The only real wealth is health. 
The great hope of modern medicine is the 
prevention of disease.—Cabot THE 
PREVENTION OF DISEASE 
IN THE INDIVIDUAL 
BY / 
KENELM WINSLOW,"B. A. S., M. D. 
Attending Physician to Seattle City Hospital and King County Hospital, Wash- 
ington; formerly Assistant Professor of Comparative Therapeutics at Harvard 
University; formerly Surgeon to Newton Hospital; recent Vice-President of 
the American Association for the Study and Prevention of Infant Mortality; 
Author of “The Production and Handling of Clean Milk,” etc. etc. 
SECOND EDITION 
THOROUGHLY REVISED 
PHILADELPHIA AND LONDON 
W. B. SAUNDERS COMPANY 
1923 Copyright, 1916, by W. B. Saunders Company. Reprinted January, 1918, and 
June, 1921. Revised, entirely reset, reprinted, and recopyrighted November, 1923 
Copyright, 1923, by W. B. Saunders Company 
MADE IX U. 8. A. 
PRESS OF 
W. B. SAUNDERS COMPANY 
PHILADELPHIA TO 
M. H. 
IN APPRECIATION OF CONSTANT 
ENCOURAGEMENT AND SYMPATHY 
IN THE WRITING OF THIS BOOK CONTRIBUTORS OF INTRODUCTORY 
NOTES 
Charles H. Mayo, A. M„ M.D., LL.D., F. A. C. S„ 
Ex-President of the American Medical Association; Surgeon to 
St. Mary’s Hospital, Rochester, Minnesota. 
Joseph Colt Bloodgood, B. S., M.D., F. A. C. S., 
Associate Professor of Clinical Surgery, Johns Hopkins Uni- 
versity; Associate Surgeon Johns Hopkins, Union, Protestant, 
and St. Agnes Hospitals, Baltimore; Director of the Amer- 
ican Society for the Control of Cancer; Member of the Amer- 
ican Society for Cancer Research. 
Winfield Scott Hall, M. S. (Northwestern), Ph.D. (Leipzig), M.D. 
(Leipzig), 
Professor of Physiology, Northwestern University; Fellow 
American Academy of Medicine; American Medical Associa- 
tion; Member American Physiological Society; American 
Genetic Association. Author of Text-book of Physiology; 
Manual of Experimental Physiology; Nutrition and Dietetics; 
Reproduction and Sexual Hygiene, etc., etc. 
Frederick Peterson, M.D., Ph.D., 
Ex-President of the New York State Commission in Lunacy; 
Former Professor of Psychology in Columbia University; 
Consulting Alienist for Bellevue Hospital, New York; Man- 
ager of the Craig Colony For Epileptics, at Sonyea, New York. 
Author of Mental Diseases, American Text-book of Legal 
Medicine and Toxicology, etc., etc. 
Charles-Edward Amory Winslow, B. S., M.S., Dr. P. H. 
Anna M. R. Lauder Professor of Public Health, Yale Medical 
School, and Curator of Public Health, American Museum of 
Natural History, New York; Member Society of American 
Bacteriologists, American Society of Naturalists, etc., etc. 
Author of Elements of Water Bacteriology, Elements of In- 
dustrial Microscopy, Systematic Relationship of Coccaceee, etc. 
Joel E Goldthwait, B. S., M.D., F. A. C. S., 
President of Corporation of Robert B. Brigham Hospital, Bos- 
ton; Lecturer on Orthopedic Surgery, Harvard Medical 
School; Late Orthopedic Surgeon, Massachusetts General 
Hospital; Consulting Orthopedic Surgeon to Lynn, Carney, 
Haverhill Hospitals; Ex-President of the American Ortho- 
pedic Association, etc. 
4 PREFACE TO THE SECOND EDITION 
There is no more progressive branch of knowledge 
than that of medicine. Thus, no sooner is a medical 
book born than it is dead, a thing of the past. The 
best one can do is to labor and beget a new edition em- 
bodying the latest ideas and advances. Fortunately a 
growing demand for this book, and the progressive princi- 
ples of its publishers, make such a presentation possible. 
The enormous professional experience with influenza, 
since the fatal fall of 1918, has led to the rewriting in 
toto of the article on that subject and the addition of a 
wholly new one on pneumonia, the direct cause of all the 
deaths from influenza. The increasing use of vaccines 
for the prevention of colds, influenza and pneumonia 
gives origin to additional matter on this topic. 
