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49162 
 
 THE NEW PUBUC HEALTH 
 
 The New Pnblic Health aod Tabcrculosis 
 
 B> 
 
 II W Hill. M li. M 1). I) I' n 
 
 lONDON. ONTAKIII, CANADA 
 
 Reprinted from 
 
 THE JOURNAL.LANCET 
 
 February 1, 1915 
 
 [Thl» 1h r reprint of the tenth paper In a series of 
 ten or twelve articles now appearlPK In The Journal- 
 Ljincet upon the subject of "The New Public Health." 
 Additional copies of this reprint and of the entire 
 series, as thev are published, mav be had upon applica- 
 tion to the Minnesota State Board of Health. St. Paul.] 
 
^ 
 
rm-: mav itiuk ukai.tii 
 
 TKNTH I'AI'KK 
 I MK NKW I'l'HI.IC HKAI.IM AND ll'HI K( ll.oMS 
 
 F!v II. W llii.i., Ml'.. M I),. I) I'.ll 
 
 l>lr>'ii<ir. IiiHtltiiti- uf I'lililli lli'iilili. I.<in<lori. iini 
 I.iitf liliHi'liir. I>lvl>.(uii iif i:|il.l.iii|iil..i;\ . Mliiii. -Mill 
 Sluli- Hiiar.l ut Ihiiltli 
 
 Previous artuU'-^ have oiitliiinl tlu- m'lH-rai 
 principles wliieli nuverii iiiiniern ptihlii- liealtli 
 efforts, riie jiresent article will vlmw tlie >.pecitii 
 applications of these i)rinci]iles to one specilic in- 
 fectious disease, namely, tulierculosi-. Tliis di- 
 ease is selected liecausc the same princiiiles that 
 apply to all other infectious diseases apply In it 
 ami hccausc it is the most imiiortant of all the 
 diseases now reco>j;nize<l as really prcvcitlal<li\ 
 with the possihle exception of the venereal ili^- 
 eascs. 
 
 Tuherculosis. of all forms, is due to the i;ro\\ tli. 
 somewhere in the Ixidy. of a certain yerm. ex- 
 actly as diphtheria and tyjihoid are due to the 
 Rrowth, in the iMxIy. of certain kit"'^ There 
 are many very definite individual differences, in 
 the size, shape, manner of growth, etc., of the 
 three different tjerms of these three differeiu dis- 
 eases, and these differences make it perfect!) |«)-- 
 sihle tn distinijuish each tjerm from the others, 
 just as any farmer can distintiuish oats, corn, 
 and potatoes from each other. 
 
 I'ut just as there are different \ arietie* of 
 potatoes, so there are at least tw<> varieties of 
 
 ii 
 
tiOKTciiloiii* Kcriiii wliuh affect luiinari UinKs. 
 One variety it what it known a-* thf human tu- 
 fwrciilotit nvnu pro|>rr lln- ..ilur ii fi»iin<l 
 chiefly in cattlt- and i'. ihcrtl'.irr lallnl the cattle 
 t»l)crcnlo<iis uerm (the bovine tul»erculr«it 
 Ktrnii. and this name ii nhtn t<» this variety 
 even when it i> found in tlie human. a> it -.ome- 
 timet it. 
 
