseases.

The short outline of the life-history of the worm just
given indicates the wisdom of the following measures
to prevent the spread of the infestation: first, treat-
ment of all infested; second, proper disposal of feces
to prevent soil-pollution ; third, the wearing of shoes
in infected regions ; fourth, the use of pure drinking
water.

Trichiniasis is a disease produced by infestation
with a kind of roundworms, trlchmce, that presents
still another life-history and method of infestation.

174 THE CAUSES OF DISEASE

The trichlnse are small worms about a sixteenth of an
inch in length that are natural parasites of the rat, but
may also infest man and many other animals, including
the pig and dog. The danger to man lies principally in
the fact that the pig is a rather common host, and it is
from that source that he derives his infection. The
history is as follows : Rats become infested by eating
their infested kindred, and they in turn may be eaten
by pigs. The larval worms are encysted in the muscles,
as will be described later, and are set free in the pig's
stomach, when the muscle and cyst are digested. They
then pass to the bowel, where they take up their abode,
mature, and bore into or through the intestinal wall
to the lymph spaces, where they deposit their numer-
ous progeny, averaging about fifteen hundred in num-
ber. These are carried along by lymph or blood-streams,
or possibly by their own activity, to various parts of
the body, finally penetrating the muscle fibres and set-
ting up an irritation that results in the formation of
little capsules about them. Here they live quiescent,
but capable of development, for an indefinite time,
occasionally for years. Too often, however, this rest
is shortened by the death of 'the pig and its later con-
sumption by man. If such consumption is preceded
by thorough cooking no harm will result, as the heat
will destroy the worms ; but if, as is sometimes the
case, the meat be eaten raw or underdone, the larvae
are set free in the man's stomach as the others were in
the pig's, and he in turn develops adults, has larvae
scattered through his muscular system, and suffers from
pain, fever, symptoms resembling typhoid, and, possibly,
death.

Filaria^ a. roundworm whose larvse circulate in the

EXCITING CAUSES OF DISEASE 175

blood, presents a still different history and method of
entrance to the body. For at least two varieties, whose
development has been pretty well traced, the history is
as follows : The young or embryonic forms are imbibed
with blood by mosquitoes that bite infected persons. In
the blood these embryos, which are about one eightieth
of an inch in length, are inclosed in loose individual
sheaths or capsules, within which they wriggle about
very actively. After reaching the mosquito's stomach
the blood containing them clots and they break through
their sheaths, and, after about a day, through the
stomach-wall. They live in the body of the mosquito,
growing and maturing, for two weeks or more, at the
end of which time they have increased to four or more
times their original length, and have gathered in or
about the fleshy part of the mosquito's proboscis. When
the mosquito next bites a man they break through a
thin part of the proboscis and pass through his skin by
the small wound from which the mosquito is extracting
blood. Once in the body, they wander in ways and
parts unknown for an indefinite time, until they reach
maturity, and, if both sexes be represented, begin to
turn out embryos for other mosquitoes to ingest. The
adults are very apt to take up their abode in lymph-
vessels, and by their residence there they set up irrita-
tion that leads to blocking or obliteration of the chan-
nels and is thought to be the cause of lymph-scrotum,
chyluria (milky urine), elephantiasis, and kindred
troubles. Certain insect larvce that bear a resemblance
to roundworms occasionally infest man. Blow-flies may
deposit their eggs on meat that is left carelessly ex-
posed, and, if they are not destroyed by heat, maggots
may hatch from them and appear in the stools of per-

176 THE CAUSES OF DISEASE

sons eating it. Flies also deposit eggs, and maggots
develop, on neglected sores, wounds, or ulcers, which
may later be burrowed in many directions.

Screw-worms are the maggots of a small fly found
in some of our Southwestern States, in Central Amer-
ica, the Isthmus of Panama, and elsewhere. This
fly deposits its eggs in the nostrils, or, occasionally,
on other parts of sleeping persons, especially those
afflicted with nasal disease or very foul breath. The
maggots hatch out in a few hours and bore their way
in all directions, causing great suffering and, in many
cases, death. Among twenty-three cases reported from
Arizona in the fly season of 1905, there were four deaths.

Some flies deposit their eggs on or in the skin of
animals, and the larva develop there, constituting
" warbles " in cattle, deer, and wild rabbits. Occasion-
ally man is host, though this is rarely so.

Some insects burrow into or beneath the skin in their
adult condition, and there nourish themselves and some-
times deposit their eggs or their young. They cause
irritation or disease. Among them may be mentioned
the itch-mite^ jiggers or chiggers^ and many kinds of
ticks. Itch was at one time a very widespread, com-
mon, and intractable disease, but is no longer so.

Lice of various kinds are also less common than
formerly, but are still seen often enough as human
parasites.

Leeches are at times a great pest and cause much
loss of blood, particularly in some parts of the Philip-
pines, where they get on troops marching through the
jungle, in great numbers. They may get on the body
from water or from vegetation. Clothing is the main
source of protection from them.

EXCITING CAUSES OF DISEASE 177

A number of very important and well-known diseases
are caused by animal parasites of such extremely small
size and so low in the scale of animal life jL/r:-,,,*.^
that they may, for our purposes, be re- A„;jj,ai
garded as closely allied to the bacteria. In parasites
fact, even scientists are not agreed as to
whether some of them, for instance the germs of
syphilis, yaws, and relapsing fever, are animal or vege-
table. A brief consideration of some of the small ani-
mal parasites and the diseases they cause may be
helpful.

Malaria is the best known and most common of
such diseases, and the parasites causing it are better
known than most of the others occurring in man.
There are at least three varieties of malaria, each caused
by its peculiar t3'pe of organism, though these types
have much in common. They all live in the blood and
in its red corpuscles, when so small as to be almost in-
visible with the microscope, and there grow to a consid-
erable size, destroying the blood-cell and converting it
into a mere shell and some pigment granules. In twenty-
four, forty-eight, or seventy-two hours, depending on
the variety of organism, they segment or break up into
a number of small new organisms, the number varying
from six or eight to fifteen or twenty, and also depend-
ing on the type. These young forms are set free in the
blood-stream with the breaking up of the shell of the
blood-corpuscle in which they were contained, and in
turn attach themselves to new red cells, to repeat the
performance. Corresponding to the liberation of the
swarms of young comes the " ague fit," or the malarial
chill, fever, and sweat, and it depends upon the type of
organism whether this comes daily, once in two days, or

178 THE CAUSES OF DISEASE

once in three. Various combinations of infections may
make the chills appear to come very irregularly, but
such irregularities are often explainable if the case be
well studied. After a time the body develops powers of
resistance that enable it to overcome the effects of the
organism, and spontaneous recovery may occur. Or the
recovery may be apparent only, and the disease may
recur when chill, exposure, or other illness lowers vi-
tality. Malaria causes many deaths, especially in the
tropics, in India about one million annually ; but if
a single infection is not fatal very soon, the tendency
is to recovery, as the parasites cannot maintain their
powers indefinitely unless they renew their strength
(in some unknown way) by sexual reproduction, and
that can only occur in mosquitoes of certain kinds.
Minute differences can be detected among the para-
sites of any kind of infection, and these are now
known to mark sexual differentiation. If the right
kind of mosquito bites the infected individual, these
sexual differences become more marked in its stomach,
and sexual conjugation there takes place. The impreg-
nated female (this term is not accurate, but it conveys
the idea) bores into the stomach-wall and undergoes a
development which eventually results in the production
of hundreds or thousands of young forms that finally
find their way to the salivary glands and mouth of the
mosquito, and enter, by way of the wound made by the
insect, the next man it bites, and the cycle begins
again in him. All malarial infections are conveyed in
this way, and where there are not the right kinds of mos-
quitoes the disease cannot originate. So far as known,
man is the only animal, and mosquitoes of the sub-
family anophalincB the only insects, that respectively

EXCITING CAUSES OF DISEASE 179

harbor and transmit malaria, and each derives its in-
fection from the other. Each should therefore be kept
away from the other.

Amoebic dysentery, so well known to our army because
of the great amount of invalidism it has produced
among our soldiers on tropical service, is also due to
an animal parasite of microscopic size. This is a minute
round mass of living substance endowed with the ca-
pacity for motion, by virtue of which it inserts itself
between the body-cells or wraps itself about them and
digests them ; destroying tissue and giving off poison,
it causes the formation of ulcers in the bowel, inflam-
mation of the intestinal siu'face, bleeding, wasting, diar-
rhoea, and, too often, death. Entering the blood or
lymph-streams through the ulcers they make in the
bowel, the amcehas may reach the liver and there set up
the dreaded disease known as liver abscess. The amoebas
enter the body in polluted water, and probably also on
lettuce, radishes, and other vegetables that are eaten
uncooked.

Sleejying sickness, a disease unknown in our posses-
sions but caused by a parasite closely related to that
causing the well-known and fatal surra of horses in
the Philippines, is widespread in central Africa, and
has caused tremendous loss of life there. The ororanism
and disease are transmitted by the bites of tsetse flies.

Syphilis, known everywhere, is caused by an ex-
tremely fine organism of spiral figure. This is about
1-2000 of an inch in length, and the thread that is
twisted into the spiral shape, the organism itself, is
about 1-100,000 of an inch thick. This extreme fine-
ness, and the difficulty with which the germ stains,
account for the fact that it remained so long undiscov-

180 THE CAUSES OF DISEASE

ered. This organism, which is called a Treponema^ is
not known to occur elsewhere than in syphilitic sub-
jects, but it occurs abundantly in lesions of the disease
and is free on the surface of such moist sores as the
open chancre and patches in the mouth. If from these
it passes to wounds, cracks, or other open and moist
surfaces on a healthy person, as may occur in kissing,
sexual congress, or other contact, the disease is trans-
mitted.

Yaws, a skin disease that occurs in the tropics, is
caused by an organism indistinguishable in appearance
from that of syphilis.

Many other diseases are produced by^animal para-
sites, but it is unnecessary to consider them here.

Certain diseases, such as yellow fever and dengue^
are produced by unknown organisms that pass through
fine filters and are probably so small as to be invisible
to our microscopes ; yet the course and history of the
diseases point to an animal rather than a vegetable
cause.

The disease-producing vegetable parasites are of
three classes, wowZcZs, yeasts,siud Saci^eWa, all microscopic
in size and all of them germs. The moulds
_. ° and veasts are of minor consequence as

compared with the bacteria, and cause rela-
tively few diseases, and those principally of the skin.
Fatal general infections by germs from both of these
classes have, however, been reported. Persons who have
served in the tropics recall how difficult it is there to
keep shoes, clothing, trunks, and many other articles
from moulding or mildewing, especially during the
rainy season. Heat and moisture afford such excellent
conditions for growth that a pair of shoes will turn

EXCITING CAUSES OF DISEASE 181

green in a very short time. As related vegetable forms
are responsible for many of the most common skin-
diseases of the tropics, the fact helps us to understand
the prevalence of the latter. Not all moulds are harm-
ful, and most of them are mere surface growths. The
mistake is occasionally made of rejecting a quite good
ham, for instance, because it is mouldy on the outside.
Such mould can be trimmed off with the rind, and does
not injure the meat. Roquefort and some other cheeses
are dependent on moulds for their flavor, and are not
good if these be absent.

Bacteria^ however, are the best known of the causes
of disease, so well known as such, in fact, that two
erroneous ideas have arisen in consequence :
one, that all bacteria produce disease, the
other that all disease-producing germs or micro-organ-
isms are bacteria, or, to touch a still greater error,
bacilli. Bacteria are microscopic, one-celled organisms
of vegetable nature that multiply by simple fission. So
far are they from being universally harmful, that life
would soon disappear from the face of the earth if all
bacteria were killed. This is because of the fundamen-
tal difference that exists between bacteria and the
larger forms of vegetation. All animal life is main-
tained directly or indirectly by vegetable life, even the
lion and tiger being dependent on the herbivorous deer
and similar animals. Most vegetable life draws its sub-
stance from the elements and simple compounds of the
earth, air, and water. In other words, grass or a tree
cannot eat dead grass, meat, or other highly organized
substances, until they are first decomposed and broken
up into the elements and simple compounds indicated,
and returned in those forms to the earth, air, or w^ter.

182 THE CAUSES OF DISEASE

For this purpose bacteria are necessary, and without
their action the earth would soon be covered with dead
animals and vegetables, the fertility of the soil would
be exhausted, and life would be choked out by the ac-
cumulation of its products. Because of this difference
and the fact that bacteria do not contain cellulose, as
do ordinary plants, it has been proposed to class them
as a separate kingdom and regard them as neither ani-
mal nor vegetable.^

Bacteria are found practically everywhere in nature,
and many trades and industries are dependent on their
presence. They are classified according to shape, group-
ing, action, and other qualities. Thus some are called
putrefactive, others nitrifying, and others pathogenic or
disease-producing. The more common forms are desig-
nated as cocci, or little balls, bacilli^ or little rods, and
spirilli or vibrios, or little spirals or pieces of spirals.
Cocci in pairs are called diplococci ; bound together in
chains, streptococci ; gathered into bunches like grapes,
staphylococci ; and, as each organism tends to grow al-
ways in the same way, such names become permanently
attached as more or less generic. Thus we speak of the
streptococcus of erysipelas, the diplococcus of pneu-
monia, and the yellow staphylococcus of suppuration.

Bacteria may also be cerobic or anaerobic ; the for-
mer unable to grow without oxygen, the latter with it.
Tetanus or locljaw is caused by an anaerobic bacillus,
and that probably partly accounts for the fact that it is

^ " It has been generally assttmed that bacteria are low fonns of
plant life, but researches . . . show that bacteria contain no cellulose
and are particulate, unshielded proteins and consequently are more
nearly related to low forms of animal life. I should not classify bact©'
ria as either plants or animals." — V. C. Vaughan.

EXCITING CAUSES OF DISEASE 183

most apt to follow small deep wounds, such as nail-
punctures, to which the air does not have free access.

Reproduction among bacteria is by fission or simple
division. One bacillus divides crosswise into two, the
two into four, and so on ; and so rapidly does the proc-
ess advance, that under favorable circumstances the
increase amounts to uncountable millions or billions
in a day. The rapidly multiplying individuals may be
bound together in gelatinous masses that are of con-
siderable size, at times forming a skin-like layer many
yards in extent. When conditions are less favorable, as
when all the food-supply is exhausted, the temperature
too high, or harmful chemical substances present, the
bacteria usually die ; but some varieties may preserve
themselves under such circumstances by the formation
of spores. These may be compared to the seeds of
larger plants in that they are much more resistant to
heat, cold, and other harmful influences, and, after sur-
viving such trials, may again give rise to growth. An-
thrax bacilli, for instance, are readily destroyed by
heat, but their spores will withstand boiling for some
time. In preparing media for the cultivation of bacteria
it is therefore the practice to sterilize them at a temper-
ature higher than that of boiling water, or to use that
temperature on three successive days. In the latter
event the bacteria develop from the spores after the
first sterilization and are killed in their less resistant
forms. The amount of heat required to destroy bacteria,
what is called the thermal death-point, varies greatly
with the species. Some organisms found in water, none
of which, fortunately, produce disease, flourish in a high
temperature. All disease-producing organisms, except
those in spore form, are promptly destroyed by boiling,

184 THE CAUSES OF DISEASE

and many of them by a lower temperature. Few ordi-
nary organisms will survive a temperature of 67° C.
for more than a short time, and this fact gives the pro-
cess of pasteurization^ as applied to milk, its value.
, This is the process whereby milk is heated to a point
between 66° and 70° C. and maintained at that tem-
perature for ten or fifteen minutes. This kills the dis-
ease-producing organisms, without changing the taste
and character of the fluid as does boiling. For the
same reason, satisfactory results have been obtained in
the British service with a camp water-heater that
raises the supply to 85° C. for only a very short time.

Moisture is necessary for the growth of bacteria, and
drying checks their growth even when it does not kill
them, as it does many varieties. Being solid bodies
heavier than air, bacteria are not given off from moist
surfaces. Occasionally they may be thrown into the air
with droplets of water by the bursting of bubbles, but
in general a tubfuU of bacteria-laden water would not
endanger the purity of the atmosphere. On the other
hand, dried or partially dried bacteria may be blown
about as dust and do much harm. Cuspidors and water-
closets should therefore always contain water. Sunlight
is a great enemy to most pathogenic bacteria, some of
them, for example the cholera germ, being killed by a
very brief exposure to it, and all being injured by it.
Many chemicals, such as bichloride of mercury and
carbolic acid, kill bacteria when brought into contact
with them. Such mistakes are often made as that of
regarding a stool disinfected because some antiseptic
solution has been poured over it. As a matter of fact,
the antiseptic in such a case is only brought in contact
with the surface of the fecal mass and the great bulk
of it is quite as dangerous as before.

EXCITING CAUSES OF DISEASE 185

One variety of bacteria may tend to destroy another.
Thus typhoid bacilli will keep alive much longer in
sterilized than in contaminated water, the common
water-organisms in the last case crowding them out ;
and fecal matter arid its contained bacteria are very
quickly made to disappear if mixed with dry earth
containing an abundance of nitrifying bacteria, while,
if mixed with ashes, which are sterile because burned,
they persist much longer. This warfare of bacteria
has had exploitation because of the interest attach-
ing to the recommendation that certain milk-souring
bacteria be ingested for the purpose of crowding out
from the intestines more harmful varieties, and so less-
ening the danger of poisoning by the products of these.
This explains the occasional excellent effects of the use
of buttermilk as a diet.

On the other hand, one variety of bacteria may in-
crease the danger or power of another variety. Thus
the tetanus bacillus, being anaerobic, cannot grow in
the presence of oxygen ; but if introduced into the body
with a variety of organism that uses a great deal of
oxygen, the latter may soon bring about practically
anaerobic conditions in which the former can flourish.

The virulence of the streptococcus of erysipelas is
greatly increased if the organism be grown with bacillus
prodigiosuSy an organism that is itself not pathogenic.
Smallpox, though more than a simple suppuration, is
always associated with that process and with the com-
mon pus-producing bacteria.

Some bacteria produce disease by means of the poi-
sons or toxins that they set free, rather than by their
physical presence in the tissues. The bacilli causing
diphtheria and those causing tetanus, to cite examples.

186 THE CAUSES OF DISEASE

produce soluble toxins which can be obtained in germ-
free solutions and which, when injected, produce the
symptoms of the diseases, even though none of the ac-
tual germs are introduced.

Other bacteria, such as those of plague, typhoid,
cholera, and tuberculosis, do not produce soluble toxin,
unless it be that one is set free when the bodies of the
bacteria are digested or disintegrated. Such bacteria
are at times spoken of as forming endotoxins. The
exact manner in which they cause disease is not thor-
oughly understood, though recent investigations indi-
cate that there are two main factors involved: (1) The
bacteria, in their efforts to nourish themselves, digest
and so destroy certain body cells. (2) The body cells,
in their efforts to defend themselves from injury, destroy
the bacteria by digesting or breaking them down, and
by so doing liberate from them certain products that
act as chemical poisons. The greater and more rapid
the defensive digestion, so is greater and more rapid
the liberation of the harmful products, and the more
acute and violent are the symptoms of disease until, by
practice, the cells learn to digest also the freed poison-
ous products, when recovery may occur and immunity
be established. In other words, the manifestations of
disease may be quite as much evidences of the body's
resistance to infection as of the existence of infection.
Similar digestion by the body cells, rather than by
the alimentary tract, of protein other than that con-
tained in bacteria, such proteins, for exam-
v, i" • P^^' ^^ ^o&" '^^ serum-albumen, is thought
^ ^ to account for " serum sickness " and other

manifestations of anaphylaxis.

CHAPTER X

DISEASE-CARRIERS

It has been stated in preceding chapters that diseases
are oftentimes diffused by persons, animals, insects, or
inanimate substances that act as carriers of the infect-
ive matter or germs. It will greatly aid in the main-
tenance of the health of troops if company officers and
the men themselves have a proper realization of such
methods of spreading disease, and the better known
and more important groups of carriers will therefore
be considered.

Man himself is the most important carrier of his own
diseases, and most epidemics arise from the presence of
one case of disease in man. Isolation and rr ,t,q„
quarantine are designed to limit or prevent p-rrpra
disease-transmission in this way, and in the
case of measles, scarlet fever, smallpox, and similar
diseases the danger is recognized by all. It is not so
generally recognized in many other common and serious
diseases, such as typhoid and "colds." It is not the
purpose, however, to discuss here the danger arising
from contact with well-marked cases of disease, but
rather to consider the unknown or unrecognized carrier.
Several diseases may be widely disseminated by persons
entirely ignorant of the fact that they are sources of
danger. This fact has long been recognized in regard to
some infections, is just receiving recognition in regard
to some others, and is possibly not recognized at all in
regard to still others. For several years it has been a

188 THE CAUSES OF DISEASE

matter of scientific demonstration that active and viru-
lent diphtheria bacilli may linger for weeks or months,
in the mouths, throats, or noses of persons who have re-
covered from the disease and who appear quite healthy.
It has also been demonstrated beyond dispute that some
mild sore throats, " colds," and nasal discharges are due
to diphtheria germs, even though the subjects do not
feel particularly sick and the diseased parts do not pre-
sent the appearance formerly considered characteristic
of diphtheria. Other persons who have no sore throat
or other evidence of disease, but who have been in con-
tact with cases, as nurses or otherwise, may harbor the
germs. Persons in any of these classes may ignorantly
and innocently introduce the disease in new localities,
transmit the germs to susceptible people, and so start
epidemics. One such person in a crowded and ill-venti-
lated squad-room in winter may endanger the whole
command, and if, in addition he is a person addicted
to careless spitting, to the use of other men's pipes,
cups, or linen, the danger is greatly increased. The wise
and necessary precaution in military life is to examine
and reexamine all men who have had or been exposed
to diphtlieria, and to keep them isolated until it has
been repeatedly demonstrated that they are free from
germs, and to isolate cases of sore throat as though they
were all diphtheric.

The germs of cerebrospinal meningitis and infantile
paralysis are also occasionally found in healthy mouths
and noses, and the diseases may be transmitted by such
healthy carriers. Scarlet fever often leaves an irritated
throat, a nasal discharge, or a running ear, and persons
who have otherwise recovered from it may transmit the
infection to others and so start epidemics.

DISEASE-CARRIERS 189

Typhoid carriers constitute one of the means of ty-
pTioid transmission that is now best recognized and is
always considered in the investigation of an outbreak
of the disease. A chronic typhoid carrier is usually a
person who has had the disease and apparently recov-
ered, but who continues to excrete typhoid bacilli in his
feces or urine. Occasionally, however, a carrier is found
who gives no history of the disease. Then, too, persons
in the early stages of the disease may act as carriers
and cause wide dissemination of the infection before
they give up to their sickness.

The germs of cholera and dysentery may be passed
by persons quite ignorant that they harbor them, and
may give rise to infection through contact, water, the
use of latrines from which flies may obtain the germs,
and in other ways. Epidemics of bacillary dysentery or
" flux " not rarely result from carelessness on the part
of a carrier or a man but slightly sick. During a jail
epidemic of cholera which was started by a carrier at
Puri jail, in India, in 1912, thirty convalescents were
examined at the time of their discharge from hospital
and eleven of them found to be still excreting cholera
germs. In August, 1911, six cases of cholera were ad-
mitted to the quarantine hospital at Ellis Island, fifteen
cases developed in quarantkie, and thirty-one carriers
were detected.

As stated in the preceding chapter, man is the carrier
of the commonest intestinal worms, and it is his ig-
norance or carelessness that is responsible for their
spread. Persons who spread tuberculosis, tonsillitis, and
other troubles by their careless spitting usually do it in
ignorance of the fact that they are doing wrong. Most
consumptives do not realize that they have the disease

190 THE CAUSES OF DISEASE

until after they have been expectorating tubercle bacilli
for some time. Other disease-carriers who may be quite
ignorant of the role they are playing are sufferers from
certain eye and skin diseases, such as trachoma or granu-
lar lids, gonorrhoeal inflammation of the eyes^rlngworm^
itch, impetigo, and many other diseases of the skin.
They may either be ignorant that they have any disease,
or that the diseases they have are contagious, and so, by
careless contact, the use of public towels or brushes,
or those belonging to other persons, through barbers'
chairs and in other ways, they may infect many persons.
Nurses and doctors may at times carry and trans-
mit infectious diseases, such as measles, smallpox or
typhoid, either innocently, as when a diagnosis cannot
yet be made and they do not know of the dangerous
contact, or culpably, as when they know of the danger
but do not take proper precautions to guard against it.
Venereal diseases, both gonorrhoea and syphilis, may
be innocently transmitted, quite aside from any ques-
tion of sexual intercourse. A syphilitic infant may in-
fect its nurse ; a girl may get a chancre of the lip from
kissing a person who has infective lesions in the mouth
and does not know it ; or possibly, though it must happen
very rarely, by following a syphilitic in the use of a com-
munion cup or other public drinking-vessel; doctors oc-
casionally become infei^ted with syphilis through needle-
pricks or slight scratches that become infected during
operations. A child may contract gonorrhoea from sleep-
ing with or against its infected mother, or an infant's
eyes may be infected daring its birth, and others may
become infected through handling it. Many men who
thought themselves quite free from all venereal disease
have infected their innocent wives through sexual in-

DISEASE-CARRIERS 191

tercourse, and every man who has ever had venereal
disease should seek the examination and opinion of a
competent physician before entering the married state.

The company officer cannot be expected to recognize
the various disease-carriers in his company, but he can
aid in their detection if he sees that all sick men report
promptly to the surgeon, and that they remain on sick
report until no longer sources of danger. Occasionally
a company officer takes the unreasonable view that a
man who is able to do a bit of window-washing or other
light work about the hospital should be sent to his com-
pany. Such action might result most seriously both to
the company and the man, and the wise company com-
mander will very rarely, if ever, clamor for a sick man.
Even diseases not directly transmissible, such as malaria,
constitute a menace in barracks, and the victims are,
ordinarily, not only better off, but also less dangerous
when in hospital. A man infested with worms may be
capable of working and may desire to do duty, but he
cannot be so well treated elsewhere as in hospital, nor
will the disposal of his stools be so well looked after
if he be free to go and to defecate where he pleases.

Certain diseases are derived exclusively or almost so
from animals. Among them are many very dangerous
infections, some of them quite incurable. Animal
We will consider some of these. Carriers

Hydrophobia is a disease that affects a
great many kinds of animals and is almost uniformly
fatal. It is ordinarily considered a disease of the dog
family, but there is some reason to believe that it is
naturally a disease of certain herbivora, especially rab-
bits, and the dog contracts it from these. So far as man
is concerned, however, it may be considered as origi-

192 THE CAUSES OF DISEASE

Dating with the biting animals, especially the dog^
wolf ^ fox, cat, and skunk. By these it may be trans-
mitted to horses, cattle, and other domestic animals,
and to man himself. No cure is known for the disease
after it has actually begun, but if treatment be begun
soon after infection, immunity may be established be-
fore the incubation period has ended, and the onset
thus prevented. As there are three prevalent errors
regarding this disease, each fraught with the possibility
of serious consequences, they will be briefly discussed
here.

The first of them is the somewhat widespread belief
that the disease does not exist, that its victims really
die from fright. This is abundantly disproved by
the deaths of people who were not fi-ightened, who for
weeks or months had forgotten the incident of the bite ;
by the ability to infect and kill rabbits, dogs, and other
animals, by inoculation from animals dead of rabies
but not from those dying of other diseases ; by the in-
fection and death of cattle, horses, and men ; by the
bites of rabid animals, but of no others ; and in other
ways. Hydrophobia exists.

The second error relates to the diagnosis of the dis-
ease in the dog. Not every dog that slobbers and bites
is rabid, and it is foolish and frequently a cause of great
and needless worry to assume that he is and kill him.
The disease usually begins in the dog with a change
of disposition, shown commonly by restlessness and ir-
ritability. The animal is easily startled and crouches in
fear, or it may wander away from home. The appetite
may fail, or there may be difficulty in swallowing food.
Drinking is apparently less interfered with, and the
name hydrophobia (fear of water) is not accurately

DISEASE-CARRIERS 193

descriptive. Even later, when, because of paralysis of
the throat, the animal is wholly unable to swallow, it
may still lap water with avidity, though it succeeds in
doing no more than wetting its mouth. Change in the
bark or absence of barking is often noted. The dog may
show no tendency to violence, but pass from a state of
bewilderment to aimless restlessness, characterized by
a tendency to wander or to chew and swallow all sorts
of unusual articles such as wood, cloth, grass, or earth, to
paralysis and death. Or it may snap at things about it
or at the phantoms of its disordered brain, and pass into
a furious stage, that of typical madness, when it bites
or tears at any thing or any animal in its way. Always
the disease ends in paralysis, usually first showing in
the muscles concerned in swallowing, later of the hind-
quarters, the jaw, and the entire body, death coming
in from four to seven days after the onset. The disease
probably begins with the invasion of the dog's brain by
the parasites, and the saliva is not always dangerous
at the beginning. The diagnosis can be properly made
only by observation of the whole course of the disease,
or by examination of the animal's brain. Therefore, the
correct course of procedure is either to capture the dog
and confine it so that the disease may be observed, or
to hill it and at once cut off its head and send that to
a competent pathologist for examination.

The third error relates to treatment of bitten per-
sons. It is computed that about one sixth of the persons
bitten by rabid animals develop hydrophobia, the rest
escaping because the saliva was not at the time infec-
tious, because the clothing wiped all saliva from the
biting teeth, and for other reasons. Nevertheless, the
sixth that do develop the disease always die, and proper

194 THE CAUSES OF DISEASE

preventive treatment is essential. This consists in the
cleansing of the wound with heat or antiseptics, the pro-
motion of bleeding, proper dressing, and the Pasteur
treatment for the establishment of immunity. " Mad-
stones " and charms are quite useless.

Glanders is well known as a disease of horses and
mules^ less so as a cause of human illness. Neverthe-
less, human beings do contract it, usually with fatal
results. Its contagious and fatal characters are so well
recognized in the army, that its presence constitutes
proper grounds for the destruction of animals, even
though their usefulness is not yet greatly impaired. The
persons who most often contract it are those concerned
in the care and treatment of horses. As the disease in
its early stages may not present characteristic or well-
marked symptoms, it may be mistaken for a " cold,"
quinsy, or other less dangerous malady, and the animal
be handled or treated without the observation of proper
precautions to prevent infection. Special care should
always be exercised to prevent any discharge from the
nose or from sores on horses coming in contact with
wounds, scratches, or the respiratory tract, and to keep
the animal from blowing its nasal discharge or saliva
into the face of one examining it. All suspected ani-
mals should be isolated and handled as though known to
be glandered until the diagnosis is settled. The disease
may also be contracted from handling dead animals
during their removal, or in the course of post-mortem
examination, and proper precautions as to cleanliness,
avoidance of wounds, and disinfection should be ob-
served. Glanders and farcy are different forms of the
same disease, are due to the same organism, and must
be treated with equal respect.

DISEASE-CARRIERS 195

Plague or the pest is one of the most serious and im-
portant diseases for which man owes a debt of hatred
and warfare to his animal neighbors. It has not as yet
gained an extensive footing in our country, but it took
San Francisco some years to get rid of it ; at this writ-
ing New Orleans is struggling to do so, while the Pan-
ama Canal is menaced from Colombia, Peru, Chili,
Cuba, and other points; and it is only by unremitting
care that we can hope to prevent its spread there and
at home. Starting in southern China some twenty years
ago, it has since invaded each of the continents and
many of the islands of the seas, while its toll has been
millions of lives and vast treasure. As lately as 1911 it
caused 842,000 deaths in India, and 273,000 in 1912,
199,000 in 1913, and 178,000 in the first six months
of 1914, in spite of the active campaign that has been
waged against it there for almost two decades.