The recent discovery that asthma, hay fever and other 
ailments are due to the action on sensitive individuals of 
proteid substances in food or in pollen of plants, or in 
emanations from animals, or in products of bacterial 
growth in the body, has revolutionized prevalent medical 
theory and practice, and indicated certain means of pre- 
vention for these hitherto almost incurable disorders. 
New sections are therefore devoted to these maladies. 
Another widespread affection, adolescent or endemic 
goiter, is considered for the first time in this volume. A 
gemarkably simple preventive measure is proving of 
great practical value. 
The discovery (1921) of a specific remedy (insulin) for 
diabetes by that brilliant young Canadian, Banting, has 
aroused unusual popular interest in this common disease 
5 6 
PREFACE TO THE SECOND EDITION 
and in the previous work of the distinguished Americans, 
Allen and Joslin, in this country, who have accomplished 
so much in the way of prevention and treatment of dia- 
betes. Very considerable new matter concerning this 
subject will be found in the present edition. 
Rather a large amount of space was occupied in the 
first edition in order to emphasize and popularize the 
most useful and comprehensive advance in medical 
thought in this generation—the recognition of the influ- 
ence of focal infections in the production of general 
diseases. The passage of time has but enforced and 
sanctioned the views there expressed, while further 
experience enables one to amplify to a greater extent their 
practical application. 
No preventive measures have had more far reaching or 
beneficent results than those directed against hookworm 
disease and, for this reason, a wholly new article is sup- 
plied on this theme. 
Vitamines have attained great prominence of late as 
newly discovered substances in food essential to life, 
growth and nutrition. Their absence in food is responsi- 
ble for the important deficiency diseases. Considerable 
new material will be found herein relating to vitamines 
and foods rich in these bodies. 
In closing it may be said that besides all the new mat- 
ter added in this second edition, most of the topics in the 
first edition have been amplified, deleted or revised in 
accordance with the latest facts developed by investiga- 
tion and experience. 
Kenelm Winslow. 
Seattle, Washington 
November, 1923. PREFACE 
“An ounce of prevention is worth a pound of cure” 
is a truly weighty maxim, and expresses fairly accurately 
the comparative ratio of value between curative and 
preventive medicine, i. e., as 16 to 1. Modern preventive 
medicine may be said to have begun with Sir Edward 
Jenner (1796), who introduced vaccination against small- 
pox. This was founded solely upon the experience of the 
laity, and a whole century elapsed before another English- 
man, Sir Almoth Wright (1897), was enabled, through ad- 
vances in knowledge and his own genius, to re-introduce 
vaccination as a general method of protection in various 
germ diseases. At one stroke he annihilated the dangers 
of a disease (typhoid fever) whose bacilli are more fatal 
than bullets and placed it in the growing list of preventable 
disorders. 
The meaning of vaccination has been amplified, and 
while originally signifying inoculation with a cow (vacca) 
virus, the term may now be properly applied to the use of 
any material for preventive inoculation. 
But this book is not a record of the progress in preven- 
tive medicine. 
It is a detailed practical guide for the layman that he 
may avoid the various diseases described herein. The 
7 8 
PREFACE 
first three chapters are devoted to the proper methods of 
living in health so as to evade ill health. 
These pages contain the essence of matters to which 
whole books are often dedicated. The matter on diet, 
exercise, tea and coffee, and alcohol the author believes 
will prove of special interest and worth. 
While the secret of cancer remains to be solved, yet 
recent knowledge may enable an individual to escape this 
most dreaded and fatal malady. In fact, the importance 
of this matter is so great that its discussion alone should 
make a book of this kind worth while. 
In relation to the germ diseases, the common methods 
are considered whereby one may protect oneself or others. 
The means of preventing malaria, colds, and the proper 
diet and exercise in the prevention of constipation and 
obesity should appeal to a large number of persons. The 
prevention of nervous disorders in children of neurotic 
parents has a large field of usefulness in this country. 
The very recent work of Billings and Rosenow in Chicago, 
emphasizing the influence of diseased tonsils, gums and 
teeth, and other local infections in the production of the 
most serious chronic diseases, has been deemed worthy 
of a special chapter. The use of a new instrument of 
precision in the last decade for estimating blood-pressure 
has greatly enlarged our knowledge of arterial disease, or 
premature old age, and a chapter is devoted to this sub- 
ject. Prevention of the diseases of childhood is perhaps 
the most essential subject in preventive medicine, and a 
chapter will be found on this topic. PREFACE 
9 
The knowledge that infant mortality results chiefly 
from the feeding of raw cows’ milk has enormous signifi- 
cance. While there is no specific for the prevention of 
tuberculosis, yet we believe that the practical points given 
in this connection will be found of much service. 