 Ill MAN Tl IIKK( I KISIS 
 
 A motf im|Kirfant ilifTercnce that the nernit of 
 human tubcrculoti*. of (hphtheria, and of tvphoid 
 fever slwiw anioncst tlieniselvet is not a differ- 
 ence in size, shape, etc . hut in the parts ,,f the 
 t)f>dy each selects. Thus the di|>htheria yerm 
 flourishes chietlv in the nose ami throat, and the 
 typhoid KPrm flourishes chiefly in the intestine 
 and perhaps the blood; while the human tut>er- 
 culosis Kcrin will flourish almost anywhere in 
 the body, K'-inds, bones, joints, intestine, kidney, 
 brain, lungs. This selection is no mere accident, 
 although \vc do not know how it comes alK)Ut. 
 .Ml tliree serins enter the lK)dy chiefly by the 
 mouth, conveyed thereto diiefly by tlie futtuix. 
 but also more or less through food and milk. and. 
 in rhc case of tyjihoid fever, through water and 
 flics. On entering the mouth, all three germs, 
 which are of course far too small to taste or feel, 
 are swnllowed in the fiKxl, milk, etc., in which 
 they happen to l)e present, or merely in the saliva, 
 if, as is most usual, they reach the mouth di- 
 rectly or indirectly from the fingers. ( )nce swal- 
 lowed, all three pass into the stomach, where 
 many arc killed by the acid there present, the 
 •survivors, if any, passing on into the intestine. 
 On the journey from mouth to intestine, some 
 arc left, of course, by the wayside, stranded on 
 the tonsils, thr at. gullet, etc. Here at once i- 
 
thn^n tHrir rr"«|»rrtt\r iH-iiiliaritu"" < »f all the 
 diphtheria ucrttH that arc thu< •.walkivviMl, pra»- 
 ticalty onlv thoM? that arr otraixlnl in thrthmat. 
 will llotirith ; iIhho diphthrria Ktmi'* which fta" 
 on into the stomach <ir intr>ttnc arc ilcslroycd 
 i>r |>aHS out harmlri<<l\. ( >m the other hand. t\- 
 phoid Ki^rni^, if •<trandcii <iti the throat, do n<>t 
 tloiiri-.h there, nor do tlnoe which reach the 
 Htxniach tlonri^h in that uruan. It i^ only tho-c 
 t>Iihoid Ker n> which lurvive the joiirtiey untd 
 the intestine is entered that can succeed in pm- 
 ilncinj,' typhoid fe\er. i'he Innnan lulK'rcn|i»»i« 
 K'ernj has a still longer road to yrn. Not onl\ 
 nni-t it , ass itionth. stomach, and intestine, hut 
 it mu-t lie also ahsoriicd from the intestine into 
 the hIcKid, as the food is; hut it does not ^fow in 
 the hIcKxI. The hl<M»d is only a river, hy which 
 it can Ik- carried to a favorable dcvelopini: 
 ground. \\c tlo not know at all why human 
 tul»erculosi> ycrms enterinj; tiic hUxxl tlui». 
 should elect to settle an<l nmw in a joint in one 
 person, in a lunjf in another, in a kidney or a 
 i;land or a Ixme in anotiier. However, this is the 
 way in which these different forms of human 
 tuberculosis develop. The old idea that human 
 tuberculosis of the lunjj (^consumptioti ) is con- 
 tracted chiefly by breathing the yerms directly 
 into the lunns, has been definitely upset. The 
 lunKS are infected from the bkxi<l-stream chictly. 
 just as are the other internal organs, bones, and 
 joints. 
 
 Another an<l, from the public health stanil- 
 jwiint, an even more important ditTerence exist>. 
 Diphtheria gemis developinn in the throat, and 
 typhoid fever K«^rms develo|)in>: in the intestine, 
 can readily escape from the body; in the ca-'e of 
 diphtheria, throURh the mouth and nose dis- 
 