The investigations of the British commission ap-
pointed to study the disease in India show clearly that
epidemics of human plague arise after and in conse-
quence of epizootics of rat plague. 'The infection is
transmitted from rats to man by fleas, usually those
of the rat, and the relation of the epidemics to the
epizootic is beautifully shown as follows : There are
two principal species of rat concerned there, the brown
or Norway rat and the black or house rat, the former
also known as the ship and the sewer rat. It is among
that class that the epizootic arises, usually, and in about
7.2 days later it is also prevailing among the house
rats. This 7.2 days is accounted for by tlie fact that
it is also the average experimental time elapsing be-
tween the biting of the black rat by an infected flea
and the death of the animal. (The rise of the epizootic

196 THE CAUSES OF DISEASE

is measured by the numbers of rats found dead or dy-
ing.) The black rat epizootic precedes the height of the
human epidemic by from ten to fourteen days, a period
accounted for as follows : The rat flea does not readily
attack man until starved for three days. The incubation
period of human plague is about three days. The dura-
tion of the fatal human plague averages four and a half
days. Average total, eleven and a half days.

The relationship between rats and human plague is
also proved in other ways, but they cannot be discussed
here. The fact is established, and it constitutes the
most important of the many reasons why man should be
at enmity with, and try to exterminate, rats.

It must be borne in mind, however, that other ani-
mals may be infected, and wild squirrels have been
shown to have the disease in California. They and
gophers, prairie dogs, and similar animals may yet
play an important part in disseminating it. While dirt
and unsanitary conditions cannot give rise to plague,
their influence in promoting the presence and increase
of both fleas and rats is so well recognized that it is
well to mention the matter as showing how they may
strongly predispose to disease that they cannot cause
directly.

The great Manchurian epidemic of pneumonic plague
in 1910 has been thought to have originated among
trappers of plague - infected rodents, but, however
started, that epidemic was not spread in the ordinary
manner. It spread with tremendous rapidity and killed
nearly all whom it infected. Transmission was by drop-
let infection and inhalation, the germs entered by the
respiratory tract and caused pneumonia, and in the few
months of its raging the disease caused thousands of

DISEASE-CARRIERS 197

deaths. However, the conditions favoring a similar
spread exist in few places. During the summer myriads
of Chinese go north to work in Manchuria. In winter
they return, and the writer has seen train-loads of them
riding all day in open coal cars, in windy weather when
the temperature was below zero, and at night stopping
at such places as Mukden and being packed into close
and dirty inns as they were packed in the cars in day-
time. It requires no vivid imagining to understand
how pneumonic plague would spread like wild-fire when
introduced among men so environed. So we see that
even diseases that are ordinarily insect-borne may at
times find man himself their most favored carrier.

Tuberculosis is the most prevalent disease affecting
man, and is responsible for more deaths than any other
one cause. It is also a common disease of cattle and of
some other animals, and it may be transmitted to man
from them. Tuberculous meat, if not sufficiently cooked
to sterilize it, may be the medium of infection, but milk
is probably even more commonly the carrying agent. A
cow that has tuberculous disease of the udder may give
off immense numbers of bacilli, and these may be in-
gested in a virulent condition in milk, cream, butter, or
cheese. This method of infection is so common that some
authorities who have devoted great study to the subject
contend that it is the usual, if not the exclusive method,
and they relegate infection by inhalation to a place
of very minor importance. Such a view is extreme and
probably not correct, as shown, for instance, by the fact
that tuberculosis is very prevalent in Japan and other
far eastern countries where neither milk nor beef is
a common article of food. Nevertheless, infection by
means of these food-articles can and does occur, and the

198 THE CAUSES OF DISEASE

precautions against the sale of tuberculous meat and
milk are wise and salutary. Observations made in New
York and elsewhere on the type of bacilli found in
series of cases of tuberculosis of children indicate that
about seven per cent of the cases were caused by bacilli
of the " bovine type." Wild or range cattle are much
less subject to the disease than high-bred, stabled cattle,
and many other animals that suffer from it in captivity
are free from it in their native wild state, thus showing
the predisposing influence of confinement and crowding.

Tuberculosis is rather common also in pigs, dogs, and
cats, less so in sheep and goats. The disease may be
transmitted by the flesh of pigs. Pet animals, such as
dogs and cats, are apt to contract and spread the infec-
tion because of their habits of licking up sputum and
other discharges to which they may have access. This
furnishes another argument for the proper care and
destruction of all tuberculous discharges. The urine and
fecal discharges of men or animals that have tubercu-
losis may contain the bacilli and may constitute serious
dangers. Thus a cow that is passing the germs in these
ways may indirectly infect sound cattle or their milk by
means of bacilli blown about the stable with the dust
of dried feces or urine, or by soiling the pasturage.

Fish and birds also have tuberculosis, but it is doubt-
ful if the forms of it that they have can be transferred
to man. It is not, however, necessary to go to the ex-
treme lengths that fear may carry one in the efforts to
avoid tuberculosis. Patients with the disease need to be
taught to take proper precautions as to the disposal of
their spit and other excreta, but when they take such
precautions they need not be avoided. In fact, among
investigators of tuberculosis there is a growing and

DISEASE-CARRIERS 199

pretty widely accepted belief that practically all per-
sons become infected with the disease early in life, and
that the large majority overcome it. Its appearance in
later life is then credited to a lowering of general bodily
resistance, rather than to a recent infection. This ac-
counts for the " predisposing " influence of typhoid and
measles, they lower the resistance to an infection that
already exists. Tuberculous milk is best avoided, but if
the milk is not known to be infected, but is merely of
unknown or doubtful origin, it can be rendered safe by
boiling or pasteurization. The indiscriminate sale of
tuberculous meat is properly forbidden by law ; but if
an animal is not badly diseased and the visibly injured
portions of the carcass are rejected, the rest can be eaten
with safety if it is first properly cooked. Such meat
is not purchased for the army, however, and the above
statement is made for its general worth and not to en-
courage the acceptance of inferior stores.

Anthrax is a disease that causes a very great number
of deaths in cattle and sheep in various parts of the
world. Other animals are also susceptible to it in vary-
ing degrees, among them being horses, deer, pigs, mice,
and rabbits. Man suffers from it in two or three forms,
generally obtaining his infection from the hides of ani-
mals dying of it. Wool-sorters and hide-handlers are
therefore particularly subject to it, and one common
name of the trouble is " wool-sorters' disease." Soldiers
have also been known to be infected (though not in our
army) through the use of sheepskin-lined coats, or boots
made of poorly cured leather. The disease is often fatal,
and materials from animals dead of it should not be
used. It is caused by one of the spore-forming bacilli,
and the spores are very resistant to both heat and

200 THE CAUSES OF DISEASE

chemicals. Human infection takes place in two ways :
through cuts or abrasions brought into contact with in-
fected skins, carcasses, or other matters, and by inhala-
tion of hairs, bits of wool, or dust that carry the spores.

It has been definitely shown that several species of
African antelope are capable of infection with the tryp-
anosomes of human sleeping sickness, that tsetse flies
may become infected by feeding on them and may trans-
mit the disease, and that the antelope in question are at
least " potential reservoirs " of the disease and probably
actual ones. There is still warm discussion as to whether
the government should enter upon a policy of game
extermination, the opposition being based upon what
is considered insufficiency of proof of the actual impor-
tance of such reservoirs.

Man is the occasional subject of some other diseases
of animals, and it is a good general rule to take as much
care to prevent infection from a sick animal as from a
sick person, unless the disease is known to be one, such
as rinderpest, to which persons are not liable.

Domestic animals are also occasional carriers of com-
mon human diseases. Dogs and cats have been known
to have diphtheria. Cats have been experimentally in-
fected with whooping-cough, and there is reason to
suspect that either of these animals might carry the
contagium of such diseases as smallpox, scarlet fever,
or measles in its hair. The liability of getting ring-
worms and other skin diseases, as well as lice and fleas,
from domestic animals has already been mentioned.

Insects of different kinds transmit diseases in various
ways. The first and simplest way is by acting as simple
carriers. Thus germs become attached to the legs and
bodies of flies alighting on an infected wound or a yaws

DISEASE-CARRIERS 201

papule, and these by later alighting on clean wounds
or abrasions may leave the germs there and _
cause infection. Or the transfer may be -«
less direct, as in the case of the fly that
goes from a typhoid stool to a food-article and there
leaves germs to be later ingested with the food. In
other instances the simple deposit of the germs may
not insure infection, but the irritation caused by the
insects may further it. This is well shown in the case
of plague. The flea transmitting that disease may do so
by reason of the fact that the germs are adhering to its
mouth-parts and are introduced directly by the biting
act or, as has recently been shown, the germs imbibed at
a previous feed may have so multiplied in the flea's
stomach as to obstruct the opening into it, with the re-
sult that when the insect attempts to feed again the
pumping motions that it makes simply draw the blood
into the oesophagus, whence, laden with plague bacilli,
it flows back into the wound. On the other hand, the
mouth and external parts of the flea may be free from
germs, in which case infection may occur as follows :
The flea has a habit of defecating while it sucks blood,
probably to make room for a larger meal, and in so
doing it may deposit plague-germs on the skin, near but
not in the wound. If, now, the bite is rubbed or scratched,
as is often the case, the germs may in that way get into
the wound and infection be assured. An insect trans-
mitting the disease in this last described manner is
called a contaminative carrier, and there are some
diseases, as relapsing fever carried by body lice, in
which that and the rubbing in of the contents of crushed
lice, seem to be the only methods of infection, the bite
alone being harmless.

202 THE CAUSES OF DISEASE

More complicated processes are involved in other in-
stances, as in malaria, yellow fever, or filariasis, in which
the parasites must undergo a cycle of development in the
insect ; and the latter cannot transmit the disease until
a sufficient time has elapsed to allow that to occur. Some
insects can transmit germs, and the capacity to convey
infection to man or other animals, to their offspring.
This fact has long been known regarding the tick that
transmits Texas fever to cattle, and it has more recently
been proven true as to those infecting man with the
spotted or tick fever of Montana and the relapsing or
tick fever of Africa. These diseases may be transmitted
by the bites of ticks raised from the eggs of those biting
infected persons, but which have not themselves ever
bitten people or had any other chance than through
heredity to obtain the infection. The body louse can
transmit the cause and power to infect with European
relapsing fever to its offspring, and the same sort of
thing maybe true as to some other insects and diseases.
Among proved or probable insect-carriers of general
diseases are Jliis of various kinds, several species of
mosquitoes^ sand-flies of some varieties, the harhiero
of Brazil, ^eas, lice, bedbugs, ticks, mites, and roaches.^

Among inanimate carriers of disease, food, water,
and milk have already been men'ion'id several times.

^ A most cnriona and interesting example of an insect actings as a
carrier for another insect has recently been worked out partially in
Central and South America. A large fly, Dermatobia cyaniventris, the
size of the ordinary bluebottle fly, manages in some manner as yet un-
known to get its eggs stuck to the side of the thorax of a variety of mos-
quito, Janthinosoma ItUzi. When the eggs hatch the larvae enter the skin
of a man through the wound made by the bite of the mosquito, and
there develop, causing abscesses or boils.

DISEASE-CARRIERS 203

They may serve as the conveying media for practically
all infections that can occur through the -
alimentary canal, including such important _,
ones as tuberculosis, typhoid, cholera, dys-
entery, diphtheria, scarlet fever, and many others.
These articles, and milk especially, offer such opportu-
nities for the multiplication of bacteria that they may
convey to the consumer many thousand times as many
germs as originally had entrance to them. Thus a can
of milk, becoming infected with a few hundred typhoid
bacilli from the hands of a farmer-carrier, may, when
consumed in a city, ten or twelve hours later, have
billions of germs in it, and cause a great many cases
of the disease. It is, therefore, important to prevent
the access of even one disease-germ to such articles,
and carelessness in their handling should not be con-
doned. Fortunately, thorough cooking will destroy dis-
ease-germs in all of these substances.

Clothing, books, carpets, toys, and other personal and
household belongings that have been handled or used
by persons ill with such diseases as smallpox, measles,
scarlet fever, and diphtheria may serve to convey infec-
tion for varying periods of time, periods fortunately not
usually very long, and for that reason the disinfection
or destruction of such articles is resorted to as a means
of preventing the spread of contagion. Such articles as
can be boiled or thoroughly steamed can be quite well
disinfected, but if facilities are not at hand for steriliz-
ing such large articles as mattresses, they may need
to be destroyed. Boots, hats, and certain other classes
of articles will not stand steaming and may have to be
disinfected with chemicals or destroyed, though in most
instances exposure of them to the sun and fresh air for

204 THE CAUSES OF DISEASE

some days would render them safe. In fact, there has
accumulated a mass of evidence to show that terminal
disinfection of houses and of inanimate things in gen-
eral is much less important in the suppression of infec-
tious disease than was formerly thought to be the case,
though prompt disinfection of things used during the
actual sickness, such as spoons, bedding, and utensils,
is thought as important as ever.

Such articles of personal belongings are also common
carriers of the organisms of suppuration. So widespread
are such germs that almost everything in common use
has them on it ; and if brought into contact with a
wound they will leave the article and start infection.
This alone makes the sterilized and sealed first • aid
packet of so much greater value than articles of cloth-
ing and handkerchiefs as first dressings for wounds.
The packets, if not contaminated by handling, practi-
cally never cause infection ; the other articles almost
always do so. Nails, bullets, knives, and other missiles
or weapons that have not been sterilized may infect the
wounds they cause ; or, if sterile themselves, may carry
infection from the skin or clothing they traverse.

PART III

THE PREVENTION AND CONTROL
OF EPIDEMICS

•' Thou sTiaU not he afraid . . . for the pestilence that toalketh in
darkness : nor for the destruction that wasteth at noonday."

Psalm 91 : 56

CHAPTER XI

THE DEFENSES AGAINST DISEASE IN GENERAL

Fortunately for the human race, the contracting
and development of disease are somewhat difficult mat-
ters, and only follow the occurrence of certain trains
of circumstances. They may be compared with the de-
feat of an army, for which purpose it is necessary
that the army become weakened by loss of men, hard
marching, lack of food, exposure, or some other cause ;
or that the enemy has been able to bring a superior
force on the field, that his supplies are better or are
more promptly delivered ; that one side improves its
opportunities for offense or defense and the other does
not ; or that other good and sufficient reasons are pre-
sent. The mere existence or contact of two armies does
not explain that a certain one of them is defeated. So
in the matter of sickness, the mere existence or contact
of a man and typhoid organisms is not in itself suffi-
cient to insure that the man has or will get typhoid
fever. For that purpose it is necessary that the germs
shall be alive, virulent, and capable of development,
that they shall gain entrance to the body of the man
in sufficient numbers, that the man's body shall be
unable to destroy them before they have time to de-
velop and liberate their poisons, and that his tissues
shall unite with such poisons after they are liberated.
It is relatively rare that these conditions coexist, and
typhoid fever is therefore not more common than it is.
Our defense against sickness then rests on our ability

208 THE PREVENTION OF EPIDEMICS

to break or destroy the chain of disease-favoriug cir-
cumstances. If we can entirely destroy it, we are sure
to remain well, but if we cannot do that, the destruction
of one link may save us. It is well, therefore, that we
should first consider general plans of defense or aggres-
sion, and later pass to the discussion of special cam-
paigns or battles.

The body is defended from disease by many natural
factors, and we should try to preserve these intact. The

skin presents an impassable barrier to most

Natural . a c • * *•

^ , organisms, and very tew infections can

C6Z6I1S6S .

enter through it as long as it remains un-
broken. It has weak points, however, and
^ infections may occur in the hair-follicles

or in the skiu-glands. Boils are the commonest results
of such invasions. The organisms of typhoid, tubercu-
losis, and many other diseases could be put on the
sound skin with impunity, if they did not later gain
entrance to the nose, mouth, wounds, or other openings.

The mucous membranes are all warm and moist, and,
in that way, offer favorable conditions for bacterial
growth ; but they are all covered with mucus to which
the germs may adhere, and with which they may be
passed out of the body by spitting or otherwise. The
cells lining some mucous surfaces have little, moving,
hair-like projections, and by means of these are able to
pass along and expel small foreign bodies getting on
them.

The gastric juice is sufficiently acid to destroy many
varieties of micro-organisms, and digestive disturbances
that lessen that acidity increase the liability to infec-
tion. The fluid also has the power of neutralizing or
digesting some poisonous products, but not all.

DEFENSES AGAINST DISEASE 209

The urine, by its acidity and its irrigating and
cleansing action, doubtless has an effect in keeping
down the number of cases of venereal diseases.

The prompt reaction to in'itation is often a disease-
preventing factor. A dose of arsenic or a meal of tainted
meat may produce such prompt vomiting as to cause
the expulsion of all poison, and so prevent further symp-
toms. The inflammatory reaction following the infection
of wounds is usually a conservative process that limits
the infection to the locality of the wound, and prevents
its diffusion through the body.

As stated before, however, a man may possess an
immunity to certain diseases even though the germs
gain entrance to his body in the numbers Tjj.jj.„.
and of the virulence ordinarily producing „■*_.
such diseases. This may be hereditary or
^^?iatnral" immunity, when the man is born without
susceptibility to the disease. It is acquired when due
to something occurring after birth. Acquired immunity
is usually due to an attack of the disease, and is well
recognized in such affections as smallpox, measles, scar-
latina, and typhoid. It is common knowledge that one
attack of any of these usually protects against a second.
This is also known as active immunity, because the
body is active in maintaining it. Passive immunity is
due to the introduction into the body of ready-made im-
munizing substances, such as diphtheria antitoxin, that
is contained in the blood-serum of an immunized horse.
Active acquired immunity may also be induced by
vaccination, the procedure whereby disease-producing
organisms in an attenuated or weakened state are intro-
duced into the body and set up a very mild form of
disease, but one sufficient to set the body on the de-

210 THE PREVENTION OF EPIDEMICS

fensive and cause it to produce inamunizing substancee.
This procedure is best known in its relation to small-
pox, and as that was the disease for whose prevention it
was first used, the name vaccination in the broad sense,
that is, the introduction of disease-producing germs to
produce immunity, is taken from that instance. It has
also been used, though, to produce immunity to cholera,
plague, dysentery, typhoid fever, hydrophobia, and sev-
eral diseases of animals, in some instances with consid-
erable success.

Immunity may also be relative or absolute, temporary
or permanent. Man's lack of susceptibility to the
pleuro-pneumonia of cattle, for instance, is hoth perma-
nent and absolute. An attack of smallpox may produce
an immunity that is either 2)ei'manent or temporary. In
the latter instance the sufferer might have a second
attack after some years. A relative immunity to typhoid
might protect against a small number of bacteria, but
not against a very large number. Relative immunity
partially protects races long resident in malarious re-
gions from the more severe or urgent manifestations
of that disease. This particular form of it is probably
partly acquired as the result of the prolonged exercise
by the body of its resisting powers, and partly inherited
and due to the survival of the more resistant individu-
als and the transmission to their progeny of their re-
sistant qualities. In most highly malarious regions the
natives are practically all infected, yet they appear to
be in fair health, but foreigners going among them are
apt to be attacked by malaria in its most severe and
dangerous forms.

Immunity is due to several factors, not all of which
are understood. In regard to some diseases, such as

DEFENSES AGAINST DISEASE 211

diphtheria and tetanus, it is due to the development of
antitoxin, a substance that acts as a direct antidote to
the poison of the disease and neutralizes its effects. In
other instances, as in the case of plague, cholera, and
typhoid, it is largely due to the presence or develop-
ment of substances that kill or dissolve the bacteria.
It is probable that it is often due to the ability of the
tissues to digest thoroughly the protein of the bacterial
bodies and render it harmless, as discussed on the last
page of chapter ix. In many instances it is partly or
entirely due to the activity of certain cells, phagocytes,
that take up and destroy the germs. Absolute hereditary
immunity may be due to none of these, but to lack on
the part of the body cells of chemical groups that enable
the poisons to enter into combination with them.

Ilelative immunity is maintained by those conditions
that keep up the general health and maintain the re-
sistance of the body. It is lowered by causes -, -
that depress these, such as starvation, ex- __ - ,
haustion, injuries, shocks, worry, and grief.
It is therefore important that the man and his environ-
ment be constantly kept at their best, that abundant
and proper food, pure water, good air, and right clothing
be provided, that sufficient exercise to keep the respira-
tion, circulation, digestion, and excretion active be
taken; that overwork, improper food, alcoholic and
venereal excesses, and the entire list of things predis-
posing to disease be avoided.

All of these measures tend to strengthen the man
and put him in good condition and position for the
combat with disease ; and, as with armies, so in this in-
stance, the maintenance and strengthening of our own
forces is not less important than the weakening or bin-

212 THE PREVENTION OF EPIDEMICS

dering of the enemy ; and as the possession of a large
and well-trained army is, in these days, often spoken of
as a "national insurance policy" and a guarantee of
peace, so may the well-trained and sound body be re-
garded as insurance against disease. As the combat with
germs is, however, one that never ceases, we must also
try to injure the enemy as much as possible, giving
no quarter, as we may expect none. We should try to
eradicate all disease-producing organisms, to reduce
their numbers where we cannot do that, and to weaken
them by every means available. Many of the measures
designed to accomplish these ends have been mentioned
or discussed in preceding chapters or will be taken up
more fully in later ones, but some of them may be con-
sidered at length here and not again described. They
may be classed in two categories : measures designed to
prevent contact with the germs, and those aimed at
their destruction.

Among the former, avoidance of the sick may be
considered one of the most important measures. This
recommendation cannot be taken as coun-
tenancing neglect of the sick or lack of all
ance of i • ^ • r

e- 1- proper care and attention, but it refers to

unnecessary contact with them, that due
to carelessness, curiosity, or sentimentality. As stated
before, the principal agent in the dissemination of
human diseases is man himself, and nearly every case of
infectious disease is derived from another. Therefore,
unnecessary visits to hospitals and sick-rooms should be
discouraged, and in military life it should be axiomatic
that sick men should be removed from squad-rooms, un-
less good reasons to the contrary exist in special cases.
Even though the sick man goes into a general ward

DEFENSES AGAINST DISEASE 213

in the hospital, he is less apt to infect others there for
several reasons. One of these is that air- __ ^.
space and ventilation are more liberal there. ^
In the squad-room, where but six hundred
cubic feet of space are allowed each person, a sick man
may seriously contaminate the air. In hospital the same
amount of contagium is dilated two to four times, be-
cause the space per man is twelve to twenty-four hun-
dred cubic feet. Naturally an exposed person breathes
in only one third as many organisms. Precautions are
also taken in hospital to reduce the chances of mediate
contact.

In the more readily transmissible diseases isolation is
resorted to as a means of insuring lack of contact. For

this reason it is highly important in such , ,

LL J. ^ • li T 11 1 . Isolation

"catching diseases as smallpox, scarlet

fever, and measles, and is of value in the management
of typhoid and most other infectious diseases. Both the
character and the duration of the isolation vary in dif-
ferent diseases, according to the methods and ease of
transmission and the duration of the infectious period.
Typhoid and many other infections can be safely iso-
lated in a room or even in a general ward, if proper
care is taken in the disposal of excreta, bath-water, and
other waste material, in the exclusion of flies and ver-
min, and in the prevention of mediate contact and the
prompt and careful disinfection of the means of such
contact, such as bedding, utensils, thermometers, unused
foods, nurses' hands, etc. Such care may be necessary
for weeks or months. It is usually considered necessary
to isolate smallpox cases in a separate house or tent,
removed from other houses, and to continue the isola-
tion until the patient is well. The contagion of measles

214 THE PREVENTION OF EPIDEMICS

is so readily transmissible that isolation would seem
very important, but the period of contagiousness comes
so early in the disease that isolation is not effective, be-
cause it is not applied soon enough. In yellow fever,
malaria, and dengue the degree of isolation is not neces-
sarily greater than that afforded by the screening re-
quired to exclude mosquitoes from the sick, while in
typhus and European relapsing fever, both formerly
considered so highly contagious, it is only necessary to
keep lice from the patient and his visitors.

Infectious diseases of various kinds have different
incubation periods. These represent the time elapsing
-^ between the occurrence of infection, the

^ entrance of the germs into the body, and

the appearance of the disease. In some cases
of cholera, diphtheria, and a few other diseases, the in-
cubation period may be as short as one day or a few
hours ; while in hydrophobia it may extend many weeks
and possibly months. Diseases also vary as to length
of time during which the subjects remain sources of
danger after their apparent recovery. Yellow fever,
for instance, ceases to be dangerous, to others than the
patient, after the third day of its existence ; while a
typhoid patient may continue to give off immense num-
bers of virulent organisms and constitute a source of
danger to the community for many years.

The term quarantine, though used in several senses,
the oldest meaning a forty-day period of isolation for
persons thought to be possible subjects of disease, is
now most commonly used to indicate the separation from
the general community of persons presumably exposed
to infectious disease, and observation of them during
the period of incubation of the disease in question. In

DEFENSES AGAINST DISEASE 215

practice the term is also used to cover the isolation of
the sick. Employed rationally and under sound medi-
cal advice, quarantine is often a valuable measure and
may prevent epidemics. It is one of our main reliances
in excluding plague, cholera, and many other diseases
from our ports.

But it is always attended with hardship to its sub-
jects, and when controlled by laymen actuated by
panic, fear, or malice, it may become an instrument of
cruelty and oppression. Only trained medical officers
should direct or control systems of quarantine, and their
training should be relied upon to suit the system to
the circumstances. A fixed isolation period, say of one
month, for yellow fever and scarlet fever, would be
wrong in both instances, but in the one the patient
would be unjustly treated, in the other, the public.

In addition to the matters of barrack, camp, and
kitchen police already discussed, larger schemes of po-
licing or engineering are important in the p-j^^-
prevention of disease. These embrace such , _

diverse measures as the construction of fil- ^.„^^ .^^
, - p . 1 gmeenng

termg plants and water-systems to furnish Trr-Qj-tg

an abundance of pure water, the installation
of sewerage-systems and crematories for the removal or
destruction of waste, thorough policing and cleaning of
streets and neighborhoods to keep down dust or reduce
vermin, or the draining, filling, or oiling of marshes to
do away with mosquitoes.

The best known and most commonly employed mea-
sures for killing germs are usually spoken of as disin-
fection and sterilization. The terms are not synony-
mous, though often used as if they were. When an
article is sterile in thp bacteriological sense, it is free

216 THE PREVENTION OF EPIDEMICS

from all germs. Disinfection may free it from all

_.. . , germs, but does not necessarily do so. It

, means the destruction of infectious organ-

g, ... isms. A urinal or bedpan contaminated

^ by use by a typhoid patient might be dis-

infected by simply rinsing in hot water, as
the typhoid germs are killed in a few minutes by a tem-
perature of 70° C. It would certainly not be sterile.

Heat is the most reliable of the means of sterilization
of small inanimate objects. It may be applied moist or
dry, the former effective at much lower degrees than
the latter. Boiling water or streaming steam, both of
which have a temperature of 100 C, will destroy all
kinds of growing germs in a short time, while dry heat
of 200° C. is necessary to accomplish the same purpose.
As this temperature will burn fabrics and is dangerous,
it is not much used. Boiling is simple and is easily ap-
plied to small articles, so that it is commonly resorted
to where special appliances are not available. In hos-
pitals steam sterilization is more often resorted to, as
being more convenient and not necessitating so much
handling and drying of articles. Large institutions also
have steam-chests of sufficient size to receive such bulky
articles as mattresses, carpets, and other household fur-
nishings, which may thus be quickly and thoroughly
disinfected. Gases and solutions of chemicals are also
used for disinfecting ; the former for rooms, furnishings,
or clothing that would be injured by heat, and to pene-
trate into cracks and crevices not otherwise accessible.
As many of these substances possess disagreeable odors,
or have the property of destroying smells, the lay public
at times displays a tendency to confuse deodoriza-
tion and fumigation with disinfection. The three may

DEFENSES AGAINST DISEASE 217

coexist, but they are not the same, and the words
should not be used loosely, as such usage may lead to
confusion of the processes and so do harm. Charcoal is a
good deodorant, and burning tobacco or pyrethrum may
furnish efficient fumigation in ridding a house of mos-
quitoes, but none of these is disinfectant. The principal
gaseous disinfectants are chlorine, sulphur fumes, and
formaldehyde. All of them are very irritant and un-
suitable for use in efficient concentration in rooms or
places where they will be inhaled.

Chlorine is not commonly used in its gaseous state,
and when "chloride of lime" is sprinkled about it is
liberated in such small amoumts as to be inefficient. In
watery solution it is valuable in disinfecting surfaces to
which it can be applied. It is a powerful bleaching
agent, and cannot be used on fabrics. Of recent years
this substance has come into very wide use as a purifier
of water. Many cities use it, and its use by troops in
the field has already been discussed.

Burning sulphur gives off fumes which unite with
water to form sulphurous acid, a very efficient disin-
fectant. The dry fumes have very little virtue of the
kind, but are very useful in destroying vermin, such as
flies, mosquitoes, and rats. When it is desired, however,
to disinfect a room that has been occupied by a case
of contagious disease, such as scarlet fever, by means of
sulphurous fumes, the walls, floors, and other surfaces
should first be moistened by wiping them with a damp
rag, or in some other way. As sidphurous acid also
bleaches or fades fabrics, it is frequently not to be used
except at great expense.

Formaldehyde gas, or its forty per cent solution in
water, known as formal or formalin, is now more often

218 THE PREVENTION OF EPIDEMICS

used than any other gaseous disinfectant. The gas may
be generated in the room to be disinfected by burning
wood alcohol in special burners known as formaldehyde
generators, or it may be liberated by the evaporation of
formalin. The latter is a very simple procedure, and
while its effectiveness cannot be guaranteed, the same
may be said of other gaseous disinfection, and it is
often the best available means. Many methods of for-
maldehyde disinfection have been used, but only the use
of formalin will be described here. For disinfecting the
contents of trunks and boxes, it may be sprinkled over
them freely, or placed on absorbent cotton or blotting-
paper and the boxes then closed tightly for twenty-
four hours. For the disinfection of rooms, from four
ounces to a pint of formalin should be used for each
thousand feet of cubic contents. The gas is speedily
liberated if six ounces of permanganate of potash be
added to the pint of formalin in a large bowl, or if
unslaked lime be added, or if the fluid be poured on
hot bricks. A still simpler and quite efficient method,
however, is to close hermetically all cracks and crevices
about the room, stretch ropes or strings across it and
on them hang sheets. The formalin is then poured upon
the sheets to saturate them, and the room tightly closed
and kept so for twenty-four hours or more, after which
it should be well opened and aired, to rid it of all fumes.
None of the gaseous disinfectants can be depended
upon to penetrate thoroughly into large and thick arti-
cles such as mattresses. Their action is apt to be super-
ficial, and it is therefore important that the articles in a
room to be disinfected be disposed in such a manner as
to expose as much surface as possible. Bedding should
be taken out of piles and hung on ropes or racks, pic-

DEFENSES AGAINST DISEASE 219

tures removed from walls, books opened so as to expose
all pages if possible, pockets turned inside out, and all
boxes opened.

Formaldehyde is less harmful to fabrics and colors
than the other gaseous disinfectants, and is altogether
the most satisfactory for ordinary use, except that it
cannot be depended upon to kill insects and vermin.

Fluid and solid chemicals, the latter in solution, are
much used as germicides^ disinfectants^ or antiseptics.
The number of substances so used is large, some of the
more important of them being the various acids, per-
manganate of potash, peroxide of hydrogen, and those
to be discussed.

Bichloride of mercury, or corrosive sublimate, is
probably the most important, and for many purposes
the most valuable, antiseptic drug. It is used in watery
solution of various strengths. A solution as weak as
one part in one million has some value, but it is gener-
ally used in strengths varying from one part in five hun-
dred to one in five thousand, and in such dilution is a
very powerful antiseptic, killing most germs in a few
minutes. It has attained popularity, and is commonly
sold in tablets of such size that one added to a pint of
water makes a one to one thousand solution. The main
objections to bichloride are that it is a powerful and
deadly poison, and the tablets in which it is sold may,
by mistake, be taken for other substances ; and that it
corrodes and injures metals with which it may come in
contact. It works more efficiently when combined with
an acid, and the tablets are usually such combinations.