The prevention of sexual diseases is a subject equally 
disagreeable and vital, and the ostrich-like fashion of 
ignoring its existence is both absurd and reprehensible. 
The author wishes to express his sincere appreciation 
and hearty thanks for the kindness and generosity of 
some of the foremost medical men in America who have 
gratuitously contributed the introductory notes to be 
found in various parts of this book. 
This they did to show the laity that the matter con- 
tained herein represents the sound and scientific opinion 
of the leaders of the medical profession today. 
These leaders would be unwilling to lend their distin- 
guished names if they did not believe that the book 
would aid in bettering the lives of its readers. 
This book is not merely a compilation from literature, 
but is the outcome of a quarter-century of active medical 
and surgical practice in the East and West. 
Kenelm Winslow. 
Seattle, Washington. FOREWORD 
It is very pleasing to find placed before the people 
such a concise and simple description of most of the 
facts known to modern preventive medicine as that 
given in the following pages. 
For too long a period medicine has been looked upon 
as more or less associated with mystery, and for this 
reason all sorts of mysteries have crept into it through 
many cults and isms, and many practices and pathies. 
Such training in medicine as it has been possible for 
the public to receive has often been obtained from the 
direct advertising or faked medical news items in the 
papers and magazines of the day. 
Never before has there been such a general apprecia- 
tion of preventive medicine as now. The late war has 
shown the possibilities of protecting whole armies from 
the ravages of disease. 
By the prevention of disease great enterprises which 
were impossible twenty years ago, such as the building 
of the Panama Canal, are now possible. 
During the last half century the average duration of 
human life has been increased many years, largely 
through the protection of the people by public health 
laws. 
11 12 
FOREWORD 
The presentation of the wonderful advances of modern 
medicine here given, together with carefully considered 
rules for daily living in order to preserve health, is offered 
to those who desire them, not that they may become 
physicians by reading this matter, but that, from their 
wider knowledge of science, they may be better citizens. 
Charles H. Mayo. CONTENTS 
Page 
Foreword (By Charles H. Mayo) 11 
CHAPTER I 
rPesonal Hygiene 17 
Tea and Coffee, 17—Alcohol, 21—Tobacco, 30—Opium 
and Cocain, 35. 
CHAPTER II 
Personal Hygiene (Continued) 37 
Care of the Teeth and Mouth, 37—Pyorrhea (Riggs’ 
Disease), 40—Hygiene of the Digestion, 42—Causes of 
Indigestion, 44—Cooking, 46—Value of Food Elements, 
49—Meat, 51—Fish, 55—Milk, 55—Eggs, 57—Cereals, 
57—Fats, 58—Vegetables and Fruits, 59—Vegetarian 
Diet, 61—Salt, 63—Water-supply, 63—Purity of Water 
and Ice, 65. 
CHAPTER III 
Personal Hygiene (Continued) 69 
Exercise, 69—Special Exercises for Different Ages, 69— 
Rationale of Exercise, 72—Clothing, 79—Baths, 81—Out- 
door Baths, 83—Lukewarm and Warm Baths, 85, 86— 
—Hot Bath, 86—Turkish and Cabinet Baths, 87— 
Ventilation, 88—The Complexion, 89—Sunburn, 90 
—Freckles, 90,—Acne, 90—Care of the Hair, 91— 
Baldness and Dandruff, 91—Care of the Finger-nails 
and Toe-nails, 93. 
CHAPTER IV 
Germ Diseases 94 
Vaccination, Small-pox and Chicken-pox, 94—Typhoid 
13 14 
CONTENTS 
Page 
Fever, 102—Asiatic Cholera, 108—Dysentery, 111— 
Diphtheria, 115—Hydrophobia, 122—Lockjaw, 129— 
Scarlet Fever, 133—Measles, 136—Mumps, 138— 
Whooping-cough, 139—Bubonic Plague, 143. 
CHAPTER V 
Germ Diseases (Continued) 147 
Malaria, 147—Yellow Fever, 153—Dengue, 158 
CHAPTER VI 
Germ Diseases (Continued). 1160 
Tuberculosis, 160—Colds, 173—Influenza, 179—Pneu- 
monia, 183—Cerebrospinal Meningitis, 185—Infantile 
Paralysis, 190. 
CHAPTER VII 
Tonsillitis, Abscessed Teeth, Pyorrhea and Other 
Common Local Troubles as a Source of Serious Gen- 
eral Diseases 194 
Importance of Infections of Nose, Mouth, and Throat, 
194—Tonsils and Adenoids, 205—Riggs’ Disease, 210 
CHAPTER VIII 
Prevention of Cancer 212 
Introductory Note (By Joseph Colt Bloodgood), 212. 