-luryc, III ihr ,a.r nf ^^|,|„M.| ivsvr thr..iii;li 
 Ifw f«mcl. an.l ...inriiin.-, H,,. hb.l.Ur, .li.. Inri-,-, 
 le i- the rvalK- (.V lh«'^r . hitnnrU of tlir,r i-rrriu 
 lr..m ilir Ih«|v whuh ijwkr* thr^r .|i„iiM» 
 •.auhiny" ,>r ••iiifr.ti..ii,- „r "o.uiiminu.il.k- • 
 l..r If il.cv ...ul.l „..t rM.,|.c from th.- UnIx tluv 
 .'..u. n-l rradi ..thrr (ktm.,,. .ui.| llu-rvfurr 
 .•.ul.l Hot U- •.-at.liitiK •• Cut in human »ul.rr. 
 ■■•«I..M^. m..M nf tlu- plaic, wlurr ,. .U-vrl.,,,, 
 iM.nrv Klan.lv ,.„nt,. vU , arv n..t .nmuv.r.l 
 uith anv ..ponun; ..f the |m„|v j,,. „|,„.,, „,^. ^^.^^^^^ 
 mav l.-axr tlu- »M<h Tlioc f.,rm* .,f tulH-nul.,,,. 
 haw n.i Krrat hiKlmav t.. the ..ut,i.|,- Ivinu at 
 their .|.»,r. I., carrv ilir ^rrms ,,iit t,, utlu-r |«t- 
 "•I'v I'raitualiv oniv in human tulK•rall..^j, „( 
 •lio hiUK, arc- Midi hiKluva>, pn.vi.jr.l f„r the 
 .utnau tulK-r.ul..Hi, i;,.r,„.. althnu^rh ...im-tiiiu-s in 
 Ma.l.kr. ki.liivv. an.l mt.-Mi,ial tulK-nuj,,,!, Mut 
 u> the iattir f..rm.. the uerms ,|o not. an a rule 
 pasN out hv the hiuhwavs pn.vi.le.l for them in 
 'Udi cn.htion or smh uuml^-rs as to Iwof .ori.nis 
 miiM.rtaiue in pn-panatin^' the c|i.ea^e. I.i human 
 lunvr tiiU-rouloMs, .,n the other hau.l. the win.l- 
 pi|.f. throat, an.l in.>utli form a hiuhwav. al.mi,' 
 ulndi the uerms may eM'a|K- from the affecte.l 
 un^r m such enorm..us numU-rs that twentv-f.mr 
 l""ion (K-r .lay have l^-en .letette<l in the rlin. 
 ••har^es (sputum) from the lunp of a sin^'le a.l- 
 vanee.1 casr, althnu^;!. tlie avcrajfe numk-r from 
 ilu- averaue case is iHually "onlv" fo„r or five 
 l»illi..n daily. 
 
 Thus it comes alMnit that human tuherculosis 
 "f the lunfjs ,< the only o.mmon form nf human 
 tuherculosis which is much to Ik; feared as in- 
 lirtn.us. Practically all the other forms r.f hu 
 man tulH.rculr.si. arc .lerived from the sputum 
 "• la^es „i human hint; tuherculosis, carncl 
 
. hulls \f\ !i!MUt!i -|>r.n .mt! ••!) ilu- fianih, .itul >.f 
 lUM"' >>i lititiuui liiii^ titU'rdilioM iImI tioi .ut III 
 »|»rra«I in(«Htn>n ••> i.tluT ihtwhi*. all f'trm^ "if 
 httiiuin tutKTfnliis.v wmi' | i|i-.i|i|H';tr 
 
 \|i.r«'ti\«T, «'\fii liiiiinit lurii; liilH-riiilu'*!'. i« iint 
 MTV iiiii'i tiiiti^ III ilif «'arK ■'tas'i'*, i »• , vxlu-nllif 
 mrtii-. ari' ),'f"""ii; m tin- Uiiik Ji»mu', (hu liav*- 
 ii'il \vt ri'a»lu-il till- air |>a«'<ai;f'«, In'tati*!'. tttitii 
 lln-n, lltf l;^rtll^ tamii)! c-^tap«* itito thr uiiii||ii|h- 
 ■iimI ^<i Ii\ itu- lliriiat In llic iiioiiiji \\ lu-n in the 
 lal«T ■«lai;i"« tin- ^'crm-. rtaifi llu- air-pa"ai;r". tlir 
 *\a\ ii>t llif i>ta|>f 111 tlir i;irm>. lo tlu' ..iit-ulf 
 