Carbolic acid, or phenol, is quite as well, if not better,
known as an antiseptic. It is not so powerful as bichlo-
ride, and is used in solution of from one to five per cent

220 THE PREVENTION OF EPIDEMICS

strength. Occasionally it is used in what is called its
" pure " form, about ninety-five per cent strength. It is
a very deadly poison, but it does not corrode metals as
does bichloride, and is therefore better for disinfecting
them. Both of these substances irritate and injure the
bands if much used.

Iodine has long been known as an efficient disin-
fectant and antiseptic, but it has grown in favor very
rapidly in the last few years and is now particularly
esteemed for use in disinfecting the skin or the sur-
faces of wounds, for which purpose the tincture is gen-
erally used.

" TrikresoV^ is a disinfectant that is supplied and
much used in our military service. It is less readily sol-
uble than phenol, but is equally as powerful a disin-
fectant when used in half the strength of the solution
of the latter. It also is a poison.

There are numbers of mixtures or emulsions made
with cresols or crude carbolic as bases, which are both
cheap and excellent for many purposes. Many of them,
like the Creolin issued among veterinary supplies, are
proprietary preparations and are sold under trade
names. As cheap, efficient, and not secret in composi-
tion may be mentioned the official compound cresol so-
lution and the " larvacide " used on the Panama Canal
to destroy mosquito larvae and as a disinfectant.

Formalin is also used as a liquid disinfectant, and
for some purposes, such as the disinfection of urine
and feces, it is probably the most valuable one we have.
It should be thoroughly mixed with a stool to be dis-
infected, lumps of feces broken up, and the two allowed
to stand in contact for a time. Formalin is also a val-
uable deodorizer.

DEFENSES AGAINST DISEASE 221

For a few diseases we have remedies that may be
termed specific, or truly curative. In most infectious
diseases, however, we are at best able to
modify the course of the affection, to re-

ClUGS

lieve symptoms and maintain the strength
and vitality until nature, or the body forces, accom-
plishes a cure ; and even the specifics cannot always be
«:iven in such a way that they get at and destroy all
the organisms of disease.

Quinine is a specific for malaria, and actually de-
stroys the growing and multiplying organisms in the
blood. Yet men occasionally die of malaria in spite of
quinine, and many hundreds of army men can testify
that quinine does not always effect a prompt and per-
manent cure of the disease.

Mercury is a specific for syphilis. It kills the organ-
isms causing the disease, and causes the lesions to heal;
yet the men who have devoted the most attention and
study to the subject agree that treatment must be con-
tinued from two to four years in order to assure a cure.

The drug kuown as " salvarsan " or " 606^'^ which
was introduced a few years ago as a specific for syph-
ilis, is actually such, and it destroys the causative or-
ganisms with great rapidity. However, it is apparently
unable to reach them all, and world-wide use of it,
while proving its value, has only destroyed the hope at
one time cherished, that one injection could be depended
upon to cure the disease.

Antitoxin is a specific for diphtheria, neutralizing
the poison and making it harmless. Yet, if it be not
given early and the toxin has a chance to unite with the
tissues, it may fail, and death result in spite of its use.

Altogether, the consideration of specific remedies

222 THE PREVENTION OF EPIDEMICS

cannot but convince us that the prevention of disease
is of much more importance and value than its treat-
ment, and that the tendency, often manifested, to regard
the medical officer as one whose main office is the treat-
ment of men already sick, one who should have nothing
to do with the general administration of a post or an
army, is a very grave mistake. Specifics are very valu-
able, however, in the prevention of disease. Mosquitoes
are not apt to obtain infection from the blood of men
taking quinine. The man who is under treatment for
syphilis is less apt to transmit it than the infected man
who is untreated, and the prompt use of mercurial
inunctions after intercourse has been shown to be of
value in the prevention of infection. " Fourth of July "
tetanus, at one time all too common, was very greatly
reduced by the routine use of tetanus antitoxin after
injuries caused by fireworks.

CHAPTER XII

DISEASES DUE TO INFECTION THROUGH THE
ALIMENTARY TRACT

Typhoid and para-typhoid fevers, cholera, dysentery,
and " camp diarrhcea," which is apt to be typhoid or
dysentery, may be conveyed in other ways than are in-
dicated by the heading of this chapter. Typhoid, for
instance, may be produced by injection of the living
organisms beneath the skin. In general, though, these
diseases come from the ingestion of the causative or-
ganisms by way of the alimentary canal. The germs
are in the vast majority of instances introduced in or
on food or drink. For many years water was considered
the principal medium for the introduction, and it is still
recognized as a very important factor. Of late years,
however, so many cases, and even large epidemics, have
been traced to infected foods and so many more to con-
tact that it is really considered misleading to speak of
these merely as " water-borne " diseases.

In addition to the acute infections mentioned above,
there are a number of others that enter by the same
route. Tuberculosis does so at times, possibly in a large
proportion of cases ; many " acute food poisonings " are
properly alimentary tract infections ; " milk sickness '*
is due to infection with germs contained in milk from
diseased cows ; Malta fever to germs in the milk of
goats infected with that disease ; infestations with many
varieties of intestinal worms occur by way of the mouth,
and some of the diseases to be later described as enter-

224 THE PREVENTION OF EPIDEMICS

ing by way of the respiratory tract, such as diphthei'ia,
are known to be carried in infected milk. It is conceiv-
able, though doubtless uncommon, that typhoid or chol-
era organisms may enter the body through inhalation,
and in the throat pass to the alimentary tract and be
swallowed. In fact the throat, where diphtheria, scarlet
fever, and a number of other infections are apt to local-
ize, is common to both the alimentary and the respira-
tory tracts, and it is not always possible to say by which
tract an infection enters. However, it is generally cor-
rect to speak of the diseases here discussed as entering
by the alimentary tract, and it has been found in prac-
tice that the other avenues may be neglected without
great danger.

These have always constituted a very important group
of diseases, particularly for military men, and in ancient
and modern times, an<l in all of our wars, clear down
to and including the war with Spain and the later Phil-
ippine insurrection, typhoid and dysentery did more
damage than did hostile arms. As our knowledge in re-
gard to them has grown and we have learned of their
causes and the subtle and manifold methods of trans-
mission, we have been more and more able to avoid
them, and if they ever again cause such morbidity as they
have in the past, it will be because of neglect or of cir-
cumstances beyond control, and not because of igno-
rance. As showing how great a scourge typhoid has
been to us even in recent years, and after the method
of water carriage of the disease was well understood,
may be quoted the official, and it is thought conserva-
tive, statement that " About one fifth of the soldiers in
the national encampments in the United States in 1898
developed typhoid fever. Among 107,973 officers and

ALIMENTARY TRACT INFECTION 225

men in 92 regiments, the records of which we have care-
fully studied, the number of cases of typhoid fever,
according to our estimates, was 20,738." The above
is from the report of the " Board on the Origin and
Spread of Typhoid Fever in United States Military
Camps during the Spanish War of 1898," of which
board the late Major Walter Reed was president. That
report gave an impetus to the investigations that have
since so greatly increased our knowledge of the disease
and of the means of preventing it as to give rise to the
lively hope that such conditions as the board investi-
gated may never recur. Nevertheless cholera, which is
equally well understood and preventable, did great
damage to troops so recently as the late war in the
Balkans.

Typhoid fever* will be taken as the type disease for
this chapter, because it has been of such great military
importance in our own service, and because it has so
recently been almost eliminated from that service, and
it may well serve as a striking object lesson in hygiene,
but the general statements made are applicable to the
other infections that are transmitted in a similar manner.

The exciting causes of these diseases are as follows;
Typhoid fever is caused by a bacillus that is found in
the bowels, gall-bladder, blood, and internal -,
organs of those having the disease. It is
an actively mobile organism, does not form spores,
is easily killed by heat, and does not, under natural

^ Para-typhoid, of which at least two yarieties exist, haa only been
separated from typhoid for a few years, and even now the diagnosis
rests entirely on the identification of the causative bacilli, which in turn
bear a close resemblance to one another. For this reason most statistics
and descriptions of typhoid also include para-typhoid.

226 THE PREVENTION OF EPIDEMICS

conditions, produce disease in other animals than man.
Cholera is caused by a vibrio or spirillum, a spiral bac-
terium that occurs in the intestinal discharges and con-
tents of persons having the disease. It is actively mobile,
multiplies with great rapidity, and in so doing the
spirals break into comma-shaped fragments, whence the
name comma bacillus. It does not form spores, is easily
killed by heat and acids, and succumbs to the action of
sunlight more promptly than most other organisms.
Dysentery is a name applied to a group of symptoms
rather than to one specific disease. Consequently it is
due to several causes. One class of cases is caused by
a group of closely related bacilli that present some
differences, another to an amoeba, an animal parasite,
and still others to other microscopic animal parasites.
Intestinal infestations with worms have already been
discussed.

Every case of any of these diseases is derived from
some other case. We may at times have great difficulty
Q . . in tracing the origin of given cases, but the

, „ . more we learn about the diseases the more
J . evident the truth of the preceding sentence

becomes. Diet and unsanitary conditions
promote the spread of, but cannot originate, typhoid.
The germs must be introduced by man and are so in-
troduced. The man who first brings infection to a camp
may have the fever and not know what is the matter ;
he may be recovering from it and still not know, or he
may have had it and recovered long before, but be a
*' carrier " and continue excreting bacilli for years. As
showing the prevalence of typhoid fever in the general
population of the United States in 1898, the following
conclusions of the Reed Board are of great interest : —

ALIMENTARY TRACT INFECTION 227

" (1.) During the Spanish War of 1898 every regi-
ment constituting the First, Second, Third, Fourth,
Fifth, and Seventh Army Corps developed typhoid
fever.

'* (2.) More than ninety per cent of the volunteer
regiments developed typhoid fever within eight weeks
after going into camp.

" (3.) Typhoid fever developed also in certain regu-
lar regiments within three to five weeks after going into
camp.

" (4.) Typhoid fever became epidemic both in the
small encampments of not more than one regiment and
in the larger ones consisting of one or more corps.

"(5.) Typhoid fever became epidemic in camps
located in the Northern as well as in those located in
the Southern States.

" (6.) Typhoid fever is so widely distributed in this
country that one or more cases are likely to appear in
any regiment within eight weeks after assembly.

" (7.) Typhoid fever usually appears in military ex-
peditions within eight weeks after assembly."

Because of increase of knowledge of the methods of
transmission, and the dissemination of that knowledge
by state and local boards of health, by doctors, socie-
ties, magazines, and newspapers, because of improved
water supplies, sewage disposal, anti-fly campaigns, and
other advances since that time, it is probable that the
general conditions are not nearly so bad as they were
then, while experience has demonstrated that introduced
typhoid is not now allowed to spread as it then did. The
improvement in general conditions is not limited to our
own country, nor do we lead in it. In fact, we have been
behind both England and Germany in much public health

228 THE PREVENTION OF EPIDEMICS

work, and the latter nation has long led the world in its
low typhoid rate.^ America's bad showing was proba-
bly dependent on several factors, prominent among them
being (1) our very widely scattered population, (2) the
great extension of typhoid to all parts of the country by
soldiei's of the Civil War, (3) poorer and less enlight-
ened medical and public health service than in Ger-
many, (4) ignorance and indifference on the part of the
public. The first of these factors still obtains, though
modified by improved facilities for transportation, the
influence of the second is beginning to yield to opposi-
tion, the third is being corrected as rapidly as may be
expected, and that the fourth follows the third is shown
by the generous support now given by the public to
many movements for the improvement of health, by the
prominence given such subjects by the papers and mag-
azines, and by the fact that many line officers do know
and all have it in their power to know more concerning
the methods of spread and the means of prevention of
typhoid than did the medical officers of 1898.

Methods of Transmission

Investigators generally now regard sick and healthy
carriers to be the source of typhoid, while some of the
^ . most eminent of them regard endemic ty-

phoid, that is, typhoid always present in a
place, as nearly always due to healthy, chronic carriers.
A carrier of typhoid is a person who passes the living

^ Professor Max Rubner, Director of the Hygienic Institute, Uni-
versity of Berlin, said in 1913, " As a young man I saw the mighty
typhoid fever epidemics in our country, especially in Munich, my na-
tive town, which formerly decimated the population : to-day typhoid
fever has diminished, as I have been told by a clinical friend, until
there is not sufficient typhoid fever for the clinical lectures."

ALIMENTARY TRACT INFECTION 229

and virulent bacilli from his body, usually in his feces
or urine, in such a condition that they may infect other
persons. The carrier may be just entering on the disease,
may be very sick with it, or may be in good health. In
the last named instance he may have had the disease
and recovered from it, or he may be merely a " contact
carrier," a person who has obtained the germs from an-
other case and in whom they multiply, but one who has
never been sick with the disease. Ordinarily the term
" carrier " is used as meaning a chronic carrier and well
person, but a person in the early stages of the disease,
who continues at his work, is quite as dangerous, and
some of the most serious typhoid epidemics of recent
years have been due to carriers of this type. This in-
cludes the cases of " walking typhoid." As tending to
show how commonly infected persons continue at their
work, the following conclusions of the Reed Board may
be quoted : " (43.) In addition to the recognized cases
of typhoid fever, there were many short or abortive at-
tacks of this disease which were generally diagnosed as
some forms of malarial fever." " (46.) Army surgeons
correctly diagnosed about half the cases of typhoid
fever." Since that time the methods of diagnosis have
so greatly improved that the disease can be detected
with much more certainty and touch earlier, with result-
ing improvement in its control, but even yet early cases
are a source of great danger, for the reason that diag-
nosis is not always sought early by the patient, who is
apt to think that he has only a bit of indigestion or a
cold. An examination of the blood of every patient
showing any sort of febrile intestinal disturbance at Val
de Grace in 1907, '08, and '09 showed typhoid bacilli in
forty per cent of them, though in many there were no

230 THE PREVENTION OF EPIDEMICS

other symptoms suggesting typhoid. The actually bed-
fast patient is less apt to spread the disease widely be-
cause of the limitation of his activities. Except that his
dejecta may be disposed of so carelessly as to infect water
supplies, he is mainly dangerous to his attendants.

The chronic carrier, however, is a menace to nearly
all with whom he deals or comes in contact, because
neither be nor they suspect that he is a source of
danger. Since the investigation of the first recog-
nized chronic carrier, many interesting cases have been
studied and their histories worked out, and, as they
illustrate the dangers from this source, a few of them
will be detailed. The first case reported was that of the
female proprietor of a bakery in Strassburg. All of her
employees would sooner or later get typhoid, and the
cause could not be located. It was at length ascertained
that the woman, who had had typhoid ten years pre-
viously, was still passing very large numbers of typhoid
bacilli in her stools. In a British reformatory there had
been intermittent outbreaks of typhoid, three, four, or
five cases occurring at a time. Inquiry pointed to milk
as the cause, but inspection of the dairy and its sur-
roundings showed good sanitary conditions. Neverthe-
less the disease continued to appear. Search among
those handling the milk in the institution led to the
examination of a girl who had had typhoid six years
previously. Two examinations of her stools were nega-
tive, but the third showed that she was passing typhoid
bacilli. Her removal from the kitchen ended the epi-
demics.

The first instance thoroughly worked up in America
was a very instructive one. The investigation began
with the efforts to trace a small epidemic, six persons

ALIMENTARY TRACT INFECTION 231

in a household of eleven being attacked with the disease.
Thorough investigation at the time of this outbreak and
for some time subsequently failed to disclose the source
of infection in the food, drink, or general sanitary con-
ditions. At length suspicion was directed to a cook who
had worked in the house for a few weeks, beginning
about three weeks before the appearance of the disease.
With great difficulty Dr. George A. Soper was able to
trace part of her history during a period of ten years,
in which she was known to have lived in eight families
where inquiries could be made. In seven of these she
had been associated with typhoid outbreaks, always
escaping the disease herself. In the seven families there
were twenty-six cases of typhoid, with one death. Owing
to the cook's refusal to tell anything about herself, and
the fragmentary character of the history obtained, it is
probable that she had been associated with other cases.
On the information obtained, however, the New York
Department of Health caused her removal to the Deten-
tion Hospital, where she was examined, in spite of her
objections and resistance, and was found to be passing
great numbers of typhoid germs in her feces.

Another striking case is reported from Prussia, where
typhoid had been epidemic on a large estate for four-
teen years. During that time there had been thirty-two
cases of the disease among one hundred and eighty
persons on the estate. Investigations focused attention
on the dairy, all of the persons involved having used
milk from it. A woman employed there had had typhoid
seventeen years before, and the bacteria were found in
her stools almost to the exclusion of other varieties.
She had worked in the dairy fourteen years, and had
been spreading the disease during that time. Instances

232 THE PREVENTION OF EPIDEMICS

of epidemics caused by chronic carriers have been very
numerous and such carriers are well recognized as one
of the more common causes of epidemics. Usually the
epidemic is due to the fact that the carrier deals in or
handles food for other persons. That such is not always
the case, however, is shown by such instances as the
following: A nursing mother had typhoid and her in-
fant was taken to a friend's house. The child had a
slight diarrhoea but was being weaned, and no particu-
lar attention was paid to this until, one after another,
six members of the friend's family developed tj-^phoid.
Examination of the child's blood then showed that it
had typhoid.

The case of a sailor investigated in San Francisco is
of striking interest. In three years and seven months
there were 26 cases of typhoid on a ship whose crew num-
bered 21 men, and this sailor, who had had typhoid
four years before, was found to be a carrier and almost
certainly responsible, though he did not handle foods
as cook or kitchen helper. The close and intimate con-
tact of life on a small vessel gave him the opportunity
to spread the infection. A case known to the writer has
suggested the thought that a prostitute who happened
to be also a chronic carrier might scatter the disease
by plying her trade. Conversely, as the infection in
male carriers is at times localized in the seminal ves-
icles, it is possible that such a one might infect the
female having intercourse with him.

Still, as said before, the danger usually comes through
contamination of food, and the very great importance
of cleanliness on the part of cooks and other persons
handling foods, and the necessity of investigating the
kitchen in the case of company outbreaks, should al-

ALIMENTARY TRACT INFECTION 233

ways be borne in mind. A severe company outbreak at
Fort D. A. Russell in 1909 was found to be due to
contamination of food by men working on kitchen police
while in the early stages of the disease.

About five per cent of typhoid cases are carriers after
their recovery. They may remain such for months or
for years. Epidemics have been traced to persons who
were carriers after attacks occurring more than fifty
years previously, and more than one instance of " family
predisposition " to typhoid has been traced to a family
grandmother who had been distributing the infection
with food prepared for the rising generations.

As already stated, healthy carriers of cholera are
well recognized, and epidemics have been traced directly
to them. So far as is known, however, they do not re-
main carriers for many years as do typhoid carriers,
eight weeks being a long period. The belief that this
is true is strengthened by the history of cholera in Italy
in 1911 and 1912. In the former year it caused 7000
deaths, but it died out in the winter and did not re-
appear in 1912. This would scarcely have been possible
with so extensive an outbreak of typhoid. Dysentery
carriers are also numerous in some countries, and some
of them remain carriers for many years. They are com-
mon in the Philippines.

The effort is always made in our military practice, and
in the better class of civil institutions, not to discharge
typhoid or cholera patients from hospital until repeated
examinations of stools and urine have shown that they
no longer excrete the causative bacilli.

Water was not found by the Reed Board to be an
important factor in the spread of typhoid
in the national encampments in 1898; but

234 THE PREVENTION OF EPIDEMICS

it has so often been demonstrated as the most impor-
taut factor in other epidemics, that all authorities
agree in considering it one of the first subjects to be
investigated in case of any outbreak. This method of
transmission is so well recognized and so generally
known that it is not necessary to cite any of the very
numerous instances showing it. Prior to 1898 practi-
cally all of the great epidemics that had been studied
wei'e traced to infected drinking-supplies, and the dis-
ease was regarded as mainly, if not entirely, water-
borne. This fact helps to account for the size and extent
of the great camp epidemics of that year. Cholera and
dysentery have also usually been traced to infected
water. There is, however, the possibility that both may
be transmitted in the other ways to be considered.

The germs may be ingested directly in polluted drink-
ing water, and such is the usual method in large epi-
demics due to water. The danger in such instances of
course increases with the dose of germs, that is, with
increase in the degree of pollution or in the length of
time the water is used. It may also occur in less obvious
ways. Thus, water that is used in clothes-washing or
bathing may become infected from the clothing or per-
sons of sick men or carriers, and may later infect the
hands or persons of the people handling or using it, or
the vessels in which it was contained. Or men may con-
tract the disease by bathing or swimming in infected
streams or pools, and inadvertently taking water into
their mouths, noses, or, possibly, their eyes.

The influence of water in spreading typhoid is well
shown by the drop in typhoid deaths in cities putting
in new and good water supplies. The statistics of
deaths in 6fty such cities showed, upon examination in

ALIMENTARY TRACT INFECTION 235

1913, very great improvement, the most striking in-
stance of it being in Pittsburg, where the typhoid deaths
per 100,000 of population fell from 74.3 to 12.7, and in
the districts getting the good water to 6.9.

The U. S. Public Health Report for August 7, 1914,
contains an article on "Safe Ice" which concludes
with the following summary: —

" 1. Clear ice is, of itself, as free from
the danger of conveying infectious diseases as we need
wish.

" 2. Dirty or cloudy ice may be dangerous. It should
not be placed in water nor on food which is to be eaten
uncooked.

" 3. There may be danger in eating iced foods or
using iced drinks if the ice is improperly handled when
placed in contact with the food or drink.

" 4. We may eliminate all danger by avoiding the
handling of ice with dirty hands, by washing the ice
with pure water, and by using only clear ice.

" 6. The average laboring person does not always
have the opportunity, even if he have the inclination,
to cleanse his hands after attending to those necessities
of nature which require their use for purposes which
almost invariably result in their contact with excreta
which may contain the organisms of disease, even in
apparently healthy people.

*' It is therefore impossible to overestimate the dan-
ger resulting from the handling of ice by unknown per-
sons if the ice is placed in direct contact with drinking
water. Consequently in hotels, cars, stations, and simi-
lar places where intelligent personal supervision is im-
possible or impracticable, those furnishing the water
should be instructed, and indeed compelled by law, to

236 THE PREVENTION OF EPIDEMICS

adopt such means of cooling water as do not require
direct contact of ice and water."

Milk-borne epidemics of typhoid are also well recog-
nized, and many of them have been thoroughly studied.
The milk is, in the great majority of in-
stances, contaminated from the hands of
milkers, dealers, or other handlers who are suffering
from beginning typhoid and have not yet ceased work,
who are convalescing from the same disease, or who
have had it formerly and are still " carriers," The con-
tamination may occur in other ways, such as the use of
infected water for washing cans or diluting milk. It
may also linger long in cans once infected, if they are
not properly washed and sterilized, as the germs will
multiply in milk. As the same thing is true of the
germs of cholera and dysentery, they may also be milk-
borne.

One of the largest milk-borne epidemics of typhoid
fever occurred in the suburbs of Boston in the spring
of 1908. Four hundred and ten cases occurred, the in-
fection being traced to a milk-dealer who continued his
work for two weeks after the onset of the typhoid fever
from which he later died.

An epidemic of 295 cases at Worcester, Massachu-
setts, in 1911, was traced to milk infected by a carrier
who had had typhoid twenty-six years previously. That
both of these epidemics are reported from the same
state is an indication of the thorough investigations
and reports made in that state, and not to any greater
prevalence of typhoid there than in other states.

Lettuce, radishes, and other vegetables or fruits that
are eaten uncooked may be contaminated by unclean
handling, by washing in polluted water, by contact with

ALIMENTARY TRACT INFECTION 237

typhoid feces or urine in manure, by flies, or by in-
fected dust blown and deposited on them.
Bread, cool meats, and other food-articles , , ",

may also be contaminated in some of these
ways after they are cooked. Any article so
polluted might cause the disease if it were
eaten.

An interesting typhoid outbreak in the German army,
reported in 1909, was traced to a woman carrier who
prepared vegetables in a maneuver camp. The very
careful investigation made indicated that 124 men
were probably infected, though only 27 of them were
sick enough to be classed clinically as typhoid. Yet
any or all of them might have been sources of danger
to the commands to which they belonged.

The avoidance of uncooked fruit and vegetables
from and in places where cholera prevails is a matter
of great importance.

Many epidemics of typhoid fever have been traced to
the consumption of oysters and other shellfish gathered
from sewerage-infected beds. For twenty-
five years the city of Belfast had had the ®

greatest mortality from typhoid of all the cities in the
United Kingdom, in spite of a good water-supply and
good general sanitation. A commission appointed in
1907 to investigate the matter showed that the endemic
prevalence of the disease was due to the unrestricted
gathering of cockles, mussels, and other shellfish from
the " slob-lands " of Belfast Lough, which are laden
with the city's sewage. Hundreds of acres are exposed
at low tide, and the shellfish are gathered by the poorer
classes, who generally eat them raw. The Jews, who do
not eat them, were exempt from the disease. It is prob-

238 THE PREVENTION OF EPIDEMICS

able that cholera and dysentery may be transmitted in
the same way.

Living and virulent typhoid organisms have been
found in the mouths of persons sick with the disease,
and the vomit of cholera may contain the
germs of that ailment. It may therefore be
understood that the common use of drink-
*^ ing-cups, clinical thermometers, and other

articles that are put to the mouth, may lead to infection.
In all of the diseases discussed in this chapter the or-
ganisms occur in the intestines, and careless use of
rectal syringes may spread them. Such an accident is,
of course, more apt to occur in hospitals.

None of these diseases is air-borne in the sense that
smallpox and scarlet fever are, but feces, urine, or
other material containing the causative or-
ganisms may be scattered as dust when well
or partially dried and pulverized, and may be inhaled
in that form, or may light on articles of food or drink
and be ingested with them. The Reed Board reported :
" (31.) It is probable that the infection was disseminated
to some extent through the air in the form of dust."

" (28.) Flies undoubtedly served as carriers of the
infection. Flies swarmed over infected fecal matter in
the pits, and then visited and fed upon food prepared
for the soldiers at the mess tents. In some instances
Flies where lime had recently been sprinkled over

J the contents of the pits, flies with their feet

other whitened with lime were seen walking over

Vermin *^^ food. It is possible for the fly to carry
the typhoid bacillus in two ways. In the
first place, fecal matter containing the typhoid germ
may adhere to the fly and be mechanically transported.

ALIMENTARY TRACT INFECTION 239

In the second place, it is possible that the typhoid
bacillus may be carried in the digestive organs of the
fly and be deposited with its excrement."

Several asylum epidemics of dysentery, notably one
at the Dan vers State Hospital (Mass.), have been shown
to be spread by flies, and the large annual epidemics in
Fiji from December to March have been ascribed to
the same agency. Flies caught during an Indian epi-
demic of cholera in 1912 were found to have cholera
vibrios both on their external appendages and in their
intestinal canals.

Recent work in the Philippine Bureau of Science
has shown that cockroaches fed on human cholera feces
may harbor cholera vibrios in their intestines, and these
may appear in enormous numbers in the insect's feces
for at least two days after the feeding, and in smaller
numbers for a longer time, and if deposited on human
food with the cockroach feces they may there survive
for another four days. By means of either feces or
vomit from cholera cases the cockroach may carry in-
fection to human food. The same investigation showed
that cholera vibrios may be found in the bodies of ants
for eight hours after they have ingested feces from
cholera patients. There is little room for doubt that
both of these insects could carry typhoid, probably
more readily than cholera.

It would be well for the line officer to know the
following facts concerning house-flies. They breed in
horse-manure, human feces, and other filth, and can
readily emerge through six inches of loose earth, but
not through earth saturated with water. When breed-
ing in feces, the larvae will go into the earth five or six
inches as the feces dries, and there find more congenial

240 THE PREVENTION OF EPIDEMICS

surroundings. Flies are naturally most numerous about
manure piles, trench latrines, and kitchens, because they
find in those places the best breeding and feeding
places respectively. The female lays about 120 eggs,
and the development of these varies with the tempera-
ture, in the tropics somewhat as follows : —

Hot Weathkk Cold Wkathbb
Days Days

Eggs hatch in 12

Maggots change to pupse in 5 14

Pupse change to adult flies in 3 5

Total Short 9 long 21 or more

In temperate and cold climates all the stages of the
fly's life may be prolonged, so that the full change from
adult to adult may require as much as two months,
while adults and possibly pupae last through the win-
ter and start the cycle again in the spring. The fly does
not pupate in a wet medium if the full-grown larvae
can find means of migrating to a dry place protected
from the sun; for example, at the edge of the manure
pile, under boards, or in cracks. Here the pupal cases
may be found as small, brown shells the size of plump
grains of wheat, and in great numbers. It has been
found that bacteria such as those causing typhoid sur-
vive much longer in than on flies, and longer in the in-
sect's gut than in its deposited feces. A study of the
flies of New York City in 1911 brought out the follow-
ing facts that are of interest as bearing on the seasonal
occurrence of typhoid and summer diarrhoea (bacillary
dysentery). Up to the end of June the flies were found
to be practically free from fecal bacteria. During July

ALIMENTARY TRACT INFECTION 241

and August the flies examined carried millions of bac-
teria, whereas at other seasons they carried hundreds
only. Fecal bacteria of the colon bacillus type were
first found abundant in July. The bacteria were 8.6
times as numerous in the intestines as on the surface
of the flies. Extensive experiments and observations
in Cambridge, England, indicate that houseflies tend to
travel against or across the wind, apparently attracted
by odors. The chief conditions favoring dispersal of
flies are fine weather and warm temperature. They do
not travel as far in towns as in the country, the maxi-
mum flight observed in thickly populated parts of
Cambridge being a fourth of a mile, while in the open
country single fliglits may double that.

Contact with sick persons offers many opportunities
for both mediate and immediate infection, and the class
of diseases under discussion often infect r* t i-
nurses and attendants. The typhoid patient,
as stated before, may give off the germs of the disease
from his bowels, bladder, or, occasionally, his mouth.
From these sources the bacilli get on towels, bedding,
urinals, chamber pots, the patient's skin, and into bath
water. Any of these articles may be handled by nurses,
associates, or casual visitors, who may thereby infect
their own hands or persons, and later take the germs
into the mouth. Persons using the same drinking glasses,
linen, or other personal articles, as the sick man, are
especially apt to be infected. This method of infection
is now regarded as very important. The greatest care
in cleanliness and disinfection is necessary on the part
of all hospital attendants and others brought in contact
with the disease. The danger is of course greater if the
nature of the disease is unknown, and the subject pur-

242 THE PREVENTION OF EPIDEMICS

sues his ordinary course of life, eating, drinking, sleep
ing, defecating, and urinating, with no thought of being
a menace to others.

Tent-mates and bed-mates, and members of the same
family and household, are particularly exposed. The
Reed Board published the following conclusions that
bear on the subject: " (30.) Typhoid fever, as it devel-
oped in the regimental organizations, was characterized
by a series of company epidemics, each one having more
or less perfectly its own individual characteristics. . . .
Of 1608 cases of typhoid fever which we have been
able to accurately locate in the particular tents in which
they occurred, together with the date of the commence-
ment of the attack, the results may be summarized as
follows : —

" Directly connectable attacks, 563, or 35.01 per
cent.

" Indirectly connectable attacks, 447, or 27.79 per
cent.

"Total connectable attacks, 1010, or 62.8 per cent.

. . . "We believe, therefore, that personal contact
was a very important factor, probably the most im-
portant, in the spread of the disease."

The Germans, after years of careful and most valu-
able work by a government commission on typhoid in
southwest Germany, regard contact as the main method
of spread of the disease. The contact is with the sick,
the sickening or the healthy carrier, but usually with
one just sickening. The German commission found
typhoid bacilli in the blood of an apparently healthy
boy of twelve, whose sister, in the same house, had the
disease. Four days later the boy sickened. He was a
source of danger even before he appeared sick. Exam-

ALIMENTARY TRACT INFECTION 243

ination of 600 cases of typhoid in the Saar district
showed that a large proportion of contact infections
must have occurred during or before the first week of
sickness of the infecting cases, even assuming the in-
cubation period to be so short as ten days. In fact, more
than half of the contact cases seemed to have been in-
fected thus.