CHAPTER IX 
The Prevention of Sexual Diseases and Sexual Hy- 
giene 234 
Introductory Note (By Winfield Scott Hall), 234—Sex- 
ual Hygiene in Marriage, 252. 
CHAPTER X 
Prevention of Acute and Chronic Rheumatism, Neuritis 
and Acute Tonsillitis 258 CONTENTS 
15 
Page 
CHAPTER XI 
The Prevention of Diseases of Children 269 
Circumcision, 270—Proper Food for the Infant, 271— 
System, 279—Vaccination, 282. 
CHAPTER XII 
The Prevention of Diseases of Middle Age 285 
Arteriosclerosis, 285—Heart Disease, 293—Bright’s Dis- 
ease, 294—Prevention, 295. 
CHAPTER XIII 
The Prevention of Nervous and Mental Diseases . . . 304 
Introductory Note (By Frederick Peterson), 304—-Neu- 
rasthenia, 304—Hysteria, Paresis, Dementia Prsecox, 
Paranoia, Mania, Melancholia, 304. 
CHAPTER XIV 
The Prevention of Diseases of Digestion 319 
Constipation, 319—Ulcer, 330—Gastritis, 332—Gall- 
stone, Appendicitis, Stone in the Kidney, 332—Nervous 
Dyspepsia and Visceroptosis, 336 
CHAPTER XV 
Food Poisoning 343 
Introductory Note (By Charles-Edward Amory Wins- 
low), 343—-Milk Poisoning, 344—Ptomain Poisoning, 350 
—Meat Poisoning, 351—Botulism, 354—Fish and Shell- 
fish Poisoning, 355—Vegetable and Fruit Poisoning, 356. 
CHAPTER XVI 
Deficiency Diseases and Disorders of Nutrition .... 360 
Beriberi, 360—Scurvy, 365—Rickets, 367—Pellagra, 370 
—Adolescent Goiter, 372—Obesity, 373—Prevention of 
Diabetes, 383. 16 
CONTENTS 
Page 
CHAPTER XVII 
The Prevention of Asthma, Hay Fever and Hookworm 
Disease 385 
Asthma and Hay Fever, 385—Hookworm Disease, 392. 
CHAPTER XVIII 
The Prevention of Some Deformities 396 
Introductory Note (By Joel E. Goldthwait), 396—Round 
Shoulders and Lateral Curvature of the Spine, 397— 
Humpback, 399—Knock-knees and Bow-legs, 403—Weak 
Foot and flat-foot, 404. 
CHAPTER XIX 
Prevention of Infection and Bleeding in Wounds . . . 409 
Sterilization with Iodin, 409—Inflammation, 412—Steril- 
ization by Washing, 412—To Prevent Lockjaw, 413—Spe- 
cial Wounds, 413—Bullet Wounds, 414—To Stop Bleed- 
ing, 415. 
Index 417 THE PREVENTION OF DISEASE 
CHAPTER I 
PERSONAL HYGIENE 
Tea, Coffee, Alcohol, Tobacco, Morphin, and Cocain 
TEA AND COFFEE 
It is a singular and noteworthy fact that there appears 
to be some instinctive demand or craving among human 
kind for caffein. All over the world natives have discov- 
ered and habitually drink beverages containing this active 
principle, although the plants have no common resem- 
blance and the effects produced are not marked, as in the 
cases of alcohol, opium, and hashish. 
Thus, tea, coffee, chocolate, and cocoa all contain 
caffein or allied bodies—thein and theobromin. Caffein 
is also the active principle of the African kola nut, of the 
South American guarana and mate tea (from a species of 
holly), while in the West Indies and Mexico the habitual 
beverage is made from the fermented chocolate bean. 
Caffein is one of the most powerful heart and nervous 
stimulants employed in medicine. A cup of coffee con- 
tains from \}/2 to 3 grains of this substance, a full medici- 
nal dose. Tea contains 1 to 4 per cent.; coffee, 0.6 to 2 
per cent.; mate, 1.3 per cent.; kola, 1 to 2 per cent.; 
guarana, 3 to 6 per cent, of caffein. 
In the roasting of coffee there is developed a volatile oil, 
caffeol, to which the flavor and aroma is due. It is so 
17 18 
THE PREVENTION OF DISEASE 
powerful that one drop of caffeol will fill a room with 
coffee odor. 