 • liul »<i lo iitluT tlliitlllw l> "m|H-M " iVr-.nll'. Ill 
 
 llii* tlanf <if liilHrnilii-n arr falKil "<i|»rti ' la-n'-, 
 ami It i-< ilnrcfiirf <.nK tlif ""Hkii" »a>T'> iliat ari- 
 -truuiNlv l<i Ik- ffarn! a> ii\f«'> Ikhi'. 
 
 till MliilllloN (iK t \lllf 11 lihHi I liisl-, i\ mi- 
 lt t \i \\ 
 Alllioimli tlu- laltif iiiIktviiIii^is ^jirm <litTfr- 
 In nil llu' liuinan liilitri ulnsjs ucrtn Hnim-wliat in 
 >i/f. ^iiajH, ill- . llu- iiKisi iiniMirlanl pulilic litallli 
 
 • lillfirtiicc Is ihis; tlif r«|lk- luUrr»i!iisi> (,'orm 
 scliloni prodiUfK lutiij tulicrculosis m tin- human. 
 It prodiuis iKiiif, ylanil, juittf, itf . tulKTculusis, 
 hut h\\\K tiilKTriilosis hardlv fvtr, l'i>n>iiUT hi>\v 
 inilMiriant tln<. fact is. It nieans that cattle In- 
 hi'iiiilosKi rxistini; in a hutnaii tan iwry sclilum 
 he conveyed from that humtin to another human. 
 In (ilhiT W'iriU. ratlU* tiilivrculo-is tiiav liv traiis- 
 inittfii fpiiii cattle to man, hut practualiv is not 
 furthi-r transiiiittc"! frimi man to man. In prc- 
 vont c.-.ltic tiihtTcnlosis in the hiiman. we dn not 
 need In take into account exisfinjj; casi-s of cattle 
 tiihercniosis in the hmiian. hut only •.•xistiny cases 
 of catiie tulKTculnsis in cattle. If we free <Hir 
 cattle of callli' tnlKTcnlosis, wt- shall free our 
 Imtnans of cattle tiihercniosis also; aiul this is the 
 
 I 
 
only practical way that cattle tiiherculosi", in the 
 human can lie alKilished unless and until the hu- 
 man race abanclons the use of raw co-v's miik. 
 
 Till- ABOLITION (.1- Ml MAN TinERCUI.OSIS 
 
 How can we abolisli human tufwrculosis^ I-'x- 
 act y as we can, and .s„„,e day shall, abolish anv 
 and all other infectious diseases, bv killinp off 
 the irerm that causes it. exactlv as we have al- 
 most abolished the race of buffalo bv killing off 
 the existinR buffalo. We know well eiiouKb that 
 when t c last buffalo is dead, no man. however 
 wise, no >jovernnient. however powerful, could 
 ever pnHliice another buffalo. So .nee tlic e\- 
 istinfi <liphtheria or scarlet fever or tuberculosi, 
 perms are all dead, there is no wav under heaven 
 by w iich these particular jrerms could !,< pro- 
 duced ajfaiii. Those which exi^t now are not 
 evolved from dirt any more tliai. ,.re buiTalo or 
 roses I hose which are livinjj todav are >implv 
 the descendants of those which existed ^c^ter- 
 day and so on. just as in the case of buffalo or 
 roses, back to the dawn of history. Once anv 
 race or plant or animal is wiped out. it can never 
 be redeveloped; and the tuberculosis frerm, just 
 as well as the Rerms of diphtheria or tvphoi(' 
 fever, can be alMilished exactlv as the 'mega- 
 therium or dinosau. has been alx.lished, i. e.. bv 
 the killuiR: of the existing individuals. 
 
 "But consider the enormous numbers and the 
 tiny size of perms and that thev are present 
 cvery.i'here~m air. water, food, milk, dust • in 
 and on everything we touch or taste or handle 
 It IS quite impossible to kill them all." 
 