Contact infection was the main cause of the spread
of cholera in the Bulgarian army in 1913. Recruits
neglected to use latrines, soiled the ground, and later
infected their hands in removing shoes and clothing.

It will be readily understood that the dangers of
contact would be greatly increased by crowding, poor
ventilation, and uncleanly habits.

House epidemics of cholera are common in the Philip-
pines during epidemic seasons, and owe their origin and
spread to the causes discussed above, to the common
use of food and drinking utensils, and to infection con-
tracted in cleaning up vomit and watery stools. There
is good reason to think that dysentery and diarrhoea
may be spread in the same ways, while it is well known
that intestinal worms often are, among children.

The above discussion of the dangers of contact with
sick persons may be applied equally well to similar re-
lations with carriers, except that they are not known
to their associates to be sources of danger, and are
thereby rendered mpre harmful. They are more apt
than sick men to sleep with other persons, to lend or
borrow clothing, to be put on duty in kitchens, or han-
dling foods, or caring for cows, while no precautions are
taken in the matters of disinfecting their clothing,
stools, or urine.

It does not require lengthy argument to demonstrate

244 THE PREVENTION OF EPIDEMICS

that, if urine and feces contain disease-producing germs

and are deposited on the surface of the ground about

_ ., , camps or are allowed to soil the edges

Soiled , . . . f , . , .

and vicinity of latrines, men may get their

shoes soiled with such matters and the con-
tained germs. Such being the case, the contamination
might easily be conveyed to tents, bunks, company
streets, and the hands of the men. Needless to say, such
infection could be conveyed even though all gross evi-
dence of fecal or urinary soiling were removed.

The term fomites includes such inanimate articles or
substances as are thought capable of absorbing, preserv-
_, . ing, and transmitting tlie contagion of dis-

ease, and is used as a general designation
for such things as books, clothing, tents, bedding, and
baggage. Clothing that is grossly contaminated, such as
sheets or shirts soiled by the diarrhoeal discharges of
sick men, is, of course, most dangerous, but the danger
in such cases is apt to be recognized and provision made
for it. On the other hand, bedding soiled by dirty
shoes, tents that have been urinated upon, the clothing
of apparently well carriers, and other articles may be
infected and show no signs of it, and so do great harm.

Laundry-workers, hospital attendants, and tent-mates
of the sick are naturally more liable than others to
infection in this way; yet all may be exposed to it in
time of epidemics.

Prevention and Control

The general measures for the prevention of these

diseases are those hygienic precautions that have been

discussed in preceding chapters. If cases do begin to

appear in a command, it is evident that they have not

ALIMENTARY TRACT INFECTION 245

been sufficient, and more vigorous steps should be taken
to protect the men not yet infected. If they show in
the neighborhood of the command, or along lines of
communication with it, the same active measures should
be adopted. The best prospects for the prevention or
control of the epidemic will be offered if the following
steps be taken.

One of the most important of these is early diagnosis
of the dangerous cases. As long as their nature is un-
known, they continue to disseminate the — ,
disease-germs ; and such undiagnosed or _.
wrongly diagnosed cases apparently had
much to do with the spread of typhoid fever in the
camps in 1898. At that time the methods of diagnosis
were not so good as at present, and a positive diagnosis
of typhoid could not usually be made until after the
patient had been sick a week or more. Laboratory
methods now permit of it sooner, but they are not
always available, and the safe rule is to regard and
handle suspected cases as though the disease were known
to be typhoid.

The diagnosis is a matter for the medical officer to
worry over, but the line officer can be of assistance if
he instructs his men to go on sick report if they are not
well, and if he does not unduly encourage the notion
that men only seek sick report to escape work. It is
at any rate better that two or three frauds should be
allowed to loaf for a time than that one sick man should
be allowed to spread disease through the command.
The Reed Board made the following findings that bear
on the difficulties and importance of early diagnosis : —

" (46.) Army surgeons correctly diagnosed about half
the cases of typhoid fever."

246 THE PREVENTION OF EPIDEMICS

" (14.) A man infected with typhoid fever may scat-
ter the infection in every latrine in a regiment before
the disease is recognized in himself."

Diagnosis is of no value in the prevention of epi-
demics unless it leads to immediate steps to prevent
T lat'nn i^^^ction through contact, soil - pollution,
water -pollution, and in other ways. It
should therefore lead to the isolation of all recognized
or suspected cases, and such measures of care as will
prevent their spreading the disease in any of the ways
discussed in this chapter. Such measures must include
screening from flies, disinfection of clothing and linen,
of bath water, dishes and utensils, of stools, urine, and
spit. Only the necessary attendants, and they well-
trained ones, should have access to the patients. The
isolation should at times include suspects who have
been exposed to disease as well as the actually sick.
This is particularly true as regards cholera. It is neces-
sary in a less degree for typhoid, and still less for dys-
entery. Whenever resorted to, such isolation should
more than cover the ordinary period of incubation of
the disease. Cholera suspects should be isolated for five
days, those suspected of typhoid for three weeks or un-
til well and free from bacilli. In the latter disease such
strict isolation may not be necessary, but in case of se-
vere epidemics it will be wise, and can be done in iso-
lation camps, where the men can work, drill, and play.
At times it may be advisable to quarantine entire or-
ganizations as suspects, or to direct the measure against
towns or communities.

Isolation cannot be made an effective measure of
disease-prevention unless it includes all cases of the
disease in question, and, in many instances, all sus-

ALIMENTARY TRACT INFECTION 247

pected cases. It is, therefore, essential that all cases
and suspects be promptly reported to the central au-
thority, in order that proper steps may be _, .

taken. It is only rarely that difficulty will _

1 . 1^ -0. J ^1 M- Bory Re-

arise in this matter as it regards the mili- ' .

, , . '^ . .,. porting

tary personnel ; but cases among civilians t r*

and residents of the locality in which the
troops are quartered may be willfully concealed. Epi-
demics " hurt business," and often interfere with trans-
portation and traffic, and for this reason and others it
is not uncommon that great efforts are made to hide or
deny their existence.

It therefore occasionally becomes necessary to make
regular and frequent inspections and examinations of
all persons in camp, and less frequently of _, . ,
those in the neighborhood. If the commu- _
nity is under military control, this may be a .
relatively simple matter, but where such is
not the case it may be one of extreme difficulty, and call
for the display of much forbearance, good temper, and
tact. When such measures are necessaiy, they should be
under the charge and direction of medical officers who
will see that they thoroughly accomplish their purpose,
but at minimum of inconvenience, and that they are
conducted in such a manner as to gain rather than alien-
ate the sympathy and the cooperation of the civil pop-
ulation and its medical practitioners. If many sick
are found it may be necessary, in order to control the
epidemic, to establish large isolation camps and special
hospitals for civilians. The gathering of large crowds
from many places, as in pilgrimages, fairs, and religious
festivals, should be particularly forbidden during chol-
era epidemics. Health-inspections may also be made

248 THE PREVENTION OF EPIDEMICS

the means of much sanitary instruction, and may thus
do great good in addition to that accruing from a know-
ledge of the location of cases. Such inspection, exami-
nations, and instructions have been resorted to in times
of cholera epidemics, and among peoples living under
military control, with great success. They redound to
the benefit of the civil as well as the military population.
Inspections of troops for the presence of disease are not
infrequently resorted to, and often do much good.

Every case of any of these diseases that is reported
or discovered should be investigated as thoroughly as
T *j possible as to its origin. This investigation

may show no results in single cases, but
p, when the findings in many cases are com-

pared they may give important information
as to the cause of the epidemic. Thus it may be
found that it is confined to persons using a certain water,
to those consuming milk sold by a special dealer, or
who eat the productions of a certain cook, or who have
partaken of shellfish ; or that the cases are otherwise
connected in some way. The information thus gained
may direct attention to the cause of an epidemic, and its
removal may put an end to the whole matter. The trac-
ing of epidemics is, however, often a difficult matter,
and the detection of typhoid-carriers is particularly so.
If, for instance, a carrier were put on kitchen police for
a day and infected the food of a company, a dozen men
might contract the disease as a result. They might de-
Telop it, however, in from one to three weeks, or possibly
more, and meanwhile a large number of men may have
worked in the kitchen, and many other factors having
an apparent bearing may have come to light, so that all
thought is diverted from the man really causing the

ALIMENTARY TRACT INFECTION 249

trouble. However, the report of a well-studied carrier-
caused epidemic of 93 cases in Hanford, California, in
1914, showed that more cases developed on the sixth
than on any other day, two thirds of all cases appeared
by the tenth day, and one case developed in three days.

In very many instances the cause of the epidemic can-
not be ascertained, or at least not soon enough to permit
its removal in time to prevent numerous infections, and
protection must be sought in the practice of such general
preventive measures as are applicable. These should
take into consideration the various methods in which
the diseases are transmitted, and will embrace the fol-
lowing.

Cleanliness of persons, tents, kitchens, and camps is
of paramouut importance, and officers should encourage
it by precept, example, orders, and, if nee- ^ .

essary, punishment. Those associated with -_
the sick should be particularly careful as
to their persons, surroundings, and food. They should
keep clean tents, wash themselves frequently, disin-
fect their hands after handling the sick, their bedding,
clothing, or other personal belongings, should be care-
ful not to use the same drinking or eating utensils,
and in other ways should avoid the dangers of contact.
Disinfection of clothing, bedding, tents, rooms, bar-
racks, urinals, latrines, and all the things used by the
sick man, should follow his removal from the barracks,
tent, camp, or temporary hospital. Articles that cannot
be well disinfected, such as hats and leather gloves,
should be destroyed if probably infected. Latrines that
are infected should be disinfected as well as possible,
and, if pits or other cheap arrangements, closed. Great
care should be taken to make sure that all latrines are

250 THE PREVENTION OF EPIDEMICS

fly-proof. General good hygiene should prevail. Sun-
shine and fresh air should be provided in abundance to
destroy and dilute the poison ; temperance, order, and
regularity of habits encouraged, overwork and idleness
alike avoided, and cheerful and rational living enjoyed.
The ground should be kept so clean as to leave no
opportunity for fecal or urinary contamination of shoes,
no breeding-places or food-supplies for flies or roaches,
and no infected dust to blow about. The effect of not
doing these things is seen more promptly in cholera
than in typhoid, because the incubation period in the
former is shorter and effects become manifested before
causes are forgotten. In that instance, lack of sunshine,
intemperance in food and drink, fear, and unhygienic
surroundings are regarded as important predisposing
causes of the disease. Increased care and attention
should be given to the disposal offeces^ urine, vomit^
and other wastes, and to the elimination of fiie& and
other insects and protection from them. Cremation of
waste materials should be resorted to if practicable.
Men should be instructed to use only the latrines and
urinals of their own companies so far as it is possible
to do so, and under no circumstances to urinate or defe-
cate on the ground. The Reed Board reported : " (15.)
Camp pollution was the greatest sin committed by the
troops in 1898."

Cleanliness of camp-sites and good general police are
therefore of very great importance, both as preventing
accumulations of infective material and as keeping
down flies and other vermin. The Reed Board pub-
lished an important conclusion bearing on this : —

" (37.) The fact that a command expects to change
its location does not justify neglect of the proper polic-

ALIMENTARY TRACT INFECTION 251

ing of the ground occupied. ... A camp-site should
be thoroughly policed up to the moment of vacating it.
This should be insisted upon as a matter of military
discipline, and camp commanders should regard proper
attention to the sanitation of the site occupied by their
troops as one of their highest duties, and its neglect as
a crime."

Recent experiments show that typhoid bacilli can re-
tain their virulence in soil for several weeks or months.

When, because of want of foresight, neglect, or for
any other reason, a command is located on a polluted
site, a change may be desirable. This can-
not be depended upon to rid the command r cs-
of infection; and disinfection, isolation, and
the other measures herein advocated must continue to
be used, but the change may at any rate reduce the
number of channels of infection. The dust blown about
camp would be less dangerous, the number of flies
smaller, and the opportunities for fecal contaminations
fewer, in the new camp.

The water used for drinking, dishwashing, and sim-
ilar purposes can, of course, be sterilized by boiling ; but
as many men seek other water to drink, it is .^
desirable that only a pure supply be avail-
able, and if one purified by large filtration '^^ ^

plants or other means is to be obtained, it should be.
At times it may be necessary to take steps to guard the
purity of a supply known to be good. Reservoirs, fil-
ters, or watersheds may need to be patrolled to prevent
their contamination. Bathing in drinking - supplies
should of course be prevented. The rule to be followed
always in time of epidemics is, however, to drink no
water not purified by heat. No matter how good a

252 THE PREVENTION OF EPIDEMICS

general supply is to-day, the possibilities of infection
are so many, and so hard to guard against, that there
is no certainty as to the purity of to-morrow's supply.

Ice, unless made from distilled water and handled
with all possible care, should not be allowed to come
in contact with articles of food or drink during the
prevalence of epidemics. It may contain germs frozen
in it, or they may have been deposited on the surface
by improper handling.

The safest rule as to foods is the same as that just
applied to water, — to take none that is not sterilized.
_, J This rule is pretty generally applied by

« , Americans in the Philippines, especially

during cholera epidemics, but it has not
had such general application in our own country or as a
measure of defense against typhoid. Heat is the means
of sterilization for most foods, and cooking the method
of applying it. However, such articles as bananas,
mangoes, apples, cucumbers, melons, that are protected
by a thick skin or rind, may be washed in bichloride
or other antiseptic solution, and later peeled. The use
of pies, soft drinks, milk, and similar articles sold by
peddlers, is in general to be deprecated, and it may
be advisable to stop such sales. Green vegetables may
also have to be banned, particularly in cholera times
and where dysentery and the practice of manuring
with human feces coexist. If either typhoid or cholera
appears in the person or family of a dealer in food-
stuff or milk, his business should be stopped at once, or
allowed to continue only under such rigid rules as will
destroy all chance of dissemination of the infection. If
the person cannot be controlled by military authority,
the soldiers should be forbidden to deal with him.

ALIMENTARY TRACT INFECTION 253

Typhoid, cholera, and bacillary dysentery are all dis-
eases in which protective value has been attributed to
the injection of the living or killed germs
beneath the skin, the procedure commonly ^
spoken of as vaccination against the dis-
eases. Vaccination against dysentery has had relatively
little use, but good results have been claimed. The use
of cholera vaccine has been mueh more extensive, and in
India, Japan, the Philippines, and elsewhere the results
have been considered most encouraging. According to
statistics published in 1913 by the originator of the
most widely used cholera vaccine, it appears to reduce
both the morbidity and death rates to about one seventh
of what they are among the unvaccinated.

The latest available figures relating to this vaccine
are those concerning its use in the Gi'cek army at the
end of the Balkan war. Following an extensive out-
break of cholera in the army and the territory occupied
by it, 150,000 troops and 350,000 civilians were vacci-
nated. The attempt was made to give two injections at
an interval of eight days. The immediate effects of the
injections were not such as to prevent military duty, and
were probably much like those following the use of our
typhoid prophylactic. In the whole army about 19 per-
sons per 1000 developed cholera. Among the unvacci-
nated the incidence was 93 per 1000 and the mortality
was 27.5 per cent of the sick. Among those who had
one injection the incidence was 42 per 1000, with a
mortality of 12.2 per cent, and among those having two
injections it was 7 per 1000 with a mortality of 10.2
per cent. That this entire improvement was due to the
use of vaccine is improbable, but how much of it was due
to improved measures of sanitation and to the general

254 THE PREVENTION OF EPIDEMICS

dissemination of knowledge of the methods of preven-
tion that must have gone into effect as the vaccination
progressed is not known.

Typhoid vaccine, or prophylactic, as it is officially des-
ignated, has had its most extensive use in our own army,
and the results have been so good that its use has there
been compulsory and universal since 1911. Typhoid
has now practically disappeared from the United States
army, its incidence and mortality for seven years being
shown in the following table : —

Typhoid Incidence and Deaths per 1000 Persons in

the U.S. Army

Year Cases Deaths

1907 3.53 0.19

1908 2.94 0.23

1909 3.03 0.28

1910 2.32 0.16

1911 0.89 0.11

1912 0.26 0.03

1913 0.03 0.00

Just how much of the reduction shown here is due
to the use of prophylactic and how much to other fac-
tors it is impossible to say. In his annual report for
1913 the Surgeon General sai<i, " It must be especially
emphasized that there has been no lessening of the
efforts in the army to prevent, by improved sanitary
measures, the occurrence of typhoid infection. Advances
in the other sanitary measures have gone on, hand in
hand, with the extension of the typhoid prophylaxis."

It must be emphasized also that no one is justified,
because of his use of typhoid vaccine, in neglecting to
care for himself or his fellows in all known ways.

CHAPTER XIII

DISEASES DUE TO INFECTION THROUGH THE
RESPIRATORY TRACT

To group the diseases discussed in this chapter under
the above heading may be somewhat misleading, but as
it is thought that all of them do frequently gain admission
to the body by way of the respiratory tract, and some of
them always, as the above caption is less misleading
than the phrase "air-borne diseases," and as the group
cannot be considered as conveniently and satisfactorily
in the preceding or the following chapters as in this,
the grouping is considered justifiable.

Most of those now to be treated of are also known
as contagious diseases. The term is elastic and may
be used in different senses, but as ordinarily applied to
the diseases discussed in this chapter it may be taken
to mean that they are more readily transmissible than
most others and are very apt to spread, especially by
contact or association.

The principal diseases, from a military standpoint,
in this group are measles, scarlet fever, German mea-
sles, smallpox, chickenpox, influenza or grippe, mumps,
whooping-cough, diphtheria, tonsillitis, epidemic men-
ingitis, and acute anterior poliomyelitis or infantile
paralysis. It is true, though, that tuberculosis, pneu-
monia, pneumonic plague, and some other diseases are
sometimes widely spread in the same way.

Some of the diseases mentioned above — influenza,

256 THE PREVENTION OF EPIDEMICS

tuberculosis, diphtheria, meningitis, tonsillitis, plague,

^ . and whooping-cough — are known to be

Causative j u i .. • i xi.

O an ama ^^^^^^ "Y uacteria, and the organisms can

be isolated and identified. The causes of
measles, German measles, scarlet fever, and smallpox
are still unknown, and it is possible, though not certain,
that they are due to organisms invisible with our micro-
scopes. Supposedly causative organisms have been de-
scribed for each of them, but convincing proof of the
relationship has in no instance been produced.

Certain factors have an important influence in pre-
disposing to some of these diseases, and enable us to
p -. exercise some measure of control over them.

. Most of them are so prevalent in the very

^ young as to be known as " the diseases of

childhood." By this phrase we usually speak
of the group including mumps, measles, scarlet fever,
German measles, chicken-pox, and diphtheria. Before
the era of vaccination, smallpox was also principally a
disease of childhood, and produced its greatest mortal-
ity among those under five years of age. Thus in " Ge-
neva from 1580 to 1760 there were 25,349 deaths from
smallpox, and of these 21,078 were under five years
old and 961 per 1000 were under ten years old. In
Edinburgh in 1764-83, the proportion under ten years
old was 993 per 1000. In the Chester epidemic of 1774
there were 202 deaths, all among children under ten
years old." All of these diseases do attack adults, how-
ever, though less frequently and usually less severely
than children.

Season exercises some influence. The cold, raw
weather of the late winter and early spring particularly
favor most of them, while they are also commoii in wIq-

RESPIRATORY TRACT INFECTION 257

ter and rather rare in summer. Infantile paralysis, how-
ever, is more apt to occur in summer than at other times,
which fact is one of the several used as arguments that
the disease is conveyed by the common biting stable fly,
Stomoxys calcitrans.

Crowding favors epidemics, quite apart from the
question of ventilation, and it also predisposes to severe
attacks. Many cases of a very severe type of measles
developed in the concentration camps in 1898, and an
epidemic of 600 cases occurring at Columbus Barracks
between December, 1910, and May, 1912, was thought
to have been aggravated by crowding. School epidem-
ics of measles, German measles, scarlet fever, mumps,
and diphtheria are rather common.

Poor hygienic conditions, such as dirty surround-
ings, the breathing of effluvia from decomposing matter,
and bad ventilation, are all thought to predispose to them,
and probably do so by reason of the fact that persons
exposed to such influences are pretty sure to be living
in such a manner as to be subjected to unusual oppor-
tunities for too close contact with neighbors.

Unhnown atmospheric conditions apparently influ-
ence the rise and fall of some of them. Influenza and
diphtheria increase and decrease in ways thus far not
fully explained.

A previous attack of one of these diseases usually
protects from a second, but such is not the case in all of
the group. One attack of diphtheria or influenza, for
instance, seems to predispose to a second rather than to
protect against it. Second attacks of smallpox, scarlet
fever, and mumps are rare, those of measles less so.

These diseases are not all transmitted in exactly the
s^me way, but the transfer of no one of them is so

258 THE PREVENTION OF EPIDEMICS

limited as the title of the chapter would indicate ; so

liiT ii. -a the various methods will be considered and

Saetnoos . ^. .

of Tra « exceptions noted as we progress.

. . Some of these affections are coutaffious

mission X 1 1 1 11

to such a degree that near approach to the

patient and breathing of the air surrounding him in
a greater or smaller zone, without any contact, seems
- . sufficient to allow infection. This is par-

^- ticu.arlytrueof.easles,b.,titiss„fficieLy

true of all the diseases of the group to make isolation
ordinarily worth while as a matter of routine in mili-
tary practice, and this is none the less true because of
the fact that transmission of most of the diseases of the
group is by contact, rather than by air-borne infection.
The following excellent observations that bear on this
point were published in the London Lancet of June
13, 1914.

In a common open ward with good ventilation, hav-
ing twelve beds and an allowance of 195 square feet
of floor space and 15 linear feet of wall space per bed,
there were treated in two years 274 patients with 332
cases of contagious diseases, including 112 cases of scarlet
fever, 63 of diphtheria, 24 of chickenpox, 47 of whoop-
ing cough, 11 of mumps, 2 of incipient measles, 6 of
German measles. At each patient's bed were a table,
eating utensils, towels, gowns for nurse and doctor, and
such things as the patient needed. No toys, books,
or other articles that would be apt to be passed from
one patient to another were allowed in the ward. On
entering the ward every officer or person who was to
touch a patient, his bed, or anything connected with
him had to scrub his hands and nails with soap, water,
and 1 to 200 solution of lysol at the bedside, to put on

RESPIRATORY TRACT INFECTION 259

a gowu reserved for that bed, and, having finished, to
remove the gown and scrub again before leaving the
bed. Under this regime secondary cases occurred as fol-
lows : Scarlet fever, two cases, due to a nurse ; diph-
theria, none ; German measles, none ; mumps, none ;
whooping-cough, five cases ; chickenpox, eight cases ;
which facts the reporters regarded as tending to show
that diphtheria, scarlet fever, and mumps are not air-
borne, that measles and chickenpox are so in their early
stages, but not after the third or fourth day, and that
whooping-cough is probably so for an indefinite period.

As showing the very high degree of contagiousness
of measles in its early stages it is well to cite instances
from two official health bulletins. In Chicago thirteen
children attended a birthday party, two of them hav-
ing " colds." Next day both of these two had typical
measles. After eleven to fourteen days every child of
the party, except one who had had the disease within
a year, had measles. One of them developed a cold
twelve days after the party, and she was taken from
her convent school-room and put for a short time (an
hour or less) in a large room with fourteen larger girls.
Twelve days later all fourteen of those girls developed
measles. Some of these then started epidemics and forty-
seven cases were known to result from the first one.
Aerial transmission of the contagion seemed very evident
in the school-room, where contact could be ruled out.

" A farmer and stockman from the little town of A.
went to Kansas City with a carload of cattle. Nine days
later he had a bad cold. He spent two days wandering
from store to store in the little town telling his friends
what a fearful thing his cold was. On the third day the
eruption occurred and his physician tacked up a measles

260 THE PREVENTION OF EPIDEMICS

sign on the house. But it was too late. Two weeks later
28 of his friends who had listened sympathetically to his
' cold ' troubles also had measles. In two weeks more
28 other cases resulted, and two weeks later 30 cases —
86 in all. That, being nearly the entire population of
the town, ended the epidemic in that community. But of
the first crop of 28 cases at A. one visited the home of
a physician in the city of B. The physician, not know,
ing his child was exposed, permitted its attendance at
school regularly, and the child ' broke out ' in school.
From this child it spread to 43 families, or 90 cases. A
visitor from the city of C. in the town of A. came home,
attended the city schools of C. and the disease spread
to over 100 cases there. During the county examina-
tions held in C, and at the height of the epidemic
there, a pupil from the city schools of D. was exposed
to the infection. In spite of this knowledge this pupil
did not cease school attendance, and thirty cases re-
sulted in D."

Healthy persons may be carriers of and may convey
diphtheria, cerebro-spinal meningitis, and infantile pa-
ralysis ; while persons apparently recovered
V/am from them but still harboring the germs

may convey the diseases just named, influenza, and
scarlet fever.

Fomites conveyance of infection is of course a form
of mediate contact. It is more apt to occur the more
recent the contact of the fomites with the
sick person, as time, sunlight, drying, and
other factors constantly tend to destroy the causative
organisms unless these be on substances offering them
food and favorable conditions, such as milk, meats, iind
other articles of human food. It is for this reason that

RESPIRATORY TRACT INFECTION 261

terminal disinfection of houses after the occurrence
of these diseases has of late been found to be much
less important than it was formerly considered to be, with
the result that it has been almost abandoned in several
cities. Of the fomites the most dangerous are toys,
handkerchiefs, and such other things as come into close
contact with the patient, and especially such as are apt
to be contaminated with the secretions from his nose,
mouth, or other parts. It is often extremely difficult
to draw hard and fast lines separating air-conveyance,
dust- and droplet-infection, fomites-oonveyance, and in-
fection by direct contact. Where there has been a pos-
sibility of infection in one of these ways there have often
been other opportunities for it. Infection by direct con-
tact we know to be possible in all these diseases, and
kissing or sleeping with a person having any of them is
particularly dangerous. They are dangerous cases to
nurse or to treat, and nurses and doctors r^ a. ^
ofteu contract them, and would do so much
oftener except for the protecting influences of previous
attacks, age, and constant sanitary precautions.

The virus of most of these affections is given off in
the spit and nasal secretions of persons suffering from

them. Such is certainly the case in diph- ^
, . 1 r 1 1 Sputum

thena, scarlet fever, measles, mumps, whoop- *^

ing-cough, poliomyelitis, and sometimes in meningitis,

and it may be true of all the others.

It is quite probable that the virus of some or all of

these diseases may also be contained in other -^. , «

, • r 1 . Other Se-

natural secretions of the patient, or in pus

crcuions
or eruptions that sometimes occur. It is

highly probable that the ears may be infectious in

measles, and discharges from the ears and nose are

262 THE PREVENTION OF EPIDEMICS

certainly so in scarlet fever. The virus of poliomyelitis
has been demonstrated in the lining membrane of the
stomach and bowels.

The eruption of smallpox consists at different periods
of papules or pimples, vesicles or little blisters, and
g,,. scabs. Both the vesicle contents and the

scabs are known to contain the virus of the
disease and are therefore to be avoided. While proof
is lacking that the similar products of chickenpox and
the scales or strips of skin shed after measles or scar-
let fever are dangerous, it is the part of wisdom to avoid
them also and to burn them as they are cast off.

In most or all of the diseases here considered the
virus is at some time contained in the blood, and contact
with that, as in dressing wounds or clean-
ing up spilled blood, would probably offer
chances of infection.

The introduction of infectious matter into wounds
serves to inoculate most of these affections. It is much
_ , resorted to in efforts to infect animals for

^ experimental or other purposes, and in pre-

vaccination times inoculation with smallpox
was sometimes done as tending to produce a milder
attack of the disease than resulted from natural infec-
tion.

Infection through the medium of utensils, such as
cups, spoons, thermometers, bedpans, or pipes, may
-.. ., readily occur, but is an evidence of mediate
contact rather than of contagion by virus
contained in the air. Such articles can only rarely con-
vey the disease in question, unless they have been soiled
by contact with the mouth, skin, or other parts, or the
secretions of a patient.

RESPIRATORY TRACT INFECTION 263

Animals may convey these diseases in various ways.
They may gather up infected dust, sputum, or flakes
of skin by lying on or near the sick-bed, . . ,
and, by shaking themselves, liberate it else-
where. It is possible that they might lick up moist
sputum or other secretions, and retain the germs alive
in their mouths and transmit them through fondling or
fawning, even though they do not themselves have, or
are not subject to, the disease. In other instances they
are subject to the diseases, and may contract them
through contact from eating spit, or in other ways, and
breed and give off germs just as do human patients.
Cats, dogs, and many other animals are subject to diph-
theria, and may aid in spreading it. Cows suffer from
a disease of the teats which, it has been said, can by
means of milk set up scarlet fever in the human sub-
ject. Cattle suffer from smallpox in the mild and al-
tered form known as vaccinia or cowpox, which, when
in turn inoculated into man, affords protection against
the first, or more severe disease. Whooping-cough has
been transmitted to animals experimentally.

Epidemics of scarlet fever and diphtheria have many
times been traced to contaminated milk, and it is not

impossible that several of the other diseases __.,,

J- Ti • V, Milk

we are discussing may likewise be so con-
veyed. The milk may, in exceptional instances and in
the two diseases just named, be infected by the animal
giving it, but the virus is usually if not always derived
from some human carrier of the organisms. Milk is a
good culture medium for most disease-producing bac-
teria, and we have already seen how important it may
be in the diffusion of typhoid fever and how readily it
may be infected with the germs of that disease. It is

264 THE PREVENTION OF EPIDEMICS

therefore easily conceivable how milk-baudlers suffering
from influenza, mild diphtheria, mild scarlet fever, or
others of the diseases we have been discussing, might,
through coughing, tasting the milk, careless handling of
vessels, or in other ways, introduce germs into it. Milk
epidemics of scarlet fever, like those of typhoid, are apt
to show a somewhat " explosive " character, that is,
many cases develop at or near the same time. In Bos-
ton, Baltimore, and Chicago very large epidemics of
septic sore-throat have been traced to infected milk.
The following milk-borne epidemics of the diseases here
considered have been investigated in Boston : —

In 1907, 717 cases of scarlet fever from one milk supply.
" " 72 " "diphtheria " " " ♦'

"1910, 842 " "scarlet fever " " " "
" 1911,1000 " "septic sore-throat" " " "
Measles is not thought to be milk-borne.

The virus of any disease having gained entrance to
a susceptible body, some time is required for its mul-
tiplication and development, and for it to
incu - manifest its effects on the body. This time
_ between the entrance of infection and the

appearance of the first symptoms of disease
is known as the incubation period, and is more or less
constant for each disease. As it is important to take
this into consideration in attempting to trace, control,
or prevent epidemics, the following may be considered
as representing it with tolerable accuracy in the diseases
named : —

RESPIRATORY TRACT INFECTION 265

Diseases Incubation Pkbiods

Smallpox 8 to 20 days, oftenest 12.

Chickenpox . . . . 10 to 15 days.

Scarlet fever . . . . 1 to 7, oftenest 2 to 4 days.

Measles 7 to 18, usually 14 days.

German measles ... 14 days or more.

Mumps 14 to 21 days.

Whooping-cough . . . 7 to 10 days.

Influenza 1 to 4 days.

Diphtheria 1 to 7 days, usually 2.

Tonsillitis 1 to 3 or 4 days, usually 2.

Poliomyelitis . . . . 3 to 33 days, usually 8 or 9.

The incubation period is of value in enabling us to
approximate the time and plaee of infection and to judge
correctly of the length of time that suspects
should be isolated. After the disease has J»

developed, however, the character and length
of the isolation period for the sick will be
controlled rather by the degree of the con-
tagiousness and the time at which it is ^
gi'eatest or during which it persists. It will
therefore be well to summarize briefly our knowledge on
those points.