Tea naturally contains a volatile oil (0.6 per cent.). 
Both tea and coffee have a considerable amount of tannic 
acid in their composition, but that in coffee is compara- 
tively inert, although it tends to impair digestion some- 
what. That in tea, however, is active and astringent, 
and exerts a tanning effect upon the mucous membrane of 
the stomach in strong solutions. Theoretically neither 
coffee nor tea should be boiled in their preparation, since 
the volatile oil, or flavor and aroma, are considerably 
lost in the process. Coffee may be made by percolation 
with boiling water, or by enclosing coffee in a tea-ball 
and pouring boiling water over it and allowing it to steep 
for a few minutes. Tea is commonly made in this fashion 
and is permitted to steep from two to five minutes. 
But, in practice, boiling coffee for not more than five 
minutes, and serving it directly, yields a finer flavored 
beverage than any percolated product—to many palates. 
What more delicious than camp coffee made in this way. 
The preparation is really a matter of taste. 
The longer tea stands the darker it gets and the more 
tannic acid it contains. The confirmed tea drinker, who 
keeps the tea standing in the teapot all day and drinks it 
cold, is getting enough tannin to convert hide into leather. 
There are but 1 to 2 grains of caffein in a cup of tea, as 
less tea than coffee is used to the cup. 
The volatile oil in coffee stimulates the brain, the 
stomach and bowels, and in some persons acts favorably 
as a laxative. In others, coffee causes overacidity in the 
stomach and diarrhea owing to this action. Strong tea, 
through its active tannin, on the other hand, lessens 
acidity in the stomach and favors constipation, although 
more immediately stimulating to the brain than coffee. TEA AND COFFEE 
19 
In nervous indigestion and nervous conditions generally 
both tea and coffee are injurious because of the exciting 
action of caffein on the nervous system. It is a curious 
fact that after drinking many cups of tea or coffee daily 
for months or years a person may become suddenly 
oversusceptible to their influence, so that a single cup 
may cause bad effects. The same phenomenon is seen 
in the case of tobacco users. It is a matter of common 
knowledge that whereas one person may drink several 
cups of tea or coffee without disturbing sleep, in another a 
single cup hours before bed-time may keep him wide 
awake and restless with active mind most of the night. 
The action of preparations of kola sold at the soda- 
water fountains depends upon caffein, and the kola habit 
is more prevalent in the South. 
Chocolate contains 0.3 to 2 per cent, of theobromin and 
up to H of 1 per cent, of caffein. 
Chocolate is very rich in fat (30 to 50 per cent.) or 
cacao-butter. In cocoa we have the fat much reduced 
(15 to 30 per cent.) by its removal through hydraulic 
pressure. 
The active principle of chocolate (theobromin) is much 
less stimulating to the brain than caffein, but has a more 
powerful action on the kidneys. Chocolate is extremely 
nourishing, but the amount of fat and sugar in it retards 
the secretion of gastric juice and the motions of the 
stomach, while its theobromin is apt to cause loss of 
appetite. Cocoa is less prone to disturb digestion by 
containing less fat, while the cheaper kinds are mixed 
with starch, and so hold less theobromin. Some cocoas 
have the fat in a more digestible form by treating them 
with an alkali by the Dutch process. Phillips’ digestible 
cocoa is especially suited for those with weak digestions. 
While cocoa is a valuable and very nutritious beverage 20 
THE PREVENTION OF DISEASE 
for the invalid, chocolate is too rich and sweet to be 
digestible. A heaping teaspoonful of cocoa and sugar 
added to milk nearly doubles its food value. Cocoa 
should be boiled five minutes to cook the raw starch 
(10 per cent.). It also contains about 15 per cent, of 
protein. 
Action.—Now as to the general physiologic action of 
the caffein-containing beverages: Caffein is an active 
stimulant to the brain, heart, and muscles. 
It enables persons under its influence to do more and 
better mental work. It increases the perception and 
association of ideas and the acuteness of the senses, as the 
sense of touch. In thus sharpening the intellect caffein is 
directly opposed to alcohol. It more nearly resembles 
strychnin in action, and in poisonous doses renders the 
nervous system so acute to stimulation that a touch on 
the skin may throw an animal into convulsions. It 
has been found experimentally that stenographers will 
do more, better, and speedier work after one cup of 
coffee than without any, and fatigue does not follow the 
extra work. Larger doses of caffein retard the speed, 
but do not impair the quality of the work. Many 
experiments have shown that soldiers march longer with- 
out fatigue under the influence of caffein or coffee. It 
stimulates the muscles directly as well as the nervous 
system. For any especial mental effort, as in taking an 
examination, coffee in moderate amount (one or two 
cups), will enable one to do better work, but the continued 
use of it for night-study only leads to nervousness and 
mental confusion. 