 True, ^cnns are everywhere but >wt disease 
 .s:enns. We know some fifteen hundred or more 
 species of jjerms and hardiv fiftv of these pro- 
 duce disease, while only two, already mentioned, 
 8 
 
produce tuberculosis in the human. I hat these 
 arc very small and cannot he slaujjhtered indi- 
 vidually like buffalo, is true, but it is also true 
 that their very minuteness means that billions can 
 be slaughtered in one operation, if they are only 
 kept together. As to tuberculosis germs being 
 everywhere, all over, out<l(K)rs and indixirs — thi:; 
 is not true. \o more important f' t in public 
 health has ever been formulated than this, due 
 to that keen leader in public health, Chapin of 
 Providence: l/ie };i'rms that produce disease 
 are not ubi(iuitous, not in dust everywhere, water 
 everywhere, milk everywhere. They are chietlv, 
 almost wholly, in the bodies of a few (relatisely) 
 IH-'ople, or animals; and when they escape from 
 those bodies, where alone they find the peculiar 
 food, high temperature, abundant moisture, and 
 darkness which they need, they promptly die or 
 become harmless. Even in water, milk. food, 
 etc., into which they may be introduced from in- 
 fected persons, their lives are short, and thev 
 must quickly reach a new living victim, or die. 
 
 To alwlish any one race of disease germs is 
 far easier than to destroy some much larger 
 things. Thus to abolish t1ies means not only kill- 
 ing all flies, indoors in all houses everywhere, in 
 all stables everywhere, in and around all dwell- 
 ings everywhere, but al.so throughout all fields 
 and forests, mountains and valleys everywhere, 
 because flies are hardy outtloor beings as well as 
 indoor beings. They can breed and flourish al- 
 most anywhere, where any kind of food, even in 
 vanishing quantity, is to be had. Moreover, thev 
 can move of their own volition with promptness 
 and despatch, have quick eyes antl quicker w ings 
 to escape designing enemies, and in a thousand 
 wavs can take care of themselves. 
 
^m 
 
 Disease K't-rms, in contrast with the »ly. are 
 very liny and helpless particles of protoplasm, 
 having no eyes to see an enemy, no nose to smell 
 hmi. no means of rnnninj,' awav from him. Thev 
 cannot nourish on almost anv "food, but need the 
 living: tissues "i the human hoily ; thev cannot prow 
 at almost any temperature, but must have the 
 heat of the human body. In brief, thev are not 
 merely indoor plants: they are incubator plants 
 and cannot jrrow. thrive, or reproduce themselves 
 in nature, except in the incubators— our iM.dies. 
 or. in a few cases, animal bodies. ,,nnide them' 
 llence It we were able to take a visual census of 
 all the hviUK tuberculosis or scarlet fever or diph 
 th-ria fjcrms in the world we should see them 
 not m the dust everywhere, the water everv- 
 whcre. the food everywhere, etc.. but in a verv 
 few place> only, and those places would be in 
 almost all cases, the bodies of humans (or ani- 
 mals). 
 
 Indeed, we can iV.retell just about what the 
 census (.f tuberculosis perms in Minnes.ita or 
 in any other district of the temperate zone, would 
 show. It would show about one person in every 
 seven hundred of the jxipulation carrying a large 
 number of active, living, growing germs in the 
 lungs.— germs that were escaping to the outside 
 and reaching other persons' mouths. It would 
 show also a number of other persons in whom 
 the germs were present in joints, bones. ;;lands. 
 etc.. but not escaping to others; and it would 
 show a number of persons affected in the lun.'s 
 and. later, likely to develop to the point whe're 
 the germs onild escape, but practically harmless 
 to others .so far. Beyond thi.s. hunt high, hunt 
 low. search garbage barrels, manure heaps, dead 
 animals, dusty streets, sewage, water, foods. 
 