Smallpox is one of the most contagious of diseases,
and prior to the introduction of vaccination almost every-
body had an attack, usually in childhood, as natural
immunity is very rare. It is probably contagious from
an early stage, and it continues so until the patient has
recovered from the disease and has ceased to desqua-
mate or shed scabs. As showing, however, that it is
much more contagious in its early than in its late stages,
may be cited the fact that the writer was able to infect

266 THE PREVENTION OF EPIDEMICS

monkeys with the vesicle contents gathered from early
skin lesions, never with the scabs or late products of
lesions from the same case. The monkey is, of course,
naturally much less susceptible to smallpox than is man.
The same experiments seemed to indicate that for mon-
keys and in the Philippines the contagium is evanes-
cent. However, it is reputed to be very persistent and
to cling for long periods to infected places or things.
Varioloid is a mild form of smallpox, usually seen only
in persons who have been vaccinated. It may give rise
to virulent forms of the disease if transmitted to more
susceptible persons.

ChicJcenpox is probably air-borne from its onset and
for three days thereafter.

Scarlet fever is contagious early, possibly more so
when the fever is highest, and may continue so after
the subsidence of all fever and for some weeks after
the disease has apparently ended.

Measles is more contagious than smallpox or scarlet
fever, but fortunately the period during which it is so
is relatively short. The contagiousness is most marked
during the period of onset and probably does not ordi-
narily last beyond the second or third day of the erup-
tion. The virus is more evanescent than that of scar-
latina and neither places nor things retain it long.

The contagium of German measles is probably like
that of measles, active for a short time, but not per-
sistent.

Mumps is contagious for about two weeks, or a little
more, from the time of its onset.

WTiooping-cough is probably contagious during the
entire period of its existence, including the early stage
before the development of the whoop.

RESPIRATORY TRACT INFECTION 267

Influenza^ likewise, is probably contagious from the
onset. It often passes into a chronic stage, wherein the
active symptoms have subsided, but a slight cough or
some similar reminder persists. As the bacilli remain
and may be expelled by the cough, there is reason to
think that such cases may remain sources of infection
for indefinite periods.

Cerebrospinal meningitis being due to an organism
that may be found in healthy noses and throats, but
one which possesses only feeble resisting powers, it is
impossible to say how long it may be contagious. The
degree of contagiousness is not high.

The same is true of infantile paralysis.

Diphtheria is contagious from its onset until such
time as the bacilli have disappeared from the breathing
passages, a period exceeding the apparent duration of
the disease by days, weeks, or months. Different strains
of the organisms present decided differences of viru-
lence, and this partly accounts for the varying grades
of severity shown by epidemics. The virus attaches it-
self to the clothing, the bedding, and the room in which
the patient has lived, and has in many instances dis-
played great tenacity.

Tonsillitis is an inflammation of the tonsils due to
any cause. It may, therefore, be diphtheritic, but as
generally used and as intended here, the term signifies
a tonsillar inflammation due to other organisms than
that of diphtheria, and applies to the common " sore-
throat " of winter-time. Though neither so dangerous
nor so highly contagious as diphtheria, it occasions
much discomfort and may spread through a barracks
to a considerable extent, especially if the ventilation
is poor. Septic sore-throat due to milk has been dis-

268 THE PREVENTION OF EPIDEMICS

cussed. It differs from ordinary tonsillitis in its greater
severity and its greater tendency to spread to other
structures and to infect the blood-stream and the lym-
phatics.

Prevention and Control

The measures of control are general and special.
The former include all such measures of hygiene, clean-
liness, housing, heating, clothing, and so forth as tend
to lessen the dangers of crowding, contact with the sick,
poor ventilation, and bodily depression.

Ventilation should at all times be abundant, and it

should be superabundant in the neighborhood of the

sick, as it not only promotes comfort and

health, but dilutes the poison or conta-

gium, and so reduces the dose of it that

those in the neighborhood may inhale.

Water is of only minor importance in the diffusion

of these diseases, but the supply should be good and

special care should be used in disposing of that which

has been used in washing the sick or their effects. It

should be disinfected by chemicals or heat.

The common drinking cup is a source of danger in
barracks or in camp, and should be abolished in favor
of individual cups or of bubbling fountains that cannot
be contaminated by ordinary usage in drinking.

I^oods^ other than milk, are seldom responsible for
the spread of the diseases considered ; but food that
has been in contact with the sick should be carefully
disposed of. The diphtheria bacillus, for instance, might
grow on meat, bread, potatoes, or other food-articles.

Persons having any of these diseases should be ex-
cluded from kitchens, dining-rooms, and all co^atact

RESPIRATORY TRACT INFECTION 269

with any food except that for their own use and con-
sumption. Supplies from bakeries, meat-shops, or other
food-distributing places that harbor persons sick of
these diseases, are best avoided. It is conceivable that
they may occasionally be transmitted by means of food
that has been exposed for sale in places where it might
be contaminated by infected dust or by droplets of spit
expelled by coughing persons.

Milk is particularly dangerous as a means of dis-
semination of scarlet fever, sore-throat, and diphtheria,
and it may possibly act in a similar capacity for others
of these diseases. It is certainly the part of wisdom to
exclude persons having, or recovering from, or in con-
tact with, any of these diseases, from handling milk
intended for the use of others. In case of epidemic the
milk-supply should be investigated, and steps be taken
to prevent infection through it. Pasteurization or boil-
ing will make the milk safe if it is protected from sub-
sequent contamination.

Vermin should be guarded against as possible dis-
seminators, as in measles, scarlet fever, smallpox, and
occasionally some of the other diseases considered, the
circulating blood may be found infective. Smallpox
has been attributed to flea transmission, though the
evidence has not been such as to cause the acceptance
of the idea by many. Still, it is not at all impossible
that this disease may at some time be found to be in-
sect-borne. Biting flies are also said to carry infantile
paralysis, and the hypothesis is entitled to much respect
because of the support found for it in experiments at
Harvard and in the epidemiological studies published
by the Massachusetts State Board of Health.

It is obvious that houae-fliea might become polluted

270 THE PREVENTION OF EPIDEMICS

from eating or walking over infective excretions and
convey the germs to other persons or to food-articles.

Animals, such as dogs, cats, and other pets, should be
excluded from access to the sick for reasons already
set forth.

Of special measures of protection against these dis-
eases the following are probably most important : —

Early diagnosis is absolutely essential for the con-
trol of most of them, and is helpful in all. Measles is
highly contagious before the eruption ap-
^ pears, and may be widely spread by per-

° ' sons appai*ently suffering from "colds."
All suspicious cases should therefore be re-
ported to the surgeon for examination as soon as any
symptoms present themselves. As stated before, com-
pany officers should encourage their men to go on sick
report at the first appearance of disease.

Persons in contact with diphtheria should be exam-
ined to see if they are carrying the germ in their throats
or noses.

Notification of cases is the next step in control. It
follows diagnosis naturally in the case of soldiers re-
porting to the surgeon ; but occasionally
officers or their families, or more rarely en-
listed men, consult civilian physicians. In
such instances the presence of contagious disease may
not be notified and may escape official recognition, with
the consequence that preventive measures may not be
adopted. Line officers, enlisted men, and civilian phy-
sicians, all should realize that the highest function of
the medical officer is the prevention of disease, and that
they are preventing his performance of it, as well as
violating orders, when they do not promptly report to

RESPIRATORY TRACT INFECTION 271

him any cases of contagious disease in the post with
which they may be concerned. Unless agreeing to act
thus fairly, civilian physicians should not be allowed
to practice on a military reservation, and they cannot
properly do so ; and officers and men who through care-
lessness or design are responsible for the presence of
such diseases on the post being unknown, should be
punished.

Notification of the presence of any of the diseases
in this group should at once lead to an investigation of
its source, with the object of removing this m^ar'
if possible. The nature of the investigation -,
will be indicated by what has been said
as to methods of infection and incubation periods.

The sick should be isolated as soon as the diagnosis
is made or suspected. The character and duration of
the isolation will vary with the disease. It .

should in all cases be sufficiently strict to
prevent all unnecessary contact with the sick, and
should last until the dangerous period is safely past.

There can now be little doubt that much of the benefit
that results from isolation is due to lessened oppor-
tunities for contact with the patient or his secretions.
Much therefore depends on having the nurse isolated
also, or having him so thoroughly drilled in freeing
his person from the germs and in avoiding contact
with them as to reduce the chances of mediate contact
through him to a minimum.

Smallpox should be isolated at some distance from
dwelling or gathering places, even at the expense of
some inconvenience. In military life tents make suit-
able isolation hospitals unless the weather is unusually
severe. The possibility of apparently well persons acting

272 THE PREVENTION OF EPIDEMICS

as carriers must be borne in mind. Diphtheria patients
and their attendants must not be released from isolation
until their respiratory passages are free from germs,
scarlet fever patients until all discharges from the throat,
nose, and ears have ceased, and the individual has been
well a month or more. In all instances the character
and duration of isolation are matters to be determined
by the medical officer. Men breaking isolation bounds
should be severely punished, as they may expose their
comrades to grave danger. Persons known to be ex-
posed to these diseases may properly be isolated, or at
least kept under stnct surveillance, for a time equal to
the maximum period of incubation. Those suspected of
having any of them should be isolated until the diag-
nosis is definitely established in the negative.

Everything that has been contaminated by the use,
_ . . , association, or proximity of the sick should

^ be disinfected before being allowed to pass

non • i. -i. J- 1

again to its ordinary place.

The sick person and his attendants should be well
bathed before coming out of isolation, and the bath
should be followed in the case of smallpox, scarlet fever,
or diphtheria by a washing with an antiseptic solution.
Clean clothing should then be put on. Animals that have
been in the sick-room should be similarly treated. Cloth-
ing and bedding may be disinfected by boiling, steam-
ing, soaking in an antiseptic solution, or with formalin.
The last named method is less reliable than the others.
Houses^ and especially the room occupied by the sick
person, and its furniture, should be scrubbed, sunned,
and aired. The belief that fumigation and other house
disinfection is unnecessary is growing, and experience
based on the belief indicates that those measures may

RESPIRATORY TRACT INFECTION 273

usually be ignored with safety. Sunlight, cleanliness,
time, drying, and fresh air do the work. Utensils may
be boiled, steamed, or washed in antiseptics, while letters,
books, and similar articles may be sterilized with forma-
lin if they have been in contact with the patient. The
discharges of the patient should be mixed with formalin
or carbolic solution and allowed to stand an hour before
being thrown out. The sputum should receivie particular
care, as it carries the contagium of most if not all of
these diseases. The patient should only spit into vessels
containing antiseptic solution, and even then it is safer
if the spit be burned. Handkerchiefs and cloths used
to wipe the mouth or nose should be burned or boiled.
The use of paper handkerchiefs by all sick persons
would be a wise and useful measure. Surgical dressings
should be burned.

The most efficient measure for the prevention of
smallpox is the induction of acquired immunity through
vaccination. The government very properly _ , ,
demands that every recruit shall be vac- _
cinuted, but occasionally the inoculation .
does not " take " on a susceptible man, and
through a combination of circumstances he may escape
its repetition. In civil life there is a considerable agi-
tation against the use of vaccination, the agitators alleg-
ing that it does not protect against smallpox, that it is
an invasion of personal rights, and indulging in several
other incorrect statements. It is not purposed to discuss
the matter at length here, but it may be stated that the
evidence that vaccination does protect against smallpox
is overwhelming, and a belief to the contrary, however
honest and earnest it may be, cannot justify any one in
endangering the efficiency and safety of an army by its

274 THE PREVENTION OF EPIDEMICS

neglect, any more than can a belief that every man is
born with a right to smallpox if he wants it. Any oflBcer
or man who in any way interferes with the complete and
thorough vaccination of the army makes a great mis-
take and commits a grave offense.

The spread of diphtheria may be partly controlled by
the use of antitoxin. This may be and is very gener-
ally used in the treatment of those sick with the disease,
but it is also of value when used as a preventive mea-
sure. It is then injected in relatively small doses into
persons brought into contact with the disease. So used,
it greatly lessens the liability to infection, and to se-
verity in case infection does occur. However, because
of the possibility of rendering the individual suscep-
tible to anaphylaxis in case of necessity for using the
serum at a much later date, it is preferable to prevent
diphtheria by other means, if possible. Vaccinations
and the use of preventive injections of antitoxin have
not yet proved of value in protecting from the other
members of this group, though they may later be found
applicable in some instances.

CHAPTER XIV

INSECT-BORNE DISEASES

The principal human diseases now known to be insect-
borne are malaria, yellow fever, filariasis, and dengue,
carried by mosquitoes ; sleeping sickness, carried by
tsetse flies ; plague, carried by fleas ; spotted fever in
Montana and the relapsing fever of central Africa,
carried by ticks ; typhus fever and relapsing fever of
most parts of the world, carried by lice ; river fever or
tsutsugainushi disease of Japan, carried by a small red
mite ; sand-fly fever or three-day fever of the Balkans
and other parts, carried by sand-flies ; Chagas' disease
in Brazil, carried by the "barbiero," Lamus megistus;
and kala-azar, which is almost certainly insect-borne,
though it is not yet quite determined what insect is the
carrier, the bedbug being accused in India and the flea
in the Mediterranean countries. Leprosy, smallpox, pol-
iomyelitis, pellagra, and a number of other human dis-
eases have been attributed by various writers to insect
carriage, but the proof adduced has not been such as to
carry conviction to the majority of workers. Very many
diseases of animals are insect-borne, among them some
of the most widely spreading and fatal. Both animals
and man are subject to infestation with the larvae of
flies that deposit their eggs on the mucous membranes,
under the skin, or in wounds of their hosts. The screw
worm is an example of this.

The diseases named above will be considered in
groups made to conform to the insects carrying them.

276 THE PREVENTION OF EPIDEMICS

MOSQUITO-BORNE DISEASES

The most widespread and common of these is mala-
ria. It prevails in most tropical and sub-tropical coun-
-j , . tries, and in some of them it produces a
great mortality, while it causes much suf-
fering, weakness, and loss of time, even where it is
less fatal It is an important cause of sickness in our
army in many parts of our own country, as well as in
Cuba, Porto Kico, the Philippines, and the Isthmus of
Panama.

Since the beginning of the Spanish-American War
the knowledge of the methods of control of this dis-
ease has increased so rapidly that it has now become
possible for us to make healthy communities out of
places formerly notorious for the certainty and speed
with which newcomers sickened or died from malaria,
though it must be admitted that the accomplishment of
such a result is both difficult and expensive.

As stated in a previous chapter, there are at least three
varieties of this disease which differ because the para-
sites causing them do so, and which manifest themselves
in paroxysms of chill, fever, and sweat, that come at
twenty-four, forty-eight, or seventy-two-hour intervals.
This regularity of manifestation is only shown, how-
ever, in cases of uncomplicated single infections. Owing
to multiple infections or complicating circumstances,
any one of these types of malaria may show extreme
irregularity and may be mistaken for other diseases,
the diagnosis being made possible only by examination
of the blood, and, at times, with great difficulty. The
fever may be continuous and the general symptoms
such as to make the disease appear much like typhoid.

INSECT-BORNE DISEASES 277

Or it may be manifested as a neuralgia, as a sudden
attack resembling apoplexy, as anaemia, or in other
obscure ways. This disease also exhibits periods of la-
tency, during which the parasite is present in the body,
but in such numbers or under such control by the body
forces, that no signs or symptoms are present. When,
however, the vital forces are reduced, as by exposure,
overwork, alcoholism, or other disease, the parasites
gain the ascendency and the disease may manifest
itself in a severe manner. Many natives of highly ma-
larious regions may be partly immune and show no
symptoms even when harboring very severe infections.

Whatever the character of its manifestation, how-
ever, the infection is always received through the bite
of a mosquito. Many officers from time to time express
views to the contrary, usually basing them on their own
faulty observations. Occasionally there is reason to
suspect that the views are exploited to account for the
presence of malaria when the efforts to prevent mos-
quito-transmission entail an inconvenient amount of
trouble. The fact is that malaria has been investigated
with a thoroughness that has been accorded to few other
diseases, and the method of mosquito-transmission has
been abundantly proved, and no other appears even
probable. " If, after they have imbibed malarial blood,
certain species of mosquitoes be dissected at serial in-
tervals, the evolution of the malaria parasite can be
followed in their tissues, until, finally, the germs of the
parasite can be tracked into the cells and secretions
of the salivary glands of the insect.

" If after a week, or thereabouts, a similarly fed mos-
quito bites a hitherto uninfected man, in many instances,
after a few days, that man will exhibit the clinical

278 THE PREVENTION OF EPIDEMICS

phenomena of malaria infection and the characteristic
parasite in his blood.

" A non-immune, if effectually protected against mos-
quito bite, will not contract malarial disease, however
long he may live in highly malarious localities.

" Most observers are now of the opinion that the ma-
laria parasite, under natural conditions, can be acquired
by man only through the bite of the mosquito ; that the
mosquito can acquire the parasite only by ingesting
the blood of a malaria- infected man, or possibly other
mammal ; that there is no extra-corporeal life other than
that described ; that there is no authentic instance of
malaria being acquired in uninhabited places ; that in
the case of malaria in connection with soil disturbances,
it depends on the creation during digging operation of
puddles of water in which mosquitoes breed ; and that
its epidemic occurrence under these circumstances is
owing to unhygienic conditions such as usually prevail
when large bodies of men, some of whom may bring the
infection with them, are brought together on public
works attended with extensive earth-cutting, as in rail-
way, road, or canal-making."

Several species of mosquitoes are capable of trans-
mitting the disease, but they all, so far as now known,
belong to the sub-family Anophelinoe. The
-_ . , features by means of which these various
. species may be identified cannot be dis-
^ cussed here, and positive identification is a

labor necessitating some time and effort even on the
part of the specialist ; but a popular rough method of
identifying anopheline mosquitoes in general is that
the adults, when at rest, stand with their bodies almost
or quite at a right angle with the surface on which they

INSECT-BORNE DISEASES 279

are resting, while commoner species rest with the body
more nearly parallel to the supporting surface. The
larvae, or " wigglers," of the former class, on the other
hand, rest with their bodies like floating sticks, parallel
to the surface of the water in which they are swim-
ming. The more common varieties have theirs more
nearly at a right angle to it. These mosquitoes bite
principally at night.

Yellow fever is an acute and very fatal disease that
occurs principally in tropical and sub-tropical America,
though epidemics also occur on the west ■«»■ ii
coast of Africa, where the disease was pos- _,
sibly introduced by slave-traders. It has
appeared in epidemic form as far north as Philadelphia.

Until after the American occupation of Cuba and
the subsequent work of the board of army medical offi-
cers, under the presidency of Major Walter -lur ^.i, j
Reed, the method of infection was un- , _^

known, and water, contact, fomites, poor . .

police, and atmospheric conditions were all
credited as means. That Board cleaned up all obscure
questions as to the manner of transmission, and estab-
lished beyond dispute the fact that yellow fever is trans-
mitted by the bite of infected mosquitoes of the species
Stegomyiafasciata.^ It cannot be transmitted by water,
food, fomites, air, or contact, nor is its spread influenced
by poor policing, except as the latter promotes the breed-
ing of mosquitoes. The beautiful reasoning and experi-
ments which served to establish our knowledge of the
means of transmission also cleared up many hitherto
obscure points about the disease, and, better still, led
to the use of anti-mosquito measures that resulted in its
^ Since known as Stegomyia calopus and as ^de$ calopus.

280 THE PREVENTION OF EPIDEMICS

eradication from Havana, and later from New Orleans,
the Canal Zone, and other regions. This constituted one
of the greatest sanitary advances that the world has ever
seen, one making possible the rejuvenation of Cuba,
the construction of the Panama Canal, and, it is hoped,
the civilization and development of all tropical America ;
and it is well that army officers should keep in mind
that all of these things were made possible by the fact
that there happened to be in command, in Havana, a
line officer who had a knowledge and an appreciation
of the importance of military hygiene.

The Board of which Major Reed was the head showed
that contact, fecal contamination, handling of fomites,
breathing the close air breathed by yellow-fever pa-
tients in poorly ventilated places, and all such things,
were incapable of transmitting the disease, but that
the bite of some infected mosquitoes would be followed
by the fever in from three to five days, or occasionally
longer. This is the ordinary incubation-
period in man, and accounts for the fact
f , that non-immunes may develop the disease

so short a time after arrival in places where
the disease prevails. But there is also an
incubation-period in the mosquito, as shown by the fact
that it cannot transmit the disease until twelve days after
it has imbibed the infection with the blood of a sick per-
son. This accounts for the half-month elapsing between
the arrival in an uninfected place of a case of yellow
fever and the appearance of the first case of the subse-
quent epidemic. This double incubation period, three
days for a case in an already infected district, and fifteen
or more days for secondary cases in previously non-in-
fected districts, is thus clearly explained.

INSECT-BORNE DISEASES 281

Not nearly all mosquitoes biting yellow-fever patients
are capable of transmitting the disease even after twelve
days, and the Board showed that this was because of
the short period during which the yellow-fever patient
is infectious. Unless it bites him during his first three
days of sickness, the insect obtains no infection and can
transmit none. It was also demonstrated that the cause
of the disease is in the blood, that it passes through
very fine filters, and is probably too small to be seen with
our microscopes, and that it may persist in infected
mosquitoes for weeks or months.

" These experiments fully explain, Ist, the impunity
with which a yellow-fever patient can be visited by a
non-immune if outside the endemic area : the mosquitoes
in the vicinity are not infective. 2d, the danger of
visiting the endemic area, especially at night : the mos-
quitoes there are infective and active. 3d, tlie discrep-
ancy between the incubation-period, three to five days,
of the disease, and the incubation-period, fifteen days
and over, of an epidemic: the necessary evolution of
the germ in the mosquitoes infected by the original
introducing patient demanding the space of time indi-
cated by the difference between these two periods. 4th,
the clinging of yellow-fever infection to ships, buildings,
and localities : the persistence of the germ in infected
mosquitoes which are known to be capable of surviving
for five months, and probably longer, after feeding on
blood. 6th, the high atmospheric temperature required
for epidemic extension of yellow fever : such tempera-
ture favors the activities and propagation of the mos-
quito, and is probably necessary for the evolution of the
germ also in the mosquito."

The mosquito that transmits yellow fever is a very

282 THE PREVENTION OF EPIDEMICS

common one in all those parts of America that show
_, the disease. A closely allied or identical

_ .- speciesis abundant in the Philippine Islands.

_, Whether or not this Philippine variety is

-_ capable of transmitting the disease is not

positively known, but if it can do so the in-
troduction of the disease into those islands,
a thing quite possible after the opening of the Panama
Canal, might prove a disaster of the first magnitude
and a great addition to their already numerous afflic-
tions. However, yellow fever is so thoroughly under
control in Panama and other points from which ships
are apt to go to the East, and the method of its control
is so well understood and the journey so long, that the
chances of such introduction are considered remote.

The mosquito concerned is a small black one, with
white or silvery lines and bands on the thorax and legs.
There is a peculiar lyre-shaped figure on the back of the
thorax which, together with the white bands on its legs,
makes a rough diagnosis of species possible. The insects
particularly prefer low-lying shores, but may be found
in other places. They are essentially house-lovers, are
active biters, silent and very quick, so that they are harder
to catch than other varieties. They breed in small ar-
tificial collections of water, such as barrels, puddles,
cisterns, and partially filled tin cans. " The nature of
the water appears to be a matter of indifference : it is
found equally in rain or waste water, but more frequently
in water discolored by decaying vegetable matter."

Dengue is a disease of very low fatality, but one which

—. may occasion much suffering and anxiety,

and which sometimes occurs in widespread

epidemics. The disease causes, on an average, about

INSECT-BORNE DISEASES 283

one week of absence from duty, and if the epidemic
involves thirty or forty per cent of a command, a not
unusual figure, the strength of the force will be much
impaired. It prevails in the West Indies, the Philip-
pines, our Southern States, and in most other parts of
the tropical and subtropical world. Like yellow fever,
it is a disease of hot weather and low lands, that has
prevailed as far north as Philadelphia in summer-
time. It is transmitted by a very common variety of
mosquito, Culex Jatigans, and possibly by other varie-
ties, but not by contact, food, drink, air, or fomites.
The incubation-period is from three to seven days,
usually about four ; the causative organism is contained
in the blood, passes through fine filters, and is probably
too small to be seen with the microscope. The disease
resembles yellow fever in man}^ respects, and has often
been confused with it in America.

Filariasis is infestation with any one of several varie-
ties of filaria, or hair-worm, whose young circulate in
the blood. It is thought to be related to _,.. .
elephantiasis, but was suffit;iently discussed
in a preceding chapter. The parasites are introduced
through the bites of mosquitoes, one of the most com-
mon and widespread species, Culex fatigans, acting
as a carrier for at least two varieties. The insect bites
both by day and by night.

The prevention of these mosquito-borne diseases rests
entirely upon our ability to protect against the bites of
infected insects, except in the case of mala-
ria, in which we can derive aid from the
administration of quinine. Our success then _, ^
depends on anti-mosquito measures, and it
is necessary to discuss these briefly. Mosquitoes breed

284 THE PREVENTION OF EPIDEMICS

only in water, the young being as much dependent on
that fluid as are fish or tadpoles. The Culex^ or com-
mon mosquito, which transmits dengue and filaria, and
the Stegomyia^ or striped mosquito, which carries yellow
fever, generally breed in vessels of water, cisterns, or
drains. The Anopheles^ or malarial mosquitoes, breed
"mostly in shallow puddles on the ground, in small
ponds, in slow and small runnels of water, in pools of
rain water, on rocks, on the margin of slow-running
streams, and sometimes, but rarely, in vessels of water."

It must be borne in mind, though, that the Stego-
myia is really the only one of the mosquitoes known to
carry disease that is so fixed in its habits as to make
its extermination relatively easy. This mosquito is
practically banished from the Canal Zone, though still
found in the adjacent city of Panama, and in the Zone
very little work is required to keep free from it. The
work against Culex and Anopheles^ however, is con-
stant, hard, expensive, almost endless, and distinctly less
successful in its results. These mosquitoes, as repre-
sented by their various species, can manage to find favor-
able conditions in the Canal Zone at all times of the
year, and in almost all kinds of water, including a
mixture that contains a large amount of sea-water. In
fact, the largest and most annoying flights of mos-
quitoes seen on the Zone have always come from the
hydraulic filling of fresh water swamps with salt water
material, that is, with mud pumped from under salt
water. At Gatun, Toro Point, Cristobal, Panama, and
other places this has been the case.

The larvae or wigglers of all kinds of mosquitoes re-
quire at least six or seven days of life in water before
they can develop into winged insects, and the time is

INSECT-BORNE DISEASES 285

usually longer, especially if the weather be cool or con-
ditions otherwise unfavorable. Drying kills them and
also destroys mosquito eggs. On the other hand, natural
degrees of heat and cold do not necessarily destroy them
if they remain in water, and in northern latitudes both
larvae and adults may survive several freezings during
a winter and again become active when warm weather
returns. Usually only female mosquitoes suck blood,
and they do so because the rich nutriment hastens the
ripening of their eggs, and these are generally deposited
only after such a meal. As the mosquito fills herself to
a degree that greatly increases her bulk and weight,
and makes flight laborious and slow, she usually seeks
a place near at hand in which to deposit her eggs. Partly
for this reason it follows that most infested houses or
localities breed their own mosquitoes.

It has been demonstrated in the Canal Zone that
Anopheles can and on occasion do fly more than a mile
from their place of breeding. The occasions for such
flights are, in the writer's opinion, limited to such as
present the following circumstances ; a large area where
the conditions for breeding are unusually favorable,
such as one of the salt hydraulic fills mentioned above,
an enormous amount of breeding in such an area, lack
of abundant human blood for food in the neighborhood
of the breeding place, the presence of abundance of
food (a town) at a distance of a mile. Were there an-
other town within two hundred yards, or a quarter or
a half of a mile, the chances are that the town a mile
away would scarcely notice any change in the number
of mosquitoes. In fact, such has been the experience at
several places on the Isthmus. The conditions favored
a big flight, but a human barrier in the neighborhood

286 THE PREVENTION OF EPIDEMICS

served to check it and to make the increase of mosqui-
toes a merely local one. In ordinary sanitary practice,
and not considering such exceptionally large and favor-
able breeding places, the control of all breeding within
four hundred yards of towns, posts, and houses serves to
make them fairly comfortable and safe places of resi-
dence. But even this much is no small task in the trop-
ics. The Anopheles^ like the Stegomyia^ appears to be
a man-lover, though, unlike it, not a house breeder.
Practically always breeding in the open, in what might
be considered natural, though often actually artificial,
collections of water, and almost never in cans, barrels,
cisterns, and like containers, it is nevertheless usually
found fairly close to human habitations ; and many lo-
calities in the Canal Zone that formerly, when towns
were near, bred great numbers of Anopheles^ now, since
the areas in question have been depopulated, breed
almost none. "Mosquitoes, especially Anopheles, love
thick undergrowth."

The facts above stated indicate the steps to be taken
in warring against them, and of these, destruction of

breeding-places in or near camps, habita-
, tions, towns, and garrisons is probably the

most important. The measures designed to
° attain this end are numerous. Drainage by

ditches or by subsoil tile, reclamation of
swamp lands, opening fresh water or brackish swamps
to salt water tides so as to convert them to salt water
marshes and flood them daily with strong sea water,
i\xejUling of pools, puddles, hollows, and marshes, the
building of dikes and embankments to create lahes in-
stead of marshes and to protect dry lands from flooding,
the clearing of the banks of lakes and streams from

INSECT-BORNE DISEASES 287

brush and grass and cutting them steep and deep so
as to permit and favor wave action^ the cleaning^
straightening^ and narrowing of sti-eams to give them
a more rapid flow, are some of the general measures
that can be profitably employed in the vicinity of towu«
or of permanent garrisons. Each of these measures
may be very expensive as to first cost, yet each may
prove a highly profitable investment. A few specific
instances may be cited from the Canal Zone. Drain-
age by ditch and tile has been used in and about every
town in the Zone, and has always given good results and
done away with breeding places. Opening fresh water
swamps to tidal wash has done away with large areas
of breeding at Mindi Island near Cristobal. The filling
of swamps and low lands, often done as a mere matter
of convenient disposal of soil, has made dry many
former breeding places. Even the hydraulic fills that
have been mentioned as giving rise to excessive breed-
ing, only do so for a period of months, and after they
have dried out they may leave fine sites for town exten-
sion, as at Ancon and Balboa. The building of dikes
and the creation of lakes have done good by deepening
the water, as mosquitoes rarely breed in water more
than two or three feet deep, and by creating more favor-
able conditions for fish and for wave motion, both of
which destroy larvas. A small lake at Pedro Miguel,
which long produced large numbers of mosquitoes and
caused the expenditure of much money and labor on its
treatment, was rendered harmless and self-caring by
the expedient of cutting its banks at an angle of one
or one and a half to a depth of a foot and a half above
and the same below its general level, and freeing them
of vegetation. This allowed the small fish and the wave

28S THE PREVENTION OF EPIDEMICS

action to get at and destroy the larvae that formerly
found shelter from both in the vegetation growing in
shallow water along shore. The clearing and straighten-
ing of streams, " training " them to run rapidly and
strongly and to flush themselves well, act similarly.
Cleaning bodies of water of vegetation is at times a
moat useful expedient, as mosquitoes breed in water-
liolding leaves, such as those of the water " cabbage "
and the water hyacinth, while other vegetation, such as
Para grass and algae, offer shelter wherein the larvae
find protection from fish.