The bad effects of the tea and coffee habit are seen 
especially in nervous, sedentary, underfed, anemic, and 
debilitated persons. The symptoms include insomnia, 
trembling of the hands, palpitation of the heart, noises in ALCOHOL 
21 
the ears or head, pain in the stomach or heart-burn, rapid, 
irregular pulse, neuralgia and headaches, general nervous- 
ness, and (from tea) constipation. Poor and underfed 
women are specially prone to the tea habit. In all cases 
of insomnia, dyspepsia, and nervousness the first thought 
should be to stop the use of coffee and tea. 
Caffein is used in medicine chiefly as a rapidly acting 
heart stimulant, often injected under the skin, and also to 
stimulate the action of the kidneys. 
The habitual use of tea and coffee, like that of tobacco, 
does not improve the health. A single cup of either taken 
daily will not perceptibly injure the health of most normal 
persons. Used to excess and by susceptible persons the 
harm done by tea and coffee is immense. The race would 
be better off without either, and the young should be dis- 
couraged from initiating the habit. 
ALCOHOL 
The action of alcoholic drinks depends chiefly upon the 
amount of alcohol they contain. Ale, stout, beer, and 
porter contain from 3 to 7 per cent, of alcohol. The 
bitter they hold (hops) tends to improve the appetite, 
but the sugar and starchy matter may cause gas in the 
bowels. The older and darker foreign beers appear to 
produce, much less of this fermentation in the bowels and 
are less apt to cause “biliousness” and indigestion. 
The lighter wines contain from 7 to 15 per cent, of 
alcohol, more often 12 to 14 per cent., as California clarets, 
Madeira, muscatel, sherry and Riesling, and the Rhine 
and Hungarian wines. 
The yeast plant, which produces wine by the fermenta- 
tion of saccharine grape juices, is itself killed by an 
amount of alcohol much over 15 per cent., and so the 22 
THE PREVENTION OF DISEASE 
stronger wines are fortified—that is, have alcohol added 
to them in the form of distilled liquor from grapes, figs, 
raisins, or sweet potatoes. 
The fortified wines are imported sherry, port, and 
Madeira, and contain from 17 to 25, or even 30 per cent., 
of alcohol. 
Champagne is considered one of the most stimulating 
wines, and yet contains but about 10 per cent, of alcohol. 
It, like some kinds of Burgundy, is called a sparkling wine 
on account of being charged with carbonic acid gas. 
It stimulates the stomach and its effect is much more 
rapid, for the reason that it reflexly stimulates the heart 
(through stimulation of the stomach), and by increasing 
the blood-supply and movements of the stomach leads to 
more rapid absorption. Somewhat the same effect is 
seen when whisky is mixed with soda water. 
The bouquet of wines is due to the development of 
compound alcohols, or esters, by long standing. A red 
wine is prepared by fermentation of the juice of red grapes 
with their skins. If it contains much tannin it is said 
to be rough. White wines, as Sauterne, Chablis, Ilies- 
ling, are made from grapes freed from seeds, skin and 
stems, and usually contain no tannic acid. A dry wine 
contains little sugar, it having been all fermented into 
alcohol, while a sweet wine contains free sugar. 
Distilled liquors or spirits are made by distilling any 
fermented liquor. Alcohols, volatile acids, and esters 
are found in distilled liquors. Distilled liquors should 
age (over four years) in order that the bouquet may 
develop from the action of the acid on the alcohol and 
form esters. Also that the fusel oil, which causes the 
after-headache from new whisky, may undergo change 
and become innocuous. Distilled liquors are made from 
fermented grains (corn, rye, wheat, barley), as whisky ALCOHOL 
23 
and gin, and from fermented fruit juices, as brandies. 
Ordinary brandy or Cognac is distilled from wine; and 
peach, pear, and apple brandy from fermented juice of 
these fruits. The distilled liquors contain from 45 to 55 
per cent, of alcohol. Rum is distilled from fermented 
molasses. Scotch and Irish whisky have a smoky taste 
from being distilled over peat fires, or from being made 
from malt dried over peat fires. Gin is distilled from 
fermented rye, and then redistilled with juniper berries, 
which makes it more useful in relieving pain, and 
it is much used by women for this purpose during 
menstruation. 
Cordials are artificial mixtures of aromatics, sugar, 
alcohol, and water. They contain from 50 per cent. 