 10 
 
milk, etc.. and linnian tiiJ)erciil()sis gcrm>, alive, 
 •.Towintj, capable of pnxjncin),' tlic (li>iea>e. Ti-okA/ 
 not he found, rriie, in the immediate neijjlihor- 
 li<K)d of the "open" cases the sputum thev throw 
 out, their mouth-spray, and their hands would 
 show the ffcrms, and thinji^ they spit into, mouth- 
 spray into, or touch, would show for a short time 
 a few; hut these would he dyinjj or already dead, 
 holdinj,' out dantrer to other jiersons onlv durini,' 
 tlie short time which elapses hetween leavinj,' 
 their happy homes in the human luni; and death 
 outside from starvation and dryinj,'. This ap- 
 plies, not to tuberculosis ^erms alone, but prac- 
 tically to all the germs of the or<linar\ mfectious 
 diseases, anthrax and tetanus forming; two chief 
 exceptions, both rare diseases here. 
 
 So person ciiertictic cnoui^li to advocutc tlir 
 abolition of flics should hrsitati' a moment to ad- 
 vocate the far simpler, smaller, ea'ier, and far 
 more important 'n'ork of aholishini^ the !:;erms 
 that alone can make the fly a dani:;er. 
 
 In brief, the method, and, I believe, the only 
 rapid. coni])lete, effectual method of abolishing 
 human tuberculosis, is this; find the "open' cases 
 and prevent the spread from tliem of the j„'erms 
 thev alone throw out in numbers and condition 
 to be feared. That means, find the one person 
 in every seven hundred whose infection threatens 
 all the rest, and supervise him just enough to 
 keei> his discliarges from entering other people's 
 mouths. 
 
 How is this one person in every seven hundred 
 to be found? Xot without hunting, not without 
 ingenious, skillful, deliberate, sagacious, well 
 trained hunters, epitlemiologists as devoted and 
 l)ersistent in their work as the average insurance 
 agent is in his, — men who devote themselves to 
 
 II 
 
the atmlition of tuberculosis as whole-heartedly 
 as any merchant does to niakinj,' money. 
 
 .\n<l how? Where shall we hcRin? Must wo 
 canvass the whole |K)puL, t one by one? True, 
 that would do it, hut epidemiology has found a 
 simpler, keener, more scientific, far more eco- 
 nomic |)lan. illustrate<l for typhoid fever in a 
 |)revious article of this series ( So. 3 ). Hefiin with 
 the known cases and search the zones of infec- 
 tion surroundinjj each for mild, unrecognized, 
 and concealed cases. ( In tulwrculosis the search 
 for carriers is probably unnecessarv, certainly at 
 the present time. ) 
 
 "liut why not concentrate on the incipient lunj; 
 case, the case iiiat may l)e cured, and by prevent- 
 mp this case from Roinj; on to the "open" in- 
 fectious stage get ri.l of danger to others thus, 
 nistead of by attention to the open case?" For 
 several reasons, the alit.Iition of tuberculosis 
 through care of incipient lung cases onlv cannot 
 at present be accomplished : 
 
 1st. P.ecause incipient cases, in the truly in- 
 cipi-;nt "non-open" stage, are discovered, 'i)er- 
 haps are di.scoverable. in a verv small percentage 
 only of their total number. 
 
 2nd. P.ecause a large proportion of the in- 
 cipients so found would not go on in any case. 
 whether found or not. to the open stage; ancl 
 the time and money and efforts spent in finding 
 and supervising them would have been relatively 
 wasted. 
 
 3rd. P.ecause a certain ptoportion of the in- 
 cipients so found :could go on, •« any case, to the 
 open stage, and thus become nfectious' cases, 
 despite all efforts. In these alon,. would the ef- 
 forts expended I)e of service in preventing new 
 cases. The troub'e is that, in the incipient stage, 
 
 12 
 
it could not 1)C ilctcrniiiiccl wlictlicr or not the 
 case would so develop. 
 
 4th. fiei-ause the time and attention devoted 
 to incipients, to prevent them Iwcoming open 
 cases, would imply, as it has, alas, so far im- 
 plied, nejjlect of the advanced "ojw-n" cases, in 
 which the danger of infection is so immensely 
 Rrcater. 
 