But efforts must not be confined to such large under-
takings, because the chances are that less ambitious
projects, carried out in or about the dwelling, may ac-
complish almost as much good, and it will be manifested
H)ore promptly. Such local measures will include the
filling of small hollows in the yard or about the house,
or cutting such outlets from them that they will empty
quickly after rains, filling or preventing the form-
ation of pockets or pools at the outlets of drains or
under faucets, filling, emptying, or obliterating hoof-
tracks, wagon-ruts, and similar small depressions, seeing
that fire-buckets, fountains, drip-pans under ice-chests
and similar water containers are emptied twice a week,
and alllarvaB contained in them killed. Empty or partly
empty bottles, boxes, tin cans, tubs, and flower-pots must
be removed or placed in such positions or conditions
that they will not catch and hold water. Useless joints
or sections of bamboo must be removed, and pieces that
are in use or that form parts of buildings should, if open,
he bored at the lowest level of the joint so as to let all
water run out. The water in tins or saucers under table-
legs or elsewhere as a protectioii from ants should be

INSECT-BORNE DISEASES 289

kept olean and free from larvae. It would be well to have
such things filled with antiseptic solution rather than
plain water. Sagging eave-troughs and drain-pipes and
catch-basins, that do not empty promptly, may afford
breeding-places, and should therefore be made right.
Banana plants afford quite sufficiently large receptacles
for breeding water at the points where the leaves di-
verge from the main stalk, and trees may provide them
in knot-holes. It may be stated, however, that breed-
ing in banana plants is less common than is generally
thought. All such places must be investigated and
faults corrected. Irrigating ditches should run freely
and with a good current when in use, and should drain
dry at other times. They should not present stagnant
pools at any time. Thick underbrush and high grass
should be cut and cleared awa}^ as it not only shelters
and harbors the grown mosquitoes, but hides and pre-
serves small collections of water and keeps them from
drying. Cisterns, shallow wells, rain-barrels, and other
large useful containers of water should be screened or
tightly covered so that mosquitoes cannot gain access
to them. Privies and cesspools should likewise be pro-
tected by netting or tight covers, so as to keep them
free from the insects, and drain outlets should empty
on smootii rocks, or be otherwise so arranged that pools
and puddles are not formed by their discharge. Other
precautions may be necessary and the circumstances
may suggest them. The object to be kept in mind is
the doing away witb all stagnant water.

Many of the measures outlined above, such as drain-
ing pools and emptying fire-buckets, are destructive
of larvae in that they allow these to dry. In some in-
stances, however, it is not possible to do those things,

290 THE PREVENTION OF EPIDEMICS

and other methods of destroying larvsB must be resorted
_ to. Mosquito larvae, like all other living

^ , creatures, have their natural enemies, and

_ these may be utilized. Many varieties of

small J?6"^ devour them, and some of these,
for instance the '* millions " of Barbados, are said to
do the work so thoroughly as to quite prevent mosquito
development in ponds stocked with them. Many va-
rieties of fish are useful for this purpose, and ponds,
streams, and marshes that create mosquito nuisances
can be profitably stocked with them. Other water ani-
mals, such as tadpoles and some kinds of beetles, are
also reported to be destructive of larvae. The larvae
of dragon flies are certainly so, but as regards the tad-
poles and beetles the writer cannot speak from personal
knowledge. Ducks, especially mallards, are said to be
very destructive to mosquito larvae.

Moulds and other germs may also attack the larvae
and cause their death through disease. Such factors
often make the task of artificially rearing mosquitoes
for experimental work one of some difficulty, but, so
far as known, they have not been used to reduce their
natural occurrence. That the natural enemies are not
alone sufficient to destroy all larvae is evident from the
fact that the latter are occasionally numerous in waters
abounding with fish and tadpoles.

Chemical 2)oisons may also be used, but they are dan-
gerous and can only be applied to waters which are not
needed and which should, therefore, be drained away
or otherwise disposed of.

Very extensive use has been made in the Canal Zone of
a preparation known as larvacide. It has been of very
great value in many places, but is not now used so ex-

INSECT-BORNE DISEASES 291

tenslvely as formerly because the cost of it has increased
so greatly. It is made as follows : Crude carbolic acid
of a specific gravity not above 0.97 and containing fif-
teen per cent of tar acids is heated. Into 150 gallons of
this 200 pounds of crushed and sifted common rosin are
stirred, and then 30 pounds of caustic soda dissolved in
six gallons of water. These amounts yield three and a
half barrels of larvacide, which for use is diluted with
four or more parts of water. It kills mosquito larvae in
five minutes in a dilution of 1 to 5000.

Oil, preferably crude petroleum, is much used as a
means of destroying larvae. It acts mechanically. The
larvae, though living in water, are air-breathers, and
must come to the surface at intervals of a minute or so
for that purpose. They breathe through a STnall pipe or
tube which rises above the back near the tail, and which
is projected from the surface of the water when air is to
be taken in. If the water be covered with a film of oil,
this little tube becomes clogged with the latter as it
passes through it, and respiration is hindered or pre-
vented so that the wiggler dies of suffocation. Other
oils will answer as well, but crude petroleum, because
of its cheapness, harmlessness in the amounts used, and
its slow evaporation, is preferred. Refined kerosene
spreads more rapidly and evenly, but it also evaporates
more readily. Some crude petroleums, especially such
as contain a considerable asphalt base, as do California
oils, will not spread well if applied to water without any
diluent. They are likewise too thick to be pumped
readily with small (knapsack) pumps or to drop relia-
bly from drip cans or barrels. It has therefore been the
practice in the Canal Zone to " cut " this heavy oil with
larvacide or kerosene, of which enough is added and

292 THE PREVENTION OF EPIDEMICS

mixed in to overcome the faults mentioned. The amount
of either required will vary from two to twenty per
cent, both amount and choice of diluent being deter-
mined by circumstances. At the present writing larva-
cide costs two and a half times as much as kerosene,
and the latter is therefore ordinarily preferred as a
diluent of crude oil, though special cii-cumstances make
the former preferable occasionally. The oil may be ap-
plied by sprinkling, spraying, or "painting " it over the
surface. In the last-named method it is applied by means
of a saturated rag on a pole that is rubbed or brushed
about on top of the water. So long as the surface is
well covered the method of application does not matter.
The applications should be renewed as necessary, and
the frequency of this will depend on several factors that
must be taken into consideration. A slight current or a
prevailing wind may drive ail of the oil to one side of
a pond or may remove it in a short time. In such cases
the renewal must be more frequent, and must be on the
side from which the oil flows. Light oils of course re-
quire more frequent renewal than the heavier ones that
do not evaporate so readily. The surface of the water
should not be left uncovered for more than three or
four days. For oiling running streams, small springs,
drainage ditches, and similar water runs, use may prof-
itably be made of drip cans or barrels. These may be
made from oil barrels, cans, or other receptacles. There
are many ways of arranging the drip, and the officer or
man in charge can devise one readily. A spigot may be
used, or a hole made in the receptacle may be stopped
with a plug having a small groove cut in one side, or
with one having a larger groove filled with wieking or
cotton waste, the idea being to have a drop fall often

INSECT-BORNE DISEASES 293

enough to keep the water covered with a thin coat of
oil. In order to make the drop break and spread when
it strikes the water the receptacle should be raised two
or three feet above the water level. Small wet places
caused by a seepage of water from a hillside or else-
where may be easily and profitably oiled by pegging
down at the upper edges of the seepage area small
bundles (a handful) of cotton waste saturated with
oil. These should be renewed about once in two weeks,
as by that time they are apt to be hard and to give oS.
an insufficient amount of oil. Another useful, simple,
and successful measure of treating such seepage areas
is to concentrate the moisture into tiles or ditches and
then oil it if necessary.

If water be drawn off through a pipe running well
under the surface, oiling does not injure it for house-
hold uses and is therefore applicable to cisterns, raiii-
barrels, and other domestic supplies.

Small collections of larvae-containing water can be
easily emptied by sweeping or other means, and the
larvae promptly die. It is said that the common prickly
pear cactus of the tropics can also be used in destroy-
ing larvae. " The thick, fleshy leaves contain a muci-
lage which exudes when the leaves are chopped and
added to water, the mucilage rising to the surface and
forming a practically air-tight covering similar to that
formed by oil."

Under ideal conditions mosquitoes should not reach

adult life where an active anti-mosquito ^

. , . -1 TT J • Destnic-

eampaign IS being carried on. Under possi-
ble conditions some are almost certain to do « , ,
so, and under the best conditions obtaina-
ble at a reasonable cost a good many are apt to be found.

294 THE PREVENTION OF EPIDEMICS

It often happens too that a camp is to be maintained
at a place for so short a time, or a given piece of con-
struction work is so small and so unfavorably located,
as to make adequate measures against breeding and
larvaB far too expensive in money and labor to be prac-
ticable or worth while. In such circumstances the de-
struction of adult mosquitoes may be the only available
means of getting rid of them. The method is especially
applicable in ridding houses of mosquitoes that have
bitten yellow fever patients. The house may be closed
and sealed and then fumigated with sulphur, the vapor
of a mixture of camphor and carbolic, or with the fumes
of pyrethrum. The first two kill the mosquitoes, but the
pyrethrum may only stupefy them, so it is necessary
to gather them up and burn them. As an antimalarial
measure, fumigation, because it cannot be continued
daily and because of the cumbersomeness of the proc-
ess, is of less value than hand catching, which may
take the form of "swatting" or may be better accom-
plished by the use of a tube or wide-mouthed bottle
containing a chloroform-saturated pad. This is best pre-
pared by taking a neckless vial one inch in diameter
and five or six inches deep, filling it for an inch with
cut rubber bands, and placing over these a disk of blot-
ting paper. Then pour in one or two teaspoonfuls of
chloroform and allow it to be taken up by the rubber.
When this tube is placed and held over a resting mos-
quito, as it may readily be, the latter drops inert in a
few seconds. To aid in finding the mosquitoes in a dark
room or barrack a small electric seai-chlight or acety-
lene lamp is most useful, and greatly aids in making
the catch thorough. With it mosquitoes may be found
in dark corners, behind doors, and on articles of clothing,

INSECT-BOUNE DISEASES 295

along baseboards and mouldings, and in other places
where they might not be detected otherwise.

Certain measures have value as tending to discour-
age adult mosquitoes and to cause their abandonment
of a neighborhood, even though not killing them. The
most important of these are the removal of stagnant
water, in which they may lay their eggs, and the cut-
ting and clearing of underbrush, high grass, and vines,
on or in which they take shelter and rest when not
busy. Smoking and anointing the hands and face with
certain volatile oils are advocated as measures of per-
sonal protection for the same purpose, but they are
not to be relied upon. A hungry mosquito will bite
through a layer of oil, and the most enthusiastic smoker
cannot produce such clouds as to protect his ankles,
bands, the back of his neck, and other parts.

The more effective method of protection from adults

is in the use of screening materials, either of wire or

of soft fabrics. Houses with wire-screened _, .

Protec-
windows and doors are in general use ^ ,

throughout our country, and add enor- . , .
mously to the comfort and safety of life in
the hot season. They have a very great influence in the
prevention of all mosquito-borne diseases. In order that
full benefit may be realized from screening it is impor-
tant that the material be kept in good condition, holes
patched as soon as found, doors provided with good
springs, cracks in floors and openings under the corru-
gations of iron roofing stopped, and all necessary mea-
sures taken to insure the complete exclusion of mosqui-
toes. For this purpose it is necessary to have buildings
and screens inspected frequently, and repairs made as
needed.

296 THE PREVENTION OF EPIDEMICS

Bed-nets are in general use throughout all barracks
in the tropics, and, if in good condition and properly
cared for, they offer adequate protection during sleep-
ing hours, unless the sleeper rolls or tosses in such a
way as to bring part of his person against the net, in
which event the insects feed through it. It is neither
pleasant nor practicable to spend all of the day, or even
most of it in bed, and bed-nets are therefore inadequate.

Head-nets are at times of value for night use in cam-
paign, and rarely so for common use in the daytime.
Most mosquitoes, though, do not bite out of doors in
the daytime, especially persons who are in motion.

Adequate clothing is of course important in ])rotect-
ing f i-om mosquito bites, and should he used for that
■p tflr purpose. In spite of all precautions an oc-
^ , casional mosquito will manacre to bite the

__ . most careful man. It is therefore impor-

. froTTi ^^^^ ^^ ^^^ ^^^^* *^® insects do not become
Infection ^^^^^^-^^ ^^^^ disease, and yellow - fever,
dengue, and malaria patients, particularly
the first-named, should be kept screened or doubly
screened during the entire time that they are capable
of giving infection. For this purpose it is essential that
all cases be known, and early diagnosis and prompt noti-
fication are therefore important, especially in yellow
fever, which is so deadly and yet is infectious only in
its early stages. In addition to screening, the malarial
patient should be taking quinine to free his blood from
germs. As natives of malarious regions are very ajit to
harbor the parasite in their blood and to keep the mos-
quitoes in their neighborhoods infected, it is important
to keep them away from barracks and healthy house-
holds, and it is wise to build dwellings or barracks at

INSECT-BORNE DISEASES 297

some distance from native towns or habitations. Na-
tives working about soldiers' quarters should be re-
quired to take quinine regularly and to observe the
general rules of hygiene.

Quiniue has been much and successfully used as a
preventive of malaria. The most extensive use of it has
been by the government in Italy, and ^J j-^ ■ •
the Germans in some of their African col- jl
onies. It may be said that there are two , . ^"
methods of using quinine in prophylaxis,
and the difference of opinion concerning the value of
this method of control arises from a confusion of them.
One method consists in the daily administration of
small doses of from two to five grains of quinine. The
evidence concerning the value of this method is con-
flicting and many instances have been cited to show
that it is of little or no use. The other method is the
administration of doses that might be therapeutic if the
person were actually infected, and it is highly effective
in keeping down the disease, by reason of the fact that
parasites entering the blood are promptly destroyed,
and of the other fact that actually infected persons have
their peripheral blood freed from parasites and are
therefore not infective for mosquitoes. It is probable
that a large part of the Italian and German successes
with quinine prophylaxis lay in the fact that it was
largely a treatment of malaria carriers. Such treatment
alone, if it could be carried out thoroughly every-
where, would suffice to eliminate the disease. Like many
other desirable measures, this is impracticable. When
a command is temporarily placed in a malarious re-
gion without other adequate protection, it is advisable
to place the whole force on quinine. The most satisfac-

298 THE PREVENTION OF EPIDEMICS

tory dosage is generally about ten grains. This may be
given daily, and when it is desired to reduce the total
intake of the drug the interval between doses should be
lengthened, rather than giving a smaller dose, the idea
beiug to have an efficient concentration of quinine in
the blood occasionally rather than to have an insufficient
amount present at all times. It should be borne in mind
that many persons are very susceptible to the action of
quinine and are apt to suffer much discomfort from the
use of a dose of this size. In such cases the surgeon
must decide whether the individual should use the drug
as a prophylactic, and, if so, how.

Experience indicates that the work of mosquito " ex-
termination " is more effectively done if regular forces
__ are kept at it to the exclusion of other work,

and every tropical or mosquito-infected post
^ . , should have such a "mosquito brigade."

Men kept on the work soon learn the lo-
cations and habits of the insects and become expert in
destruction or prevention. When the work is left to
householders or to general fatigue parties, it is usually
neglected and the plague continues unabated.

FLEA-BORNE DISEASES

Bubonic plague is the most important disease trans-
mitted to man by fleas, and it will be discussed here
_. only briefly, as mention has already been

made of it. The disease is due to a small
bacillus that is possessed of great vitality, so that the
virus may persist for a long time. Extensive investi-
gations in different parts of the world, but principally
in India, have clearly demonstrated that the disease
is usually transmitted in the manner here indicated,

INSECT-BORNE DISEASES 299

though it is occasionally communicated in other ways.
The relation of rats to plague epidemics has already
been discussed. A Russian observer states that bedbugs
also may transmit it. In Java it was found that body
lice taken from plague patients contained plague bacilli.
It is possible that they might transmit the disease.
Pneumonic plague and its transmission by contact and
droplet infection have been discussed, and experiments
carried out in Manchuria and later in Manila indicate
that during coughing, even when no visible droplets are
expelled, large numbers of bacilli are widely dissemi-
nated, and the wearing of masks, gowns, and eyeglasses
by doctors, nurses, and others attending patients with
this form of the disease is important. The germs are ex-
creted by plague patients in the spit, urine, the pus from
ulcers and buboes, and possibly the feces, so that dust-
infection and contact may account for some cases. Nev-
ertheless the rat and the rat flea are responsible for the
majority of cases and epidemics, and the measures of
prevention and control are aimed at these two. The
following facts, among others, constitute the reasons
and justification for such measures.

Rats abound particularly in houses and neighbor-
hoods which, because of poor policing or other sani-
tary neglect, afford them food, shelter, and -- ., ,
breeding-places. They are very susceptible , TrtinH
to plague and are probably the natural -y.iog4o„
hosts of the disease. When severely in-
fected they may have the germs in their blood in enor-
mous numbers, as many as 100,000,000 in a cubic
centimetre of blood. All rats have fleas, which remain
on them imtil death, when they leave them and seek
other hosts, usually rats, but in their absence men or

300 THE PREVENTION OF EPIDEMICS

other animals. Fleas breed in the nests of their hosts,
live on their blood, and in biting may readily ingest
as much blood as may contain, in the case of plague
septicemia, 5000 plague bacilli. These bacilli may re-
main alive and virulent in the flea's stomach for as
long as fifteen days, and then be ejected when the flea
bites again, and gain entrance to the wound made by
the insect, thus producing infection.

While the rat flea is the insect principally concerned
in carrying the disease, dog, cat, and human fleas may
_ ., __. act the part. The following is the ordinary

life history of the rat flea in Bombay. The
— —,. egga are laid at all seasons, from one to five

at a time, and hatch in about two days. The
larvje are wormlike and resemble some small fly and wee-
vil larvse. They live on almost any kind of refuse, often
on parental excrement, and, after varying periods of
not less than one week, spin cocoons of fine, silky
thread, which become covered with dust and rubbish
and are difficult to distinguish. The adult fleas escape
from these cocoons after one or two weeks and seek
a host, as they can only live on fluid food, especially
blood. The most favorable temperature for breeding
is from 50° to 85° F., and when the mean is above or
below this range, breeding stops or is delayed, a fact
which partly accounts for the seasonal variations of
epidemics. Each species of flea has its own host, which
it prefers to all others, but in the absence of that host,
and after a period of starvation, it will seek others.
The rat flea, for instance, will not usually bite man
until three days after the death of its rat host.

It is to be noted, however, that the " rat flea " does
not mean merely one species of flea. The common rat

INSECT-BORNE DISEASES 301

flea of the Philippines is not the same as the one most
common in India and Java. The life history and breed-
ing liabits of rat fleas therefore vary on this account
and others. In Java, where the climate is very uniform,
the mean temperature being from 73 to 75 degrees
Fahrenheit all the year and the humidity not less than
70 per cent saturation, flea breeding and plague spread
have no seasonal variation as in India and other places.
In Java, the eggs of the common rat flea (^. cheopis)
hatch in from four to eight days and the larvae develop
into mature fleas in thirty-one to fifty-two days. The
adults lived, in the laboratory, only two or three weeks.
Humidity is favorable to their development, as when the
air is driest fewer eggs hatch and both the larval and pu-
pal stages are prolonged. Infectious plague bacilli were
there found in fleas eighteen days after their ingestion.
In the Canal Zone fleas begin to leave the body of a rat
almost immediately after its death, and all have left at the
end of two hours. The common rat flea of England may
have its pupal stage prolonged for months, cold weather
so influencing it. In rubbish the adults of this flea will
live apparently unfed for as long as seventeen months,
without rubbish for one momth. It is said that this flea
will feed on man as readily as on rats, but that it does not
breed until it has fed on rat blood. In India the laying of
eggs, the development of eggs into larvae, of larvae into
pupae, and of pupae into adults are all subject to marked
seasonal variations, being most active in wet and tem-
perate weather and least so under dry and hot con-
ditions.

The measures to be taken for the prevention and sup-
pression of epidemics are indicated by the facts recorded
above. They must embrace numerous and costly expe>

302 THE PREVENTION OF EPIDEMICS

dients unless the fight is begun in earnest at the first
_ appearance of cases, and the disease eradi-

^ , cated before it has had an opportunity to

„ spread. Failure to take vigorous action

X eai'ly resulted in the spread of plague
„ . through San Francisco, so that the work

J . and expense of fighting it had to be con-

tinued for years.
General hygiene is of great importance as lessen-
ing the numbers of rats and fleas, both of which
abound in the presence of filth. Such measures must
include the removal or destruction of rubbish and other
material in which the rats hide or make their nests, the
stopping of their holes or other means of access to walls,
floors, and other hiding-places, the preven-
tion of their access to garbage and other
^° food-supplies. They must also include such

cleanliness of persons, domestic animals, houses, streets,
and communities, as will make the presence of fleas,
bedbugs, and lice improbable.

Special measures should also be adopted against rats,
such as their destruction by poisoning, trapping, and
disease. The last-named measure is em-
ployed by scattering bait contaminated with
° cultures of a bacillus that causes epidemics

among rats, but does not harm man or his
domestic animals. The keeping of cats has been advo-
cated as a useful anti-plague measure, and it is prob-
ably of value. Old and rat-riddled buildings may need
to be destroyed. Good buildings should be made rat-
proof by means of concrete, cement, and sheet-iron.
Stables and warehouses will require particular atten-
tion, and their floors, walls, and roofs should be made

INSECT-BORNE DISEASES 303

as rat-proof as possible. Because of the frequency with
which rats are transported in ships, all wharves and
docks must be freed from them as far as possible, ships
from infected ports should be required to anchor off-
shore, and all cables or chains leading to shore or to
other boats should be provided with shields that rats
cannot pass. Sewers should be well flushed to keep
them clean, and should be screened or barred so that
rats may not pass from them to houses or other build-
ings. Houses or boats known to be infested should be
tightly closed and fumigated with sulphur fumes or
other poisonous gas that will destroy the rats.

The greatest of all anti-rat measures, however, is
cleanliness. A city, a house, a wharf, or a ship may be
as " rat- proof " as it is possible to make it, and if it is
not kept clean and well policed it may swarm with rats,
despite traps, cats, and poisons. On the other hand, a
building far from rat-proof may be kept free from rats
without any of those means. Given rat-proof food storage
and garbage cans for kitchens and rat-proof grain bins
for stables, and even they can be kept freer from rats
than can other similar places with poisons, traps, and
cats, but without adequate food protection.

As helpful in fighting rats it may be mentioned that
they can climb almost anything, even an iron pipe or a
bamboo pole, may burrow as deep as two and a half
feet, can jump upward eighteen inches, "can surmount
any horizontal projection of less than six inches if the
material be such as they can climb on a vertical sur-
face, and can walk along a thin suspended wire." A
rat released 450 feet from shore reached land in six
minutes, and one released 1300 feet from shore swam a
total of 1500 feet and reached land in fifty-five minutes.

304 THE PREVENTION OF EPIDEMICS

The interesting fact that during a series of epidem-
ics there is evolved a race of rats relatively immune to
plague has been observed in India. In plague-free cities
(Madras, Raipur, Banda) infected rats show a case
mortality varying from 90 to 100 per cent, while in
plague-stricken places (Cawnpore, Lucknow, Poona)
only 20 to 40 per cent succumb. This immunity is trans-
mitted from parent to offspring and is not acquired.

The most important measures against fleas are pro-
bably good general policing, the maintenance of clean
_- floors, and the absence of litter and waste

in which they may breed ; but other mea-

. sures are also of value, and among them
against , .1,1.. 1

_,, may be mentioned the use 01 msect-powder

and antiseptic soaps on domestic animals,
the use of foot-covering and other adequate clothing,
and the use of petroleum on floors and streets, and of
putty, paint, and antiseptic solutions in cracks of floors
and walls. The Indian Plague Commission reports that
for practical purposes flake naphthalin is the most gen-
erally effective agent to use against fleas in all stages
of their life cycle. It may ordinarily be used in its dry
form, but to get it into cracks and crevices it may be
dissolved in benzene. For the treatment of rat holes
they advise the use of carbolic emulsion (larvacide is
such), or of a soap-petroleum emulsion, to which flake
naphthalin has been added. A soap-petroleum emulsion
may be made by combining 80 per cent of crude petro-
leum with twenty per cent of whale oil soap (or, pre-
sumably, other coarse soap). A room thoroughly washed
and sprayed with this is said to be freed from fleas. As
previously suggested, the use of crude oil in road-mak-
ing, as is now much practiced in this country, will pro-

INSECT-BORNE DISEASES 305

bably prove of value in lessening the number of fleas.
Fleas may be collected in rooms or houses known to
be infected by turning guinea pigs loose in them. The
fleas attack the animals, and may then be stupefied with
chloroform, combed from the hair, and burned.

Every case of plague in man or rat should be promptly
reported, so that proper measures of isolation, fumiga-
tion, disinfection, etc., may be instituted
early. All rats found dead, as well as those
trapped or otherwise captured, should be
tagged with a statement of the time and
place, and then examined for the presence of plague.
If it is found that they have the disease, active measures
must be begun at once in the neighborhood from which
they came. All persons afflicted should be isolated and
their discharges cared for. Disinfection of houses and
effects should follow.

Anti-plague vaccination has been considerably used
iu India for some time now, and the following state-
ments as to results have been published : -TT-e-j-- j»
" 1. In a native of India, who is more sus- ^
ceptible to the disease than Africans, Euro-
peans, and some other races, the inoculation now in force
reduces the liability to attack to less than one third of
what it is in a non-inoculated Indian. 2. In the one third
of cases which still occur, the recovery rate is at least
double that in the non-inoculated attacked. The ulti-
mate result is a reduction of plague mortality by some
eighty-five per cent. 3. In an inoculated European an
attack of plague, if it subsequently occurs, has so far
always ended in recovery. 4. The inoculation is appli-
cable to persons already infected and incubating plague,
and prevents the appearance of symptoms or else miti-

306 THE PREVENTION OP EPIDEMICS

gates the attack." Government reports show that in
1911 there were distributed 1,211,170 doses of plague
vaccine, and that among 118,148 vaccinated persons
there was a plague incidence of 7.96 cases per 1000,
with a case mortality of 39.5 per cent ; while among
321,621 unvaccinated persons the incidence was 34.4
per 1000, with a case mortality of 78.6 per cent, indi-
cating results as good as those claimed by the origina-
tor of the method and quoted above. Similar results
were reported from Java for the same year, yet the
statement has been published that the use of vaccine has
there been abandoned. The Indian government report
just referred to states that the protective power of the
vaccine varies with the severity of the reaction it causes.

LOUSE-BORNE DISEASES

Of these typhus and the relapsing fever of most
parts of the world have been, in former times, among
the world's great scourges, and while often known as
jail fever, ship fever, camp fever, and famine fev^r,
their appearance was by no means so limited as those
names would indicate, and palaces and great persons
were not strangers to the diseases or their carriers. At
present these diseases are almost unknown in our coun-
try, England, Germany, and the other highly civilized
Western countries, but in many parts of the world one
or both are still rather common, notably in Mexico,
where the typhus is known as " tabardilla" in north
Africa, in Bussia, in Asia, and especially in China,
while a large epidemic of typhus prevails in Japan, es-
pecially in Tokio, at the time of this writing.

Brill's disease, of the immigrant sections of some of
our cities, is a mild form of typhus.

INSECT-BORNE DISEASES 307

The germ causing typhus has not been identified to
the satisfaction of most workers. That causing relaps-
ing fever has been known for a longer period than most
other germs causing human diseases, and is a spirillum,
a motile, corkscrew-shaped organism that is readily
detected in the circulating blood at certain periods of
the disease.

It has been shown that both of these diseases are or-
dinarily conveyed by body lice, but there is also evi-
dence that both may be conveyed by head lice, and the
investigation of a case of typhus in an American sol-
dier in China suggested to the writer that the crab louse
might also carry that disease. Typhus is ordinarily
transmitted by the bites of the lice, but this is only
exceptionally true of relapsing fever, of which disease
the insects are contaminative carriers, and in which in-
fection usually occurs when the insect is crushed and
its juices rubbed into the skin by scratching. There is
evidence that both diseases and the power to infect
with them may be passed by the lice to their offspring.
The following observations on lice are not without in-
terest. Body lice are more hardy than head lice and
outlive them under adverse conditions. Both survive
longest when maintained at a temperature
of about 82 degrees Fahrenheit, in a moist
atmosphere, and allowed to feed twice daily. ^
Body lice reared in a vial worn next to the
body, and allowed to feed twice daily, afforded facilities
for the following observations by an English natural-
ist. A female lived one month, copulated repeatedly
with a male that died on the seventeenth day, and later
with another male. She laid 124 eggs in twenty -five
days. The eggs hatched in eight days under favorable

308 THE PREVENTION OF EPIDEMICS

conditions, but not at all in the cold. When larvje
emerge they feed at once if given an opportunity. They
reach the adult stage on the eleventh day, after three
moults. The adults begin to copulate five days after
the last moult and live about three weeks thereafter.
Unfed lice die in five days or less, unfed larvae in thirty-
six hours.

The above facts being known, the method of preven-
tion of typhus and relapsing fever is obvious, — avoid-
_^ ance of lice. To avoid lice, cleanliness of

person, clothing, and associations is neces-
sary. To get rid of them, infested clothing
should be boiled or steamed, infested bodies washed,
infested hair shaved or soaked for fifteen minutes in a
solution of one part carbolic in forty parts of water,
infested barracks or tents emptied and thoroughly
scrubbed and disinfected.

FLY-BORNE DISEASES

In addition to typhoid and other diseases discussed in
preceding parts of this book, in which the fly acts as a
_. . simple carrier of infection but does not ac-

_. , tually introduce it into the body, the sleep-

ing sickness of Africa is a very important
disease. It is introduced by a biting fly, and is caused
by a small animal parasite very much like that causing
surra in horses in the Philippines and other places.

The only means of prevention yet known are the
avoidance of fly bites, the cleaning of undergrowth
from near streams, and the avoidance of infected local-
ities. The disease has spread widely throughout Africa
within a comparatively few years, has caused enormous
fatalities, and practically depopulated large districts.

INSECT-BORNE DISEASES 309

All of the European countries having colonies south
of the Sahara have done much work and spent much
money in their efforts to control it. Whether or not
there are two or three kinds of sleeping sickness, caused
by two or three species of trypanosomes, is not at pres-
ent settled, but at any rate all sleeping sickness is try-
panosomiasis and is transmitted by tsetse flies. Afri-
can antelope appear to be reservoirs of the disease, and
the question of their extermination is being discussed.
The value of proper clothing as a protection from fly
bites is not to be forgotten. It appears that sleeping
sickness is relatively more common among European
women in Africa than among the men, a fact probably
partly accounted for by the less degree of protection
of this sort afforded by the women's clothing, especially
by their stockings as compared with the men's leggings
or trouser legs.

In the Balkans, in many places in or about the Med-
iterranean, in India, and elsewhere, a short, sharp, pain-
ful fever, called "three day" or "sand-fly _,
fever," has been found to be carried by _
sand flies or midges of the genus Phlehoto- p^ _..
mus^ very small insects that breed in crev-
ices of stone walls and similar places. The disease is
not fatal and bears a clinical resemblance to dengue.
Prevention lies in avoidance of bites, a difficult matter
where the flies abound, as they readily pass through
most mosquito screening.

TICK-BORNE DISEASES

The most important tick-borne diseases that have
been well studied are the African relapsing fever, due

310 THE PREVENTION OF EPIDEMICS

to a spirillum, and the spotted or tick fever of western
Montana, due to an unknown organism. The latter dis-
ease may affect American troops, as Fort Missoula is
in the country in which it occurs. No case has yet
appeared in a soldier. Both of these diseases may be
transmitted by ticks that have bitten sick persons, or
by the young of such ticks. The methods of prevention
thus far known to be of value are the avoidance of in-
fected districts and of tick bites. In the case of spotted
fever the season is short and the danger is slight, except
from the first of March to the middle or end of July.
If infected regions must be visited, the use of adequate
clothing and of head-nets and bed-nets wiU be of value,
but probably not absolutely protective. Wood-ticks,
such as convey spotted fever, disappear as forests are
cleared and the land cultivated. The ticks that convey
the African fever abound principally in rest-houses and
old camps, and cleanliness, avoidance of old huts and
old camp-sites, and the use of nets, would seem the best
measures of protection.