(Chartreuse) to 67 per cent, of alcohol (absinthe) and 
over 30 per cent, of sugar. Absinthe has a peculiarly bad 
effect upon the brain, causing mental depression, convul- 
sions, and insanity in habitues. Many countries forbid 
its manufacture, and the United States its importation 
since 1912. The great amount of sugar and alcohol in 
cordials produces a very injurious action on the stomach. 
Experimental researches concerning alcohol have quite 
altered the attitude of the medical profession toward it 
during the last decades. As a direct consequence, its use 
in treatment of disease is as rare today as it was formerly 
common. Our knowledge and ideas have changed, par- 
ticularly in reference to the so-called stimulant effect of 
alcohol and its action as a food. 
By stimulant action one may refer to stimulation of the 
nervous system or circulation. 
Action of Alcohol.—We will first consider the action of 
alcohol on the nervous system. We now know that alco- 
hol, instead of being a stimulant, is a powerful depressant 
or narcotic (producing stupor) to the nervous system, 24 
THE PREVENTION OF DISEASE 
beginning with depression of the most highly developed 
functions of the brain and continuing until there is loss of 
consciousness, motion, sensation, and even paralysis of the 
first-formed (in course of evolution) and most vital centers 
at the base of the brain, so that we have failure of respira- 
tion and circulation in alcoholic poisoning, or drunken- 
ness. In fact, alcohol acts like ether, only its action is 
much slower, because it has to be absorbed from the 
stomach instead of being absorbed in the form of vapor 
by the lungs. 
It is a well-known physiologic fact that the functions 
of the brain which have most recently developed in the 
evolutionary course of ages are the first to succumb to the 
action of drugs. Alcohol decreases or depresses the 
higher brain functions of will, self-control, reason and 
judgment, and sets us back on the animal plane. This is 
seen in the conduct of one under the influence of alcohol, 
when modesty is lost, demeanor and speech become free 
and uncontrolled (in vino veritas), and the subject is 
thoughtless of others, is reckless, oversanguine and 
confident, and deficient in reasoning power and judgment. 
The false feeling of stimulation comes from the more 
ready effect of outside stimuli, as through mental excite- 
ment produced by social intercourse, the warmth of the 
skin and stomach, and enhanced emotional and imagina- 
tive functions. In many persons, especially when alone, 
and in animals alcohol only produces depression, dulness, 
and stupor from the start, and is frequently used for this 
reason to overcome sleeplessness. 
The depression of the higher brain centers by alcohol is 
also seen in the impairment of sight, hearing, and touch, 
although the subject feels that the contrary is true. 
Type-setters make more errors, musicians strike more 
false notes under alcohol. On the other hand, muscular ALCOHOL 
25 
power is increased for a short time (up to half an hour) 
by alcohol, but later there is a corresponding loss of 
strength—as great as 50 per cent, sometimes. For sus- 
tained effort alcohol is inadvisable. Soldiers endure 
longer on the march without it, and the Germans have 
found that sugar or chocolate is superior. 
The removal of abnormal constraint and self-conscious- 
ness by alcohol may be of advantage to public speakers, 
in allowing greater freedom of speech and gestures, and in 
giving the musician greater power of emotional expres- 
sion and abandon. But the danger of overstepping the 
mark and producing stupefaction, and the greater peril 
of forming an unconquerable habit, make such use of 
alcohol unwise. 
In removing the normal restraint exercised by the 
brain over the sexual desires alcohol is the chief means of 
leading youth into immorality. This it does in two ways 
—first, by diminishing the will power, and, second, by 
increasing the animal desires—hence, “weib” is the 
natural corollary of “ wein” (“ wein, weib, und gasang”). 
The word “stimulant” is almost synonymous with alco- 
hol in the popular mind. In reference to the circulation, 
alcohol in concentration (as when whisky or brandy are 
given with an equal amount of water) stimulates the 
heart by irritating the mouth and throat. This stimula- 
tion is marked, yet lasts but a few moments. After the 
alcohol is absorbed it has very slight stimulating effect 
on the heart. 
Alcohol is no longer habitually employed as a heart 
stimulant in fevers, exhausting disease, and conditions of 
acute heart weakness (pneumonia), but is one of the best 
agents for use by the layman in emergencies, for its 
fleeting, stimulant action in faintness, after emotional 
and nervous shocks, and after accidents. But do not 26 
THE PREVENTION OF DISEASE 
give such an amount as to depress and intoxicate the 
patient, as only too frequently results from the over- 
willingness of the anxious layman. Two to four table- 
spoonfuls of whisky or brandy, with an equal amount 
of water, constitute a suitable dose. 
The action of alcohol in imparting a sensation of 
warmth to the skin, stomach, and face gives one a false 
sense of its stimulating effect. This is not stimulation, 
but dilatation of the blood-vessels. So far from being an 
evidence of stimulation, relaxation of the vessels results 
in fainting from lack of blood in the brain, if excessive. 
The injurious action of alcohol in those exposed to cold 
is accounted for by its influence on the blood-vessels. 
The lowest temperatures ever seen in the human body 
have occurred in intoxicated persons exposed to cold. 
Alcohol is tabooed in Arctic exploration on this account. 
By dilating the blood-vessels of the skin alcohol permits 
of the largest amount of cooling of the blood by external 
cold. 
There is the now classic example of the effect of alcohol 
upon an Alpine party, spending the night at a high alti- 
tude after a hard day’s climb, related by Brunton. Some 
of the party refused alcohol and turned in cold and 
miserable; others drank whisky in moderation, and 
retired feeling warmer and more comfortable; while the 
remainder partook freely and slept oblivious to all hard- 
ship. In the morning those who had refrained from 
alcohol awoke refreshed and well, those who had taken 
a small amount of alcohol found themselves cold and 
wretched, while those who had indulged freely did not 
awake at all because they were dead. 
The only time that alcohol is indicated in such cases is 
after the exposure to cold is past and when one enters a 
warm house or bed. ALCOHOL 
27 
Then one may overcome the chilliness by a glass of hot 
water and whisky, and perhaps prevent “taking cold” by 
dilating the vessels on the surface of the body, thus 
restoring the circulation to normal or equalizing the 
circulation. 
Alcohol has been truthfully called both a food 
and a poison—usually by opposing advocates. It 
is both. It may take the place of starch and fat 
as a nutrient by supplying energy in its combusion 
in the body, but without requiring any digestive 
action of the stomach. Thus, in states of severe ex- 
haustion or disease, or following great muscular or 
nervous strain, and in the aged it may be used to 
advantage as a food. 
In continued fevers alcohol is employed for this purpose 
and for its narcotic action in allaying nervousness, rest- 
lessness, and in promoting sleep. 
Alcohol excites the appetite and enables one to eat more 
than is good for him. It does not affect digestion notably, 
unless in the case of strong alcoholic liquors, which 
increase the acid of the gastric juice and favor the occur- 
rence of gastric catarrh. The starchy matters in malt 
liquors and acids in some wines may retard digestion. 
The continuous use of alcohol as a beverage must be 
condemned from the food viewpoint because it destroys 
the vital organs, produces chronic inflammation of the 
stomach, and tends toward dulness and lessened capacity 
for muscular or mental work and results in a vicious 
habit. So it is probable that those who call alcohol a 
poison are nearer the truth than those who affirm it to 
be a food. 
It is a common experience among humans, and is as 
frequently seen in experiments upon rabbits, that some 
individuals may drink large quantities of alcohol for 28 
THE PREVENTION OF DISEASE 
years without inducing perceptible deterioration of their 
vital organs. 
Others soon break down with various disorders—fatty 
degeneration of the heart, liver, and kidneys, hardening 
of the liver (cirrhosis) and arteries, Bright’s disease of the 
kidneys in some cases, and chronic catarrh of the stomach. 
Inflammation and degeneration of the nervous system are 
common—meningitis, neuritis (inflammation of the 
surface of the brain and nerves), and hardening of the 
brain and spinal cord. Great nervousness, insomnia, 
digestive ■ disturbance, or pain in the legs or elsewhere 
(neuritis) are the symptoms which bring the drinker to 
the doctor. 
To realize most poignantly the enormous number of 
persons wrecked by alcohol one should be attending 
physician at a large city hospital. 
The ordinary well-to-do and well-behaved individual 
has no means of appreciating the true significance of 
drink. Daily to see innumerable patients with delirium 
tremens and its immediate sequel (“wet brain”) in the 
more inveterate cases, with death or insanity resulting 
as a matter of course, has a most impressive influence 
upon the least thoughtful. The insane asylum is another 
splendid place to view the end-results of alcohol in the 
subject or his progeny. Alcohol renders persons less 
resistant to infections, notably consumption and pneumo- 
nia. The latter is also a peculiarly fatal disorder in the 
alcoholic. 
While scientists may differ as to many details concern- 
ing alcohol, there are some basic facts upon which all are 
agreed. These are as follows: That alcohol is