 5th. Because if all the incipient cases were 
 discovered they would form a mass of persons 
 so great as to be beyond handling properly by 
 any at present even dreamed v)f force of attend- 
 ants, etc. If, as at present, only a very small 
 projwrtion were found the actual situation would 
 not be materially changed. 
 
 "Would you then cease the care of incipient 
 cases in sanatoria, such as that at Walker. Minn., 
 and concentrate wholly on the advanced case?" 
 
 No. I'irst. because the tuberculosis sanatoria, in- 
 tended though they are for incipient cases, really 
 handle very many "open" cases, and to that ex- 
 tent prevent new infections ; secondly, because 
 the tuberculosis sanatoria do, in a measure, fulfill 
 their proper function of cure for incipients and 
 even early "open" cases to some extent and hence 
 save life. Rut as a means of abolishin}^ tubercu- 
 losis, the ordinary tuberculosis sanatorium for 
 incipient cases is quite hopeless. 
 
 The thing to do first is. find the recognized 
 "open" cases, whether tiiey be in early, advanced, 
 or late stages, and place them where they can 
 spread the disease no further. Then search the 
 "zones of infection" surrounding them, i. e., their 
 relafves and associates, for mild, unrecognized 
 or concealed cases, and also for incipients. han- 
 dling all "open" infectious cases thus found, in 
 the same manner. This system would l)egin at 
 
 13 
 
the rI^Jht ciul l)v st.ii.piiijr further infections an<! 
 would incidentally find those earlv "oiwn" and 
 "nnn-()|)^n" incipient ca>es wherein sanatorium 
 treatment would lie of most avail. 
 
 SI MMAKV 
 
 i uhirculosis is a ty|)ica! infectious disease, and 
 It must l>e handled on the same principles as any 
 other infectious disease; hence, hv hlfx-kinj; the 
 routes of infection, I.ut chiefly hv findinj,' the 
 sources and prevcntinj,' spread thence. 
 
 < »f the five preat routes of infection, —water, 
 fo<"l. Hies, milk, ami contact,— human tubercu- 
 losis travels chiefly hy contact, through sputum, 
 mouth-spray, and hands, directly, or almost di- 
 rectly, from patient to prospective patient. Prac- 
 tically, it is spread exactly as scarlet fever or 
 <li|)htheria is spread. IHihlic flies and public food 
 supplies are comi)arativelv insijjnificant convex- 
 ors. I'lihlic water supi)lies are almost ne«li>,Mble, 
 and public milk supplies act chieflv in conveyinp 
 cattle tu!)erculosis to man. althoujrh. if the milk 
 be handle.l by tuberculons humans, it may con- 
 vey human tuberculosis also. 
 
 It is evident, then, that blockinj,' of routes, 
 "ince the chief one is contact, involves chiefly the 
 far more important measure of findinjr the source, 
 jii-t as m scarlet fever, or diphtheria, etc.. and 
 if these sources are found and prevented from 
 access to the routes, the routes may he disre- 
 ,1,'arded. The measures for findinjj "the human 
 sources, practically the "open" cases of lun^ tu- 
 berculosis in the human, are epidcmioloRicai and 
 have already been discussed in principle l>efore 
 (Article 3i 
 
 The measures necessary for finding the animal 
 sources (infected milch cows) are the well- 
 
knciwti tiilKTcuIin test of herds, witli pniiK-r rc- 
 (ictitidtis, and tin- elimination of tlie tu!)croulous 
 animals Serious enoiiuli as cattle tiiltcriiilosis 
 in the human is, its jirevalence. nevertheless, i< 
 M) nuuh less than that of human tuherculosis and 
 its infei"ti\eness in the human is so nearly nei;- 
 li),nl)le. if our eflforts were concentrated wholly on 
 human tuberculosis more case-* and more fleaths 
 would l)c prevented, in a year's work, than etTorts 
 on l)ovine tuherculosis, however successful, could 
 ()ossibly achieve in many year-.. 
 
 IS