DISEASES BORNE BY BEDBUGS

As stated above, a number of diseases have been
credited to the agency of these pests, and the evidence
incriminating them is sufficiently strong to make their
avoidance and destruction a necessity, as well as an
aesthetic measure. The mere fact that they are and for
an unknown period have been closely parasitic on man
is presumptive evidence of the possibility of one or more
human diseases having adopted them as carriers, be-
cause a study of the insect-borne diseases that have
just been discussed shows that each of them is borne
by an insect closely associated with the animal host. In

INSECT-BORNE DISEASES 311

most instances in which the carrier is not a parasite
especially associated with man himself, for example
the rat flea and the tsetse fly, it could reasonably be
claimed that man is only accidentally the subject of
the diseases, which in the instances cited belong to the
rat and the wild game. Bedbugs are so generally recog-
nized as vermin and indicators of uncleanliness that their
presence constitutes a cause of shame in a well-regulated
house or barracks. The avoidance of diseases trans-
mitted by them depends on scrupulous cleanliness of
houses, beds, and bedding, and the avoidance of those
that are not clean. Soldiers, though living in clean sur-
roundings, may expose themselves to bites in seeking
sexual indulgence or drink, and they should be taught
by precept and example not to do so.

CHAPTER XV

VENEREAL DISEASES

The term venereal is usually applied to the diseases
resulting from illicit and impure sexual intercourse.
The principal members of the group are syphilis,
chancroid or soft chancre, and gonorrhoea. In a gen-
eral sense the adjective is truly descriptive, but, as
stated before, it is not always so, and all of these trou-
bles may be contracted by persons absolutely innocent
of illicit connections or even of proper intercourse. It
is, however, so generally true that in soldiers, at least,
the diseases result from improper conduct, that they are
assumed to be " not in line of duty," and a report to the
contrary requires special explanation.

These diseases are particularly frequent in youth and
C* p al ^^^^y manhood, and it is stated that " about
— 95 per cent of all cases of gonorrhoea occur

between the ages of sixteen and thirty."
The reasons for this are numerous, and some of them
may be summarized as follows : —

1. This is the period at which sexual desire and
power are at their maximum. After the age of thirty
some decline in both has usually begun.

2. It is also a period in which judgment is not ma-
tured, self-control not well developed, and ignorance
not dissipated, so that the future wife and family ex-
ercise no claims and venereal diseases are regarded as
trifling.

3. Manhood and virility are synonymous terms, in

VENEREAL DISEASES 313

common usage as well as in the dictionaries, and youth
delights in demonstrating its manhood.

4. Most men are married by the time they reach th«
age of thirty, and are less apt to be exposed to infec'
tion thereafter.

The soldier is probably more apt to contract venereal
diseases than the young civilian, because his associates
are practically all males ; his topics of conversation are
largely such as are only handled in " stag " gatherings ;
he is removed from the restraints of the family and of
the public opinion that can most influence him, that of
his friends and acquaintances at home ; he may at times
find it difficult to obtain access to other female society
than that of prostitutes, and these are always to be
found. He may also drink a bit to demonstrate his man-
liness, to relieve his loneliness, to be companionable,
or simply because he is " a young man, void of under-
standing " ; and then, with judgment perverted and
desires inflamed by alcohol, he forgets danger and seeks
intercourse where he can most readily obtain it.

For many years our army has had the highest non-
effective rate of any army publishing its statistics. The
reasons for this were probably several in number, though
not all well understood. At present the condition is
improving, official reports showing the constantly non-
effective rate in the army stationed in the United States
to have fallen from 11.44 per 1000 in 1909 to 3.58 per
1000 in 1913.

In his annual report for 1913 the Surgeon General as-
cribed this improvement to two main factors: the general
use of preventive measures after intercourse, and the
stoppage of pay during absence from duty on account
of illness due to the soldier's own misconduct.

314 THE PREVENTION OF EPIDEMICS

When to this is added the time lost because of troubles
indirectly due to venereal diseases, and the duties
poorly performed because of them, it is probably no
exaggeration to say that it was almost as though one
regiment had been eliminated from the service.

The company officer cannot expect to work a revolu-
tion in the morals of his men, or to make chastity a
_ . general characteristic of them, but he can

__ exercise some influence in that direction

, _ by his personal conduct and example, by

choosing non-commissioned officers who
will probably do the same, by making the
soldier's surroundings pleasant and attractive, and en-
couraging him to find his amusement and recreation in
the post, by providing good reading-matter and help-
ing to make the most of the post exchange as a place
of recreation and amusement, and by giving his men
instruction as to the dangers of venereal disease and the
sanity, healthfulness, and safety of sexual control and
continence. Recruiting officers can do much by careful
selection of men, as it is a well-known fact that the
great number of admissions to sick report for venereal
disease is made up by a relatively small number of men,
the majority of whom are of the less desirable class of
soldiers. Drink, poor home -training, ignorance, and
lack of self-respect lead these men to places and prac-
tices that their more decent comrades avoid.

As man is the only carrier of these diseases, as they
are transmitted in nearly all instances by direct physi-
cal contact, and as early diagnosis, isolation, and treat-
ment enable us to do much in the control of other
transmissible diseases, it seems reasonable to believe
that similar measures, if generally enforced, would

VENEREAL DISEASES 315

produce great results in these. There can hardly be
any doubt that if all cases of venereal disease were
promptly reported and then isolated and kept from
sexual intercourse until well, the diseases would be ex-
terminated. These are such chronic troubles, however,
and require such prolonged and careful treatment to
insure a cure, that such a plan is quite impracticable.
Many efforts have been made to approach it though,
by the regular examination of prostitutes and their
isolation and " treatment until free from contagious
lesions, and similar measures have been adopted in re-
gard to soldiers in our own service. But it cannot be
said that the diseases have been brought under control
by such measures, and the reasons are fairly obvious.
It is practically impossible for an examiner to know
positively that a given person is free from venereal
disease. Chancroids are easy of detection, but both
syphilis and gonorrhoea may linger, capable of trans-
mission, without giving any indications of their presence
that can be detected by the inspection that the exam-
iner of large numbers can give. This is true in the case
of soldiers, and much more so in that of prostitutes,
who, moreover, are adept in the removal of slight signs
that may be present, and whose interest lies in escaping
isolation. Most prostitutes are such for one of two
reasons, either for the pleasure and excitement they
find in the life or for the money they can make out of it.
In either case their object is defeated for the time be-
ing if they are isolated. Furthermore, there is always
and everywhere a large amount of clandestine prostitu-
tion, that is, that practiced by women not openly pro-
fessing to do so ; and as registration of the prostitute
is a necessary preliminary of her regular examination.

316 THE PREVENTION OF EPIDEMICS

a large amount of venereal disease thus escapes detec-
tion. Naturally, too, the amount of this clandestine
prostitution increases with the severity and strictness
of the measures of control over that which is licensed.
As examinations are not usually made more than once
a week, and in many instances not so often, a woman
may develop a contagious discharge or sore the day
after examination, and transmit disease to fifty men be-
fore being examined again. A prostitute living near a
Western post stated that she usually hiad intercourse
with from fifteen to twenty-five men on the night fol-
lowing payment of the troops, and with from one to five
or six men on other nights, and investigations in Chi-
cago, New York, and elsewhere have since shown that
that is no unusual record for a prostitute.

American sentiment has never favored state licens-
ing of prostitution. Without discussing the right and
wrong of the matter, we must face the following con-
dition as regards the army. It consists of aggregations
of men, mostly young, mostly unmarried, and largely
ignorant, who have abundant opportunity to gratify
their sexual instincts, but with women who are under
little or no control, many of whom are diseased, and
all of whom are interested in avoiding treatment that
involves isolation. The obvious courses of procedure
are, 1st, the provision of wholesome surroundings and
amusements to keep the men away from dives and bro-
thels ; 2d, their instruction as to the nature and dangers
of the venereal diseases, so that the large amount of
these due to ignorance may be eliminated ; 3d, advice
as to the best methods of avoiding disease in case they
are so persistently foolish as to expose themselves to
it. The instruction as to the nature and danger of the

VENEREAL DISEASES 317

venereal diseases may be derived from the following
consideration of them.

Gonorrhoea

Gonorrhoea or " clap" is a disease of such great an-
tiquity that it may be as old as prostitution itself, and
the first half of the fifteenth chapter of Leviticus indi-
cates that Moses knew it and also knew that it was
conveyed by contact, and that he provided rules to pre-
vent its spread.

The disease is due to a bacterium known as the gono-
coccus. This organism occurs constantly in the gonor-
rhceal discharge, and the disease can be pro- -^
duced by artificial inoculation with it. It
is very hard to cultivate artificially, and is readily de-
stroyed by drying, heat, and antiseptic drugs. It may
live for some time on towels or linen, or in warm water.
It grows on mucous membranes, and those of the gen-
ital and urinary passages, of the eyes, mouth, and rec-
tum may be affected.

The young are more susceptible to its action than
the old, and children are particularly easy of infec-
tion. The disease once started in hospitals j» ««
for children or in orphan asylums, espe-
cially among little girls, is apt to become epidemic.

Transmission is usually by sexual contact, but it may

occur through mediate transfer, as by towels, soiled

hands, penis syringes, or urethral sounds. irirflTia

Such methods are uncommon, however, and

mission
little credence can be placed in the story of

the man who thinks he got it from a water-closet seat.
Strain, as from heavy lifting, can never cause the dis-
ease, though often alleged to do so.

318 THE PREVENTION OF EPIDEMICS

The incubation period varies considerably, and the
disease may manifest itself within a day of the impure
_ - connection or it may not do so for ten or

^ twelve days, or for some intervening period.

It usually begins with slight burning on
urination, which leads the subject to examine his penis,
when he may find the margins of the urinary opening
«.^^ red and somewhat puffy. Or the lips of the

. opening may be stuck together when he

arises in the morning, and a drop of clear
discharge, like white of eggy can be expressed from it.
The symptoms increase rapidly, and within another day
or two the disease is at its height. The discharge is
then more profuse, is creamy in color and consistency,
the penis is sore, and urination painful. Erections may
be frequent and painful, especially when the patient is
in bed and when the inflammation has extended out
into the body of the penis. These may cause intense
pain, and the organ may be curved. This condition is
known as chordee. The inflammation may extend to
the bladder, causing very frequent and painful urina-
tion ; to the testicles, causing swelling, pain, and some-
times abscess formation, and often leading to stoppage
of the duct leading from the testicle to the seminal
bladder, and so rendering the former useless as a pro-
creative organ. Germs may be carried to the lym-
phatic glands in the groins, and cause them to become
very painful, tender, and swollen, and oftentimes to
suppurate. This glandular swelling constitutes a bubo.

These various troubles may cause great pain and
suffering, but, in the absence of further complications,
they lessen in severity after a time, usually from one
to six weeks, the swellings subside, the discharge dimin-

VENEREAL DISEASES 319

ishes or ceases, and the patient may think he is well.
Or he may recognize that he has gleet. This pg-gig*
is a condition not attended by other symp- g„«Q
toms than the presence of a small, clear drop
of discharge in the early morning, and it is usually re-
garded as of no importance. It is gonorrhoea, however,
and is capable of setting up the disease in others, and
many unfortunate brides have been so infected. It may
persist for months or years, and other manifestations
of the disease may do likewise. Many men have suffered
or died from the results of gonorrhoea ten, twenty, or
more years after they thought themselves cured of it ;
or, worse still, they have seen their wives or children
sicken, become blind, or die as the result of it, and have
had no thought that they were themselves responsible
for the calamity.

The complications of gonorrhoea are so numerous, so
serious, and some of them apparently so remote, that
there is no space to discuss them here, but nomnli
some of them will be mentioned. Stricture ^3*1---
is one of the most common. It is often pre-
sent when a gleet persists. It may cause obstruction of
urine, great suffering, and serious or fatal kidney disease
years after the acute gonorrhoea. The principal symptom
is obstruction, usually partial, to the urinary stream. In-
flammation of the prostate gland may develop and last
for years, causing pain in urination and perhaps during
defecation, pain deep between the legs, marked nervous
symptoms, and general invalidism. Gonorrhoeal rheu-
matism^ or joint inflammation, is always hard to treat,
causes great pain, and tends to last for a long time. It
may result in great deformity and permanent crippling.
Tendon inflammation may also occur and produce symp-

320 THE PREVENTION OF EPIDEMICS

toms much like the joint troubles. Pain and tenderness
of the heel or of the great tendon leading upward from
it may result from gonorrhoea and prevent marching.
Mye diseases of at least two kinds result from this dis-
ease and always endanger and frequently destroy the
sight. Gonorrhoea is one of the great causes of blind-
ness, the disease often developing in children at the
time of birth, from infection entering their eyes from
their mothers' genitals, the mothers often being infected
by their husbands, who thought themselves cured before
marriage. The disease may also be conveyed to the eyes
by the hands after urinating or wiping away discharge
from the penis. It may be transferred from one person
to another through the medium of towels, wash-cloths,
medicine-droppers, and other things in common use.
Blood-poisoning, that is, the diffusion of germs through
the blood, may result from gonorrhoea and may cause
death. Heart disease may be a complication, and often
accompanies blood-poisoning. It may cause death early
or may be apparently recovered from, and the heart
may break down from the damage done it only after
the lapse of years. Owing to the levity with which the
disease is often regarded, this complication may not be
detected at the time of its occurrence.

As already stated, the subject of gonorrhoea is a
source of danger to his companions and his family, and
— in military life it is desirable that he should

^, be confined to hospital, at least during the

time of most active symptoms, and that all
men should be cautioned against using the towels or
linen belonging to others. No man worthy the name
would deliberately infect another person with his dis-
ease, but many men unintentionally do so. All should

VENEREAL DISEASES 321

be instructed to abstain from sexual intercourse until
entirely cured.

Without condoning or attempting to justify illicit in-
tercourse, we must recognize that many men will indulge
in it in spite of instruction, warning, and ^
example, and it is the part of economy and ^
makes for the efficiency of the army if those
men can be protected from disease in spite of their folly
and misconduct. No infallible means of protection from
venereal contamination is known except chastity, but the
following measures may ofPer some degree of it. Urina-
tion^ if practicable immediately after intercourse, tends
to wash out germs that may have entered the urethra.
Irrigation of the urethra with a mild antiseptic solution,
such as permanganate of potash solution in strength of
one part to three thousand, has a similar action. The use
after intercourse of jellies or ointments containing anti-
septic or anti-gonorrheal drugs put up in collapsible
tubes has become rather common, because of the porta-
bility and convenience of these as compared with irri-
gations. The substances usually relied on in these pre-
parations are protargol or other silver preparations,
carbolic acid, and calomel. These preparations, of which
the K packet is best known, are sold under various trade
names, and most of them are fairly efficacious. Modera-
tion in intercourse is advisable. Repeated intercourse
in the space of a few hours brings about a congestion
of the genitals which is slow in subsiding and which
predisposes to infection. Condoms^ impermeable rub-
ber coverings for the penis, are sold and used for the
prevention of disease, and they should protect against
gonorrhoea.

After the disease is once contracted the best way to

322 THE PREVENTION OF EPIDEMICS

prevent complications is by rest in bed and proper treat-
p ment. Soldiers should, therefore, be taught

^ , to report early for treatment, and to con-

-, ,. tinue at it until entirely cured, to be cleanlv
^ m their habits, and by frequent hand-wash-

ing and care of towels and linen to avoid
infecting the eyes, and (very important) to avoid con-
sultation with advertising quacks or the use of adver-
tised medicines, both of which are fraudulent.

Chancroid

Chancroid, soft chancre or soft sore, is the least im-
portant of the diseases here discussed, as it is a local in-
fection and does not do the general damage or assume
the manifold and insidious forms that often characterize
gonorrhoea or syphilis.

The typical and usual soft chancre is due to a small
^ bacillus which bears some resemblance to

that causing plague, but ulcers may be pro-
duced on the penis, as elsewhere, by other organisms.

The incubation period varies from one to ten days,
and its length probably depends on a number of fac-
_ . tors, such as the degree of infection in the

^ woman, the presence and size of scratches

or abrasions on the penis, and the violence,
length, and frequency of the infective intercourse.

The disease begins as a small ulcer, or sore, which
may be no larger than the head of a pin. The favorite
a—-- location is in the depression or groove just

. back of the head of the penis, though it

may be anywhere on that organ. Many
sores may show at once, or one may appear at first and
others develop later. The ulcer enlarges and deepens.

VENEREAL DISEASES 323

the surrounding parts are red, swollen, and tender, and
the surface of the sore more so. A thin and usually
moderate discharge is present, and is highly infectious,
and its presence causes the development of the sec-
ondary sores. Under proper treatment the ulcers can
usually be healed in a few days or weeks, but if neg-
lected or improperly treated or in inaccessible positions,
they may spread and produce considerable loss of tis-
sue, half or more of the head of the penis being some-
times destroyed. The base of the ulcer, if not irritated,
is usually soft as compared with the base of the syphil-
itic chancre, hence the name soft chancre. Occasionally
this sore may appear on the bag, on the lower hairy
part of the abdomen, or anywhere, in fact, that the
virus has entered the skin.

The most frequent complication is bubo, which oc-
curs in about one fourth of all cases. It -, ..
is very painful, causes lameness, fever, and ^
may require operation.

The methods mentioned as tending to protect from
gonorrhoea are equally applicable here, except that
irrigation would not be particularly valu- ~
able, as the sore usually develops exter- ^
nally rather than in the urethra. Washing
the genitals in an antiseptic solution, such as one to
one thousand bichloride, will offer a certain amount
of protection. Early and proper treatment is required
to produce speedy healing and lessen the tendency to
the formation of buboes, and soldiers should report
promptly for it.

Syphilis

There has been much speculation and discussion as
to whether syphilis, or pock, originated in the old

324 THE PREVENTION OF EPIDEMICS

world or the new, whether the Spaniards brought it to
America, or took it from here. At any rate, the dis-
ease spread throughout Europe in the century follow-
ing Columbus's voyages, and it has prevailed through-
out the world until the present time, and is now seen
in all ranks of society and all walks of life. It is the
most dreadful of the diseases considered in this chap-
ter because of its chronicity, the long time required
for its treatment, the great variety of its manifestations,
the number and seriousness of the conditions resulting
from it, and the fact that it is the disease affording the
most striking examples of the sins of the fathers being
visited upon the children. The disease cannot be de-
scribed or adequately discussed in the space allotted here,
but a very brief outline of it will be given, in order to
enable the line officer to impart some degree of informa-
tion about it to his men.

Although the disease has been known and industri-

^ ously studied for centuries, it is only lately

that its cause has been known. This is the

very fine and delicate spiral organism mentioned in a

preceding chapter as a Treponema.

The commonest method of transmission of syphilis is

through sexual intercourse, and this is especially true

_ as regards soldiers, to whom many of the

. . other avenues of infection are not open.

mission -r» . .1 1 , 1 ,

xJut there are such other avenues and they

are numerous ; and innocent victims of this disease

are therefore more numerous than those of gonorrhoea

or chancroid. Among such methods we may mention

the following: —

Heredity. The disease may be inherited from either

parent, and may infect the child in the womb and cause

VENEREAL DISEASES 326

its death there, cause it to be born diseased, or to be
born apparently well and develop the disease soon after.
Or, in rare cases, it may be born apparently well and
continue fairly so for years, and only show the disease
in recognized form when it reaches the age of puberty.

Contact^ especially such as kissing, is a fairly common
method of transmission. Ulcers or sores in the mouth
are a common manifestation of the disease, and in such
cases the organisms are present and sometimes numer-
ous there. The saliva or discharge from such a mouth
is highly infectious, and, if brought in contact with a
slight scratch or sore, will give rise to the disease. Chil-
dren and girls have many times been infected by kissing
persons so affected, and syphilitic children may by this
means infect the nipples of their wet nurses. For this
reason, also, the spoons, cups, and other eating uten-
sils and pipes or cigarette-butts that have been used by
syphilitics, are dangerous. The blood and discharges
from sores on syphilitic persons are infectious, and
nurses and doctors are occasionally infected in dress-
ing or operating upon such cases. Several instances
of the kind have occurred in the army. Barbers may
receive infection if they get wounds or scratches con-
taminated by the saliva or blood of their patrons,
and they may also transmit it through scratches or
cuts. Dentists and their implements, if not clean, may
transmit it.

The incubation period of syphilis, the time inter-
vening between the infective intercourse and the first

manifestations of the disease, is long. It _

, , 1 . n Incuba-

is never less than ten days, is usually nearer

a month, and not very rarely it may be two

months or more before the chancre shows, while in a

326 THE PREVENTION OF EPIDEMICS

considerable proportion of infections, probably some-
thing between a tenth and a fourth, the chancre does
not show at all and a condition of latent syphilis exists.
In such cases it may be many years before any mani-
festation of the disease is recognized. As a rule, how-
ever, the incubation period is from two weeks to one
month, after which time the primary sore or chancre
develops at the point of entrance of the virus. This fact
may be of value in determining the manner of infection.
If the chancre be on the genitals, it is usually a result
of sexual intercourse ; if elsewhere, the case may be
different. It may be on any part of the body, as on the
top of the head or the ear, where it has been seen to
result from bites received in fighting ; inside the rectum
as a result of unnatural practices ; on the breast of a
wet nurse ; or on the arm of a child vaccinated with
virus from a syphilitic.

The chancre constitutes the first sign of the disease.
It appears first as a small firm lump resembling a pim-
_ . pie. This may enlarge considerably or not

« . at all, depending somewhat on its situation.

It usually ulcerates slightly at its top, and
shows a slight discharge, which may be thin and clear,
or purulent. The chancre is nearly always single, and
secondary ones rarely develop. Its base is usually hard
and firm and feels like cartilage or even like bone, hence
this is called the hard chancre. It may be so small as
not to be noticed, and, as the patient may continue feel-
ing well while he has it, he may not know that he is
diseased until the appearance of secondary symptoms
after another period of six to twelve weeks. It is not
rare to have soldiers appear with well-marked second-
ary signs of the disease and no chancre, and denying

VENEREAL DISEASES 327

that they have had any. The secondary symptoms are
usually plainly marked and lead the patient « ,

to seek treatment. They are referred par-
ticularly to the skin and mucous mem- «
branes, and the most common of them are
skin eruptions, sores in the mouth and throat and
about the anus, falling of hair, slight fever, pains in
the bones or joints, anemia and pallor, and various
eye troubles. The skin lesions of syphilis are so nu-
merous and of such varied character that it has been
said that they can simulate all other skin diseases.
The arteries, heart, and internal organs may also be
affected in the secondary stage. In fact, no other
known disease manifests itself in so many ways as
this one, and it simulates the greatest variety of af-
fections, including smallpox and other eruptive dis-
eases, malaria, liver abscess, tuberculosis of lungs,
bones, or joints, epilepsy, and very many more. It is,
therefore, obviously out of the question even to mention
most of the symptoms here.

This stage may not manifest itself if the case is well
treated in the primary and secondary stages. Other-
wise it may merge with the secondary, or it rn^j^a
may appear only after the lapse of years, gta^e
It is characterized by deeper skin lesions,
that show a tendency to ulcerate and form large and
deep sores, by destruction of bone, the formation of
swellings or tumors, and the degeneration of internal
organs. Tertiary syphilis is more often mistaken for
tuberculosis, cancer, and other chronic ailments, than
for more acute ones. The syphilitic tumors may form
in any part of the body, and those in the brain,
heart, spinal cord, and other vital parts may be rapidly

328 THE PREVENTION OF EPIDEMICS

fatal. Syphilis is the most common cause of aneu*
risin.

A large and important part of the harm done by syph-
ilis was long not charged to that disease, and it is
only comparatively recently that we have
^*' had the proof that enables us to know the

^, terrible extent of its ravages on the nervous

Nervous , t> • • vu j

system. rJegmning with nervousness and

^ neurasthenia, that may appear early in the

disease and completely destroy the happiness and com-
fort of the patient and his family, the number of cases
of disease of the nervous system due to it is very large
indeed, and embraces a great variety of manifestations.
Among these may be named many varieties of paraly-
sis, muscular atrophy, many chronic headaches, about
one fourth of all cases of insanity, all cases of general
paralysis or paresis, probably all locomotor ataxia, and
many of blindness and brain tumor.

Syphilis is transmissible in any of its stages ; highly
so in the first, more so in the second, and but slightly
«j . , in the third. The time of greatest danger
, p is that during which there are sores, with

open moist surfaces, in the mouth, the nose,
on the genitals, and about the anus ; and
it is advisable, in military service, to con-
fine in hospital men who present such lesions. At other
times, if they are kept under observation by a medical
officer and continue their treatment, they may safely
mingle with their fellows and do full duty.

A large proportion of syphilitic cases are inade-
quately treated and remain uncured because of the very
general tendency of patients to neglect treatment or to
stop it entirely as soon as they are free from discom-

VENEREAL DISEASES 329

fort and from disfiguring lesions. The disease may, in
rare instances, be cured by a single dose of salvarsan or
neosalvarsan, but in the majority of cases _ ,

that is not so, and treatment must be con- r m
tinued for a period of months or years.
Even when brought under temporary con-
trol and apparently cured, the disease may still exist
and merely be latent, to manifest itself later in the form
of aneurism, locomotor ataxia, insanity, or some obscure
trouble. There is much evidence to show that different
strains of the Treponema tend to localize in different
tissues, one strain in the skin, for instance, another in the
blood vessels, another in the nervous system. This cor-
responds to the observed fact that many cases of aneu-
rism, locomotor ataxia, and general paralysis are to be
found in persons who had few, slight, or no skin lesions
with their syphilis. It is therefore very important that
the continuance and energy of treatment should not
be allowed to depend on the mere presence or absence
of skin lesions, and that other means of determining
whether the disease exists should always be used. Of
such other means the Wasserniann test is now most
widely known and most generally effective. Treatment
should be continued until that test becomes negative and
remains negative for some months. The test should be
repeated at intervals of about six months for two years
after treatment has been discontinued, and in the event
of the test showing a recurrence, treatment should be
resumed. When a man has been free from symptoms of
disease and has had a negative Wassermann reaction for
two years it may be considered safe for hira to marry,
thoTigh it must be borne in mind that there is even
then a chance of his developing symptoms later.

330 THE PREVENTION OF EPIDEMICS

The special preventive measures that may be em-
ployed by men exposing themselves to the dangers of
_ polluted intercourse are the same as were

^ mentioned for gonorrhcea and chancroid. A

small amount of experimental and clinical
evidence also indicates that protection may be conferred,
in at least some instances, by the use of a calomel
ointment. This is thirty per cent calomel in lanolin, and
should be well rubbed into the penis and exposed parts
for from five to twenty minutes, at the conclusion of
the intercourse and after the use of the irrigation and
wash mentioned as preventive of gonorrhoea and chan-
croid.

Mixed Infections

One may be simultaneously infected with two or all
of the venereal diseases, and in such instances the more
quickly developing gonorrhoea or chancroid masks the
presence of the chancre, and great surprise may result
when the secondary symptoms of syphilis become mani-
fest. Occasionally the chancre develops inside the
urethra and occasions a slight discharge which may be
mistaken for gonorrhoea, or the latter disease may co-
exist. In either event the chancre may be overlooked.
More frequently, however, the confusion arises from
the coexistence of soft and hard chancres. It is gener-
ally believed by men having venereal sores that the soft
sore is never syphilitic, and that it always arises within
ten days, while the hard chancre is always syphilitic,
and never appears within ten days. These are usually
true as related to pure single infections. But the viruses
of soft chancre and of syphilis may both enter the skin
at the same point, in which case a soft and ulcerating

VENEREAL DISEASES 331

sore may develop early and be followed by a large
suppurating bubo, a thing not occurring in pure syph-
ilis, and may heal under local treatment, leaving no
induration, or only a slight one that is ascribed to inflam-
mation. The syphilitic virus nevertheless continues its
work and in due time the secondary symptoms develop.
Some soft sores, especially those burned with acids, have
a base of inflammatory tissue that may greatly resemble
the hard base of the syphilitic sore.

So difficult is the differentiation of syphilitic from
non-syphilitic venereal sores, by the appearance alone,
that most careful practitioners do not definitely decide
that a given sore is syphilitic, and therefore do not
begin constitutional treatment until the diagnosis is
made by the finding of the Treponema,, by a positive
Wassermann reaction, or by the occurrence of second-
ary symptoms. These things appear in the order named,
and, as it is important that treatment should begin as
early as possible, they are for this purpose valuable
in the same order.

SUPPLEMENT

THE PREVENTION OF
MENTAL AND NERVOUS DISEASES

CHAPTER XVI

THE PREVENTION OF MENTAL AND NERVOUS
DISEASES

The amount of inefficient army service and the num-
ber of discharges because of insanity and nervous dis-
eases are sufficiently great to justify and to demand a
brief discussion of those troubles and of what may be
done by the officer or enlisted men to prevent or avoid
them. For this reason the main factors influencing
their occurrence will be mentioned and the preventive
measures, so far as such are known, pointed out or made
self-evident.

The Predisposing Causes

Bad heredity is probably the largest single factor in
the causation of these diseases, and it is manifestly the
one over which society in general has least
influence and the person inheriting has ^

none.

We may say of heredity, though, that it is not always
damning in its influence; a good many normal persons
and a considerable proportion of brilliant ones are of
stock that, from a biological standpoint, can only be
considered bad. At the same time many persons who
do show the evil effects of bad inheritance are not neces-
sarily insane, epileptic, or useless because of " nervous-
ness," but they stand closer to the stage of incapacity
than do normal folk, are more heavily handicapped in

336 THE PREVENTION OF

the race of life, and lie under the greater necessity for
guarding themselves from evil influences.

Heredity is a factor in most of the disabling func-
tional disorders of the nervous system, including the
two major groups of insanity, known as dementia pre-
cox and manic-depressive insanity, epilepsy, hysteria,
and nervous instability, and those stoppages of develop-
ment that result in the states known as imbecility and
"cussedness," all of which ai-e found in the army.

Education, its lack, or the improper direction of it,
exercises a very great influence on the development of
mental and nervous diseases. It acts first
by leading directly to the formation of
proper habits of thought and conduct, and,
secondly, by imparting a degree of knowledge that dis-
sipates, or tends to dissipate, the ignorance in which
false beliefs, groundless fears, and misdirected enthusi-
asms flourish. The earlier proper measures of education
are undertaken, the more effective they are in accom-
plishing the great and important result of teaching the
individual moderation and self-control, and many a
spoiled or incorrigible child becomes a less useful citizen,
or passes to the congregation of the incompetents, for
lack of the loving but firm and wise parental training
that every child is entitled to and should get. " He that
ruleth himself is better than he that taketh a city,"
but his chances of ever doing either are not very good
unless he be taught early to rule himself. The army
itself is a great educational institution, and, though its
training comes late and its methods are inelastic and
prove harmful to some of the unstable ones for whom
they are not well adapted, it disciplines and strengthens
apd makes useful citizens of quite a number who might

MENTAL AND NERVOUS DISEASES 337

never become such without the self-control and regu-
larity of life they learn therein. Officers should try to
make discipline conform to individual needs, and should
exercise all their patience in getting the recruit started
in the right way of training.

Age is an important factor in determining the time
of onset and the type of insanity. The type most fre-
quently seen in the army is that known
as dementia precox, and it is most common °
because the large majority of soldiers are in early man-
hood, the time at which it is particularly apt to show.
It may occur as early as puberty and occasionally after
the thirtieth year. Another large group, manic-depres-
sive insanity, is particularly apt to recur from thirty-
five to fifty, and the involutional insanities, those due
to arterial sclerosis and the degenerative processes of
old age, occur after fifty as a rule.

Habits are of the greatest importance in the preven-
tion and control of nervous diseases. Education is a
failure if it does not lead to the formation
of good habits, such as are helpful to the
individual, to society, or to the race. Habits become
characteristics, characteristics make up character, char-
acter is what a man is, so that we may truly say that a
man of good habits has built his character and his very
being on a solid foundation, and the difference between
stability and instability of mind and character may
sometimes be, in the final analysis, a difference of habits.
There are some habits, however, that directly lead to
disease or poisoning that act as exciting causes of in-
sanity, and some others that develop into characteristics
so constantly found in insanity that they may be con-
sidered ^n essential part of it.

338 THE PREVENTION OF

Characteristic of all insanity is an intense egotism,
a centering in self of all thought and all natural phe-
nomena, a selfishness that alters the whole world or
the whole universe in order to allow it to act upon or
for the individual. Whether he be exalted or depressed,
a king or a worm, God or the devil, a Saviour or the
worst of sinners, he is at least the center of things, a
tremendous ego. It is obvious that habits of thought or
action that encourage egotism and selfishness, such as
introspection, disregard of the rights of others, undue
sensitiveness, suspiciousness, seclusiveness, brooding,
anxiety, and undue worrying are harmful in this as in
other directions. Harmful, also, as tending to instabil-
ity, are undue love of excitement and constant seeking
for variety, change, and outside amusements. Improper
sexual habits, such as masturbation, sexual perversions,
sexual images of thought, are harmful in two ways : by
bringing about frequent states of excitement, and by
producing a mental state of depression, shame, feeling
of unworthiness, fear, and suspicion that others may
learn the facts, all such as to upset the proper self-con-
fidence and self-respect so essential to poise, self-control,
and clear thinking. Habits of indulgence in drink and
harmful drugs, especially the former, constitute probably
the largest single factor except heredity in the causation
of insanity, and will be discussed later, while those habits
predisposing to syphilis have been considered.

On the other hand, it may be stated that there are
no greater preventives of insanity than those measures
of conduct and the cultivation of those virtues which
we all at heart recognize as good and desirable, how-
ever much onr conduct points to the contrary. Among
physical habits and practices thus helpful we may men-

MENTAL AND NERVOUS DISEASES 339

tion chastity, regularity of bowels, of sleep, food, and
exercise of body and mind, sobriety and moderation in
general, temperance in all things, and total abstinence
from things known to be harmful. Among mental traits
to be encouraged are a healthy interest in religion (and
by " healthy interest " is meant such as leads to unself-
ishness, helpfulness to others, faith, hope, charity, and
cheerfulness), good reading, good thinking, broad sym-
pathies and wide interests, and courage. The amount
of insanity and of nervous breakdown in which lack of
courage or *' loss of nerve " is a main characteristic is
very large.

The Exciting Causes

Easily chief among the exciting causes of insanity and
nervous diseases is alcohol. " It is a strange commen-
tary upon human frailty that all the poisons
which assail man through accident and the
dangerous trades in which he must engage, and all the
poisons which are elaborated within his system, as in
nephritis, diabetes, thyroidism, and acromegaly, are to-
gether responsible for but a small fraction of the number
of cases of mental disease due to his deliberate ingestion
of one poisonous substance — alcohol." Not only does
alcohol directly and alone cause a large amount of in-
sanity, but it is the last straw that serves to break the
suffering and already weak back of many a person
whose nervous organization is congenitally weak. A very
large percentage of cases of dementia precox and of
other forms of insanity first manifest signs of disturb-
ance after alcoholic excitement. Furthermore, such in-
dividuals are apt to be particularly susceptible to the
influence of alcohol and to be disturbed by relatively
small amounts of it

340 THE PREVENTION OF

The more common alcoholic nervous disturbances,
varying from mere impairment of will power to " tre-
mors," "horrors," and "jim-jams," are unfortunately
only too well known. As stated before, the person in-
heriting a predisposition to nervous unbalance is under
a heavy handicap and must take great care to avoid
harmful influences, and there is no influence that he
should more carefully avoid than that of alcohol.

Poisoning by lead, mercury, and some other metals
may cause insanity, neuritis, and other disturbances.
Other ^^^ frequency and speed with which the

~ . habitual use of morphine, cocaine, chloral,

and other narcotic drugs undermine the
will, the powers of application, and the morals of their
users and make nervous wrecks of them are all too
familiar. Addiction to such drugs is akin to drunk-
enness and is in itself an evidence of weakened mind
and disordered nervous system.

The normal body produces poisons which it is ordi-
narily able to get rid of or to neutralize without harm
-J , to itself, but when, by reason of disease,

p . such as Bright's disease, diabetes, or cirrho-

sis of the liver, these are not excreted as in
normal conditions, or when, by reason of other diseases,
as of the thyroid gland, they are elaborated either in
too great or too small amounts, nervous disturbance up
to and including complete mental upset may result. It
is possible that the poison retention resulting from mere
constipation might be influential in similar directions,
and it is a matter of frequent observation that an attack
of depression or of irritability may be caused by con-
stipation and relieved by a purge. The pregnant state
causes insanity relatively frequently, though whether

MENTAL AND NERVOUS DISEASES 341

because of retained poisons or of disturbance of ductless

glands or for other reasons is not known. Epilepsy is

greatly influenced by the kinds and amounts of food

ingested and by the state of the excretions, and there

is much to show that it is at least associated with a

condition of self-poisoning.

When because of heart disease, arterio - sclerosis,

stoppage of a vessel from any cause, or of anemia, the

circulation in the brain or the amount of _. .

blood carried to it is interfered with, it suf- ^

. . , tory

fers, and the result is impaired or disturbed -i-j- "1 i-

mentality, that may amount to actual de-
mentia or insanity.

Syphilis is the only infectious disease that causes a
very large number of cases of insanity and of other
severe forms of nervous disease. About one
fourth of all cases of insanit}', as observed ^^
in soldiers at the Government Hospital for the Insane
and in civilians at the Danvers (Mass.) State Hospital
and in a number of other institutions, are syphilitic;
])robably one fifth are due wholly to this disease. In
addition, as stated before, all or practically all locomo-
tor ataxia, many types of paralysis, much neurasthenia,
and a vast number of other cases of nervous disease
are of the same origin.

Typhus, typhoid, malaria, meningitis, pneumonia, and

other infections may cause insanity, neuritis, paralysis,

and other nervous disturbances, but the f re- -.. . _

1 • , , 1 • 1 ,. 1 Other In-
quency with which they do so is relatively , ^

slight as compared with syphilis. Diphthe-
ria is very apt to canse paralysis of the throat or of the
nerves supplying the heart. Mumps occasionally results
iu deafness from degeneration of the auditory nerve.

342 THE PREVENTION OF

Sleeping sickness is principally a disease of the nervous
system. Pellagra, though not definitely known to be
caused by infection, has so many points of resemblance
to infectious diseases that it may be mentioned here.
It very commonly has mental disturbance as one of its
most striking features.

Injury, especially injury to the head, may be the
direct, exciting cause of insanity, epilepsy, hysteria, or
minor troubles. It, like most of the infec-
tious diseases mentioned, is more apt to have
such effect in persons prediposed to nervous disturbance.
Persons strongly predisposed to mental trouble may
be upset by relatively trifling things, of a character, as
. already indicated in regard to alcohol, in-

fections, and trauma, such as would not
disturb a person of sound nervous consti-
tution. Likewise apparently unimportant worries, such
as might be occasioned by anxiety as to obtaining or
retaining a position, by an unjust accusation, by a dis-
turbing social engagement, or by a mere fear of making
a social blunder, may act as a determining factor in
mental disease. It may be readily understood, then, that
the change of environment that occurs on enlistment,
the transfer possibly from a home where the individual's
weakness has been supported, his peculiarities over-
looked, his deficiencies supplied,, to a barracks where
the men have no interests or acquaintances in common
with him, where his weakness is imposed upon, his
peculiarities pointed out and his deficiencies jeered at,
may prove more of a burden than his weak mentality
can bear. Add to that the pangs of homesickness, the
brooding over the apparent injustice of disciplinary
measures, the worry incident to learning drills and nevr

MENTAL AND NERVOUS DISEASES 343

duties, the fear excited by lonely sentry duty, the feel-
ing of isolation caused by practical jokes, and possibly
the actual petty tyranny of an unfair non-commissioned
officer, and it is not remarkable that weak men break
down under it. Later the real stress of campaign, the
excitement of real combat, the fear caused by real dan-
ger to life or limb may prove the disturbing factor. On
the other hand, if the recruit stage be once passed, the
man of poor inheritance may find in the army discipline
a steadying and regulating influence, in his officers a
parent-like, and in his comrades a brotherly control and
friendship, in his routine a method and a regularity,
and in his duties an inspiration and an ideal, which will
serve to enable him to hold to his mentality, to master
his fate.

INDEX

Abdomen, 6.

Abstinence, total, encouragement of,
28.

Acid, boric, food preservative, 39.

Acid, carbolic, antiseptic, 210; vermin
killer, 72; use of, in flush closets, 63;
for camp urinals, 98.

Acids, organic, food value, 35, 122.

Actinomycosis, transmission of, 37.

^robic bacteria, 182.

Age, affecting mental and nervous
states, 337; factor in efficiency, 4;
incidence of venereal disease, 317.

Air, infection borne by, 258; moist, in
rooms, 69; space per man, 56; supply,
as predisposing to disease, 155; value
of, 20.

Albuminuria, due to faulty diet, 34.

Alcohol, in cold climates, 136; in trop-
ics, 125; on march, 28, 31; predispos-
ing to disease, 157; use of, exciting
cause of insanity, 339.

Alimentary tract, diseases due to infec-
tion through, 223.

Amoebic dysentery, 179.

Anserobic bacteria, 182.

Anaphylaxis, 186.

Aneurism, due to syphilis, 328.

Animal carriers of disease, 191, 262.

Animal parasites, 168; minute, 177.

Ankylostomiasis. See Hookworms.

Anopheles, 278; a man-lover, 286;
breeding-places of, 284; flight of,
285; salt water, 284.

Antelope, reservoirs of sleeping sick-
ness, 200.

Anthrax, 199; transmission of, 37.

Antiseptics, 219.

Antitoxin, as remedy for diphtheria,
221; for prevention, 274.

Anus, irritation of, 64.

Appetite, effect of cooking on, 39l

Auto-intoxication, 167.

Avoidance of sick, 212.

BacilU, 182.
Bacteria, 37. 183.

"Barbiero," carrier of Chagas' disease,
275.

Barracks, heating of, 69; hygiene of,
54; odor, avoidance of, 21; vermin
in, 72.

Bathing, as predisposing cause of dis-
ease, 158; before battle, 118; by ros-
ter, 62; in camp, 83; in tropics, 129.

Bathrooms, 62.

Bathtubs, 67.

Battlefleld, hygiene of, 117.

Bedbugs, 22, 310; and plague, 299.

Bedding, airing of, 23'.

Bednets, need of, 57, 296.

Beri-beri, 34.

Beverages, 47.

Bichloride of mercury, antiseptic and
germicide, 219.

Bill of fare, weekly, 48, 50.

Bleeders, 149.

Blindness from wood alcohol, 29.

Body, natural defenses of, 208; resist-
ance to tuberculosis, 199.

Body-poisons, as cause of insanity and
nervous disease, 340.

Body-type and causes of death, 5.

Bowels, regulation of, 24.

Breeding places of mosquitoes, 286;
destruction of, 286.

Brill's disease and typhus, 306.

Brush clearing, as anti-mosquito meas-
ure, 295.

Buboes, 16; chancroidal, 322; gonor-
rhceal, 319.

Buildings, 54.

Butter, 45.

Buttermilk, 45.

Ciimp, arrival at, 117; bathing in, 83;
change of site to shorten epidemics,
251; cooking, 87; disposal of human
excrement in, 93, 100; fly-preven-
tion in, 91-100; garbage disposal in,
91; hygiene of, 73; incinerators, 91;
kitchens in, 86; kitchen waste, dis-
posal of, 89; latrines, 93; sanitary
training tat enlisted men in, 101;

346

INDEX

causes of infection of, 76, 160; choice
of, 74, 75; influence on health, 74, 77;
requirements for, 74, 75; shelter in,
77; streets in, 78; urinals in, 100;
vermin in, 78; water supplies for, 80.

Camp-sites, requirements for, 74, 75.

Cancer, as effect of smoking, 30.

Canning, in food preservation, 39.

Cans, garbage, care of, 52, 61.

Carbohydrates, 34.

Carriers, contact, 229; contaminative,
201 ; development of disease germs in,
202; food handlers as, 252; healthy,
188; human, 187; insect, 200, 202,
275; inanimate, 202; of cerebro-
spinal meningitis, 188; of cholera,
189; of diphtheria, 188; of disease,
187; of dysentery, 189; of infantile
paralysis, 188, 260; of influenza, 260;
of intestinal worms, 189; of menin-
gitis, 260; of scarlet fever, 260; of
typhoid, 189.

Chagas' disease and "barbiero," 275.

Chancre, of syphilis, 326.

Chancroid, 322.

Chest, shape, 6; mobility, 6.

Chewing gum, use on march. 111.

Chicken pox, 255; air-borne, 266; cause
of, 256; incubation period, 265; sec-
ond attacks, 257.

Chiggers or jiggers, 176.

Childhood, diseases of, 256.

Chlorine, fumigation with, 217; to
ptirify water, 108; use in field, 108.

Cholera, carriers of, 189, 233; cause of,
226; contact infection, 243; control
of food dealers during epidemics of,
252; early diagnosis of, 245; fly-
borne, 239; isolation of cases, 246;
milk-borne, 236; origin of epidemics,
226; prevention of epidemics, 244;
report of cases, 247; vaccination to
prevent, 253; vegetable-bome, 237;
water-borne, 234.

Cigar and cigarette smoking, 30.

Clap. See Gonorrhoea.

Cleanliness, habits of, revealed by
linen, 17; in prevention of typhoid,
249; personal, 22.

Climate, demands of, as to clothing,
30; cold, diet in, 34, 135; hygiene of
cold, 133; hygiene of hot, 122.

Clothing, adjustment to needs, 30; as
predisposing to disease, 158; chang-
ing of, 23; for cold climates, 136; for

marching, 113; for tropics, 126; qual-
ity of issue, 24.

Cocci, 182.

Cockroaches, as cholera carriers, 239.

Coffee, 47.

Cold, to preserve meats, 38.

Cold climates, air of, 133; clothing in,
136; crowding in, 134; effect of alco-
hol in, 136; food in, 135; frost-bites,
occurrence of, 139; hygiene in, 133;
scurvy in, 135, 140; shoes for, 138;
snow-blindness in, 142; ventilation
in, 134; water supplies in, 134.

Colds, cause of, 20.

Cold storage, to preserve foods, 46.

Comma bacillus, in cholera, 226.

Condiments, food value, 35.

Constipation, 45, 120.

Contact infection, in childhood diseases,
260; in cholera, 243; in diseases en-
tering by respiratory tract, 260; in
typhoid, 242; in syphilis, 325.

Contagion, when active in certain dis-
eases, 266.

Continence, sexual, 27, 314; as pro-
moting health of nervous system ,339.

Cooks, company, common faults of, 39;
importance of, 50.

Cough, in recruit, 10; tobacco, 29.

Cresol, solutions, as antiseptics, 220.

Crowding, dangers of, in cold climate,
134 ; favors epidemics, 257.

Culex, 283; breeding-places, 284; car-
riers of dengue and filariasis, 283.

Deaths, causes of, life insurance experi-
ence, 5.

Dementia precox, age of onset, 337.

Dengue, 275, 282; mosquito transmis-
sion of, 282.

Deodorants, use of, 64.

Deprivation diseases, 168.

Dhobie itch, 130.

Diagnosis, early, to control disease,
245, 270.

Diphtheria, as cause of paralysis, 341;
carriers of, 188, 255, 260; cause of,
256; incubation period, 265; in dogs
and cats, 200; second attack, 257;
when contagious, 267.

Discharges from body, as source of in-
fection, 261; care of, 273.

Disease, carriers of, 187; exciting
causes of, 162-186; predisposing
causes of, 147-160.

INDEX

347

Disease manifestations, meaning of,
186; influence of season upon, 256.

Diseases, immunity to, 209; natural de-
fenses against, 208; specific remedies
for, 220.

Dishes, in transmission of disease, 238.

Disinfectants, 219.

Disinfection in control of typhoid and
cholera, 249; of various diseases, 212;
means and methods of, 216.

Drainage, as anti-mosquito measure,
286.

Drains, clogging of, 62.

Drying of foods, 46.

Dust, in spread of disease, 238.

Dysentery, carriers of, 189, 233; causes
of, 226; fly-borne, 239; milk-borne,
236; origin of epidemics, 226; vacci-
nation in, 253 ; vegetable-borne, 237 ;
water-borne, 234.

Ears, examination of, 9.

Education, as factor in mental and
nervous diseases, 336.

Emissions, seminal, 27.

Endotoxins, 186.

Engineering works, in prevention of
disease, 215.

Environment, influence of, on develop-
ment of mental and nervous diseases,
342; as predisposing to disease, 154.

Epidemics, due to milk, 236; due to
water, 234; of typhoid, 236; origin
of, in diseases entering by alimentary
tract, 226.

Epilepsy, 341; due to injury, 342; indi-
cations of, 11.

Exercise, 21; in tropics, 123, 129.

Exposure, as predisposing to disease,
153.

Eyes, affections of, transmitted by
toilet articles, 22; examination of,
8; infection with gonorrhcea, 320.

Fats, 34.

Feces, disposal in camp, 93, 100; dis-
posal on march, 116; disposal from
typhoid, cholera, etc., 250; habitual
inspection of, 61.

Feet, care of, 23, 31; of reoruit, 12;
stinking, sweating, 14.

Filaria, and elephantiasis, 175; mos-
quito-bome, 275; life history of, 174.

Fingers, 12.

Fires, open, as aid to ventilation, 68.

Fish, 61 ; destroy mosquito larvse, 290.

Flat-foot, 15.

Fleas, and plague, 201, 298, 299; life
history of, 299; measures against,
304.

Flies, as carriers of cholera and dysen-
tery, 239; of typhoid, 238; as distrib-
utors of certain diseases, 269; flight
of, 241; life history of, 240; preven-
tion in camp, 91-100; protection
from, 52, 59.

Floor room, minimum, 56.

Flukes, 169.

Fomites, in diseases entering by respi-
ratory tract, 260; in typhoid-like
diseases, 244; most dangerous kinds
of, 261; utensils as, 262.

Food, care of, during epidemics, 252;
dealers in, control of, 252, 269;efifect
of, after prolonged exertion, 141;
effect of, in very cold clim»te9,_135;
in tropics, 123; on march. 111. '^>v_^

Foods and preparation, 33.

Formaldehyde gas, 218.

Frost-bite, 139.

Fumigation, to kiU mosquitoes, 294; to
prevent disease, 217.

Garbage, disposal of, in camp, 91.

Garbage cans, care of, 52, 61.

Gases, as caxise of disease, 164.

Gastric juice, as defense against dis-
ease. 208.

General paralysis, due to syphilis, 328.

German measles, 255; cause of, 256;
incubation period, 265; second at-
tacks, 257.

Germicides, 219.

Glanders, carriers of, 194.

Gleet, 319.

Gonorrhoea, carriers of, 190, 317; dis-
cussion of, 317-321.

Ground-itch, 173.

Habits, as predisposing cause of dis-
ease, 152; fixity of, after certain age,
4 ; importance of, in regard to nerv-
ous and mental disease, 337.

Ham, raw, danger of, 39.

Ham-bones, in soups, 43.

Hammer-toe, 14.

Hands, care of, 23 ; cleanliness for meals,
60; washing after visit to toilet, 64.

Headgear, for tropics, 127.

Health inspections, 247.

348

INDEX

Heart disease, 5; due to gonorrhoea,
320; due to syphilis, 327 ; irregularity
due to tobacco, 29.-

Heat, in disinfection and sterilization,
216.

Heating, 57, 59; by hot-air furnace, 70;
by hot water, 70; by open fires and
stoves, 69.

Hemorrhoids, 7, 8.

Heredity, and syphilis, 322; in relation
to disease, 147; predisposing to men-
tal and nervous disease, 335; trans-
mission of germs by, in insects, 202;
types of, 149.

Hernia, 7.

Hookworms, 128, 172.

Hydrocele, 16.

Hydrophobia, 191; description, 193;
misconceptions concerning, 192.

Ice, and disease, 235.

Ice-cheet, 52.

Immunity, causes of, 211; to diseases,

209; to malaria, 277; varieties of,

209.
Incinerators, field, types of, 91.
Incubation period, of typhoid, 248; of

various diseases, 265; of yellow

fever, 280.
Infantile paralysis. See Paralysis, in-
fantile.
Infection, as cause of insanity, 341; in

tropics, 122; transmission of, 26.
Influenza, discussion of, 255-267.
Insanity, discussion of, 328-342.
Insects, as disease carriers, 200, 275,

diseases borne by, 275; in tropics,

130.
Internal secretions, disorders of, 168.
Intestinal worms, 168-174.
Investigation of cases, 271; of typhoid,

cholera, and dysentery cases, 248.
Iodine, as antiseptic and germicide,

220.
Isolation, to prevent spread of disease,

213, 271.
Itch, cause of, 176; ground, 173; dho-

bie, 130.

Jantkosoma luUi, as carrier of fly eggs,
202.

Kala-azar, and insects, 275.
Kitchens, in camp, 86; waste from, dis-
posal of. 89; hygiene of, 50-60.

Larvacide, as antiseptic and disinfect-
ant, 220; how made, 291 ; use of, 291.

Larvae, infesting man, 275; of mos-
quitoes, destruction of, 290; screw
worms, 176.

Latrines, camp, 93; care of, 97, 99.

Lead poisoning, 165; avoidance of, 23,
25.

Leprosy, and insects, 275.

Lice, and plague, 299; carriers of relaps-
ing fever and typhus, 275; diseases
borne by, 306; Ufe history of, 307.

Lighting, interior, 56, 59, 67, 68.

Lime chloride, 63. See Chlorine.

Locomotor ataxia, due to syphilis, 328.

Limipy jaw, transmission of, 37.

Malaria, discussion of, 276; parasite of,
discussion of, 177; nervous diseases
caused by, 341; prevention of, 284;
qmnine as specific for, 221.

Malta fever, transmission of, 44.

Manic-depressive insanity, age of on-
set of, 337.

Marches, discussion of, 103-116.

Measles, 255; cause of, 256; conta-
giousness, 259; incubation period,
265; second attacks, 257; when con-
tagious, 266.

Mechanical causes of disease, 162.

Meningitis, cerebro-spinal, 255; car-
riers of, 188, 260; cause of, 256; when
contagious, 267.

Mental state, and syphilis, 328; as pre-
disposing to disease, 151; effect of,
on marching, 108.

Mess, lack of variety in, 40; manage-
ment, books on, 53.

Mess-room, 59.

Milk, as cause of epidemics, 236, 263,
264, 269; tuberculous, 199.

Milk-sickness, 37, 44.

Mites, as disease carriers, 275.

Mosquitoes, 132; breeding-places of,
284, 286; catching of adult, 294;
dengue-bearing, 282; diseases borne
by, 276; life history of, 285; malaria-
bearing, 277; measures against, 283;
protection from, 132, 295; to be kept
from sick, 296.

Mosquito net, use on march, 113.

Mouth, care of, 25.

Mucous membranes, natural defenses,
208.

Mumps, 255; cause, 256; incubation

INDEX

349

period, 265; second attacks, 257;
when contagious, 266.

Nervous system, diseases of, 337-343;

syphilis of, 328.
Neuritis, caused by infections, 341.
Notification of cases of sicknees, 247,

270, 305.

Occupation, as predisposing to disease,

154.
Oil, to destroy mosquito larvae, 291;

application to water, 292.
Oysters and typhoid, 237.

Paralysis, due to syphilis, 328; due to
diphtheria, 341.

Paralysis, infantile, 255; and stable-
fly, 257; carriers of, 188, 260; incuba-
tion period, 265; more common in
warm weather, 257.

Paratyphoid fever, 225.

Pasteurization, 184.

Pellagra, insanity as symptom of, 342.

Penis, abnormalities of, 15.

Pension, notation of grounds for, 19.

Personal hygiene, 21.

Petroleum, crude, as pit dressing, 99;
to destroy mosquito larvae, 291; in
urinals, 64.

Phenol, antiseptic and disinfectant,
219.

Piles, 7, 8.

Plague, 275, 298; cause, 298; in rats,
195; in squirrels, 196; method of in-
fection, 201, 298; notification of
cases, 305; pneumonic, in Manchu-
ria, 196, 299; prevention of, 302-
306; spread of, 195; transmission of,
299.

Pock. See Syphilis. '

Poisoning, by various substances, 166;
metallic, 46; ptomaine, 57, 167; self-,
167; tyrotoxicon, 45; wood alcohol,
29.

Policing, poor, predisposing to disease,
159; and typhoid, 250; to prevent
disease, 215.

Poliomyelitis. See Paralysis, infantile.

Predispiosition to disease, 147.

Pressure as cause of disease, 163; at-
mospheric, 164.

Prevention, of beri-beri, 34; of gonor-
rhoea, 321; of mosquito-borne dis-
ease, 284; of nervous and mental dis-

eases, 336; of plague, 302; of relaps-
ing fever, 308; of scurvy, 135; of
syphilis, 330; of typhoid, 244; of
typhus, 308.

Prostitutes, 315; prevalence of dis-
ease among, 316.

Proteids, 33.

Ptomaines, as disease producers, 167.

Pyrethrum, fumigation with, 294.

Quarantine, to prevent disease spread,
214; meaning and use of, 215.

Quinine, as specific remedy, 221; to
prevent malaria, 297.

Race, as predisposing to disease, 152.

Rats, and plague, 195, 201, 299; meas-
ures against, 302.

Reaction to irritation as defense
against disease, 209.

Reclamation of swamps, 286.

Recruit, the, 3; character of, 18; ex-
amination of, 3-19.

Relapsing fever, 275; and lice, 306; of
Africa, and ticks, 275, 309; preren-
tion of, 308.

Respiratory tract, infection by way of,
255.

Rest, need of, 20.

Rheumatism, gonorrhoeal, 319.

Ringworm, 17, 130; transmission of,
22.

River fever, 275; and camp-sites, 76;
and mites, 275.

Roaches, protection from, 52; and
cholera, 239.

Round worms, 171.

Salt water, breeding of mosquitoes in,
284.

Salts, food value, 34; formation of, in
iirinals, 64.

Sand-fly fever, 275. 309.

Sanitary soldier for each company,
101.

Scarlet fever, 255; carriers of, 188, 260;
cause of, 258; incubation period,
265; second attacks, 257; when con-
tagious, 266.

Schistosomum disease, 169.

Screening of houses, 295.

Screw worms, 176, 275.

Scurvy, in cold climates, 135; and
vitamines, 34, 35.

Seasickness, 120.

860

INDEX

Season, influence on oocurrence of dis-
eaee, 256.

Seat worms, 172.

Self-control, importance of, in preven-
tion of nervous and mental disease,
337.

Sexual hygiene in tropics, 131 ; life, 27.

Shelter in camp, 77.

Shoes for cold climates, 138; for march-
ing, 114; soiling, in camp, 244; use
of, in tropics, 128.

Shower baths, 62.

Sick persons, avoidance of, 212.

Sickness, effect of, on marching, 106.

Sinks, kitchen, care of, 52.

Skin, affections of, in tropics, 130; un-
broken, 86 defense from disease, 208.

Sleep, amount, 21; conditions of, pre-
disposing to disease, 159.

Sleeping sickness, 179, 308; and ner-
vous system, 342; and tsetse flies,
275, 308.

Smallpox, 255; as disease of childhood,
256; and insects, 275; incubation
period, 265; second attacks of, 257.

Smoking, effects of, 29, 111; in day
rooms, 58; of meat, 38.

Snow-blindness, 142.

Socks, for marching, 114.

Specific remedies, 221 ; as means of pre-
venting disease, 222.

Spirilli, 182.

Spitting, danger of, 26; promiscuous,
29, 59.

Spores, resistance of, 183.

Spotted fever of Montana, 275, 309.

Sputum, as source of infection, 261.

Staphylococci, 182.

Starches and sugars, 34.

Stegomyia fascicUa, 279; breeding-
places, 284; description of, 282.

Sterilization, means and methods, 216.

Stoves, 68.

Streets, in camp, 78.

Streptococci, 182.

8trictiu"e of urethra, 319.

Sulphur, fumigation with, 217.

Sunlight, as destroyer of bacteria, 184.

Swamps, drainage, 286; reclamation,
286.

Syphilis, 324-331; as cause of aneu-
rism,insanity, locomotor ataxia, 328;
cause of, 179, 324; hereditary, 325;
incubation period, 325; indications
of, for examiner, 9, 10, 11, 12, 14, 17;

period of contagiousness, 328; mar-
riage after, 329.

Tabardilla and typhus, 306.

Tapeworms, 169; life history of, 170;
transmission of, 37.

Teeth, care of, 25.

Tetanus, 182.

Texas fever, in cattle, 202.

Three-day fever, 309.

Ticks, carriers, of African relapsing
fever, 309; of spotted fever, 310.

Toilet articles, individual use of, 62;
transmission of disease by, 22.

Tonsillitis, 255; causes of, 256, 267; in-
cubation period, 265; contagious,
267.

Toxins, as cause of disease, 185.

Training, faulty, and disease, 151; and
insanity, 336.

Trains, troop, 120.

Transport ships, 119.

Trauma, exciting cause of disease, 162;
of mental and nervous trouble, 342;
predisposing to disease, 153.

Trembles, in cattle, 37.

Treponema, localization of, 329; and
syphilis, 324.

Trichina, 57; life history, 174.

Tropics, hygiene of, 122-132.

Trypanosomes, and sleeping sickness,
200.

Tsetse fly, relation to sleeping sickness,
275, 308.

Tuberculosis, in cattle, 199; carriers of,
189; in company cook, 51; indication
of, 14; transmission of, 26, 37, 44,
197, 199.

Typhoid, and nervous disease, 341;
carriers of, 189, 229, 230, 233 ; cause
of, 225; contact infection, 241; dust-
borne, 238; early diagnosis, 245; fly-
borne, 238; from shell-fish, 237; ice-
borne, 235; incubation period, 248;
isolation of cases, 246; methods of
transmission, 228; mild cases, 229;
milk-borne, 236; prevention, 244;
route of infection, 224; transmission
of, 22, 51; vaccine, 254; water-borne,
233.

Typhus fever, 306; and lice, 275; and
nervous disease, 341; how transmit-
ted, 306; prevention, 308.

Uncinariasis. See Hookworms.

INDEX

851

Uncleanlinesa, predisposing to disease,

159.
Urinals, 64, 67.

Urination, careless, danger of, 26.
Urine, disposal of, in camp, 100.
Utensils as means of infection, 262;

carriers of disease, 61.

Vaccination, as cause of immunity,
210; to prevent cholera, 253; dysen-
tery, 253; plague, 305; smallpox, 273;
typhoid, 254.

Varicocele, 16.

Vegetables, 41; and disease, 236.

Veins, varicose, of leg, 13; of abdomen,
7.

Venereal disease, carriers of, 190, 312;
general causes of, 314; general meas-
ures of prevention, 314; mixed in-
fections of, 330; prevalence in army,
313; urine as defense against, 209.

Ventilation, in prevention of disease,
213, 268; in very cold climates, 134;
of barracks, 56, 59, 68.

Vermin, exclusion from kitchen, 52, 55;
guarding against, to control epidem-
ics, 269; in barracks, 72; in camp,
78; on recruit, 11, 16, 17, 22; on
transtwrts, 119.

Vibrios, 182; of cholera, 226.

Vitamines, 34.

Voit's food standard, 35.

Walls, damp, avoidance of, 55.

Wassermann reaction in syphilis, 329.

Water, and disease, 26, 234, 252; drink-
ing-, in tropics, 123; purification of,
80, 110; use on march, 108.

Water-closets, 57, 63.

Water-supplies, 65, 80, 234, 252.

Weight carried, and effect on marchicK,
105.

Wet dreams, 27.

Whip worms, 172.

Whooping cough, 255; cause of, 256;
in animals, 200; incubation period,
265; second attacks, 257; when con-
tagious, 266.

Wind, regard for, in placing buildings,
55.

Worms, in feces, 64; intestinal, 172.

Yellow fever, 275; eradication from old
haunts, 280; incubation period, 280;
mosquito, description of, 282; mos-
quito transmission of, 279; natural
history of, 280; prevention, 284;
when dangerous to others, 281.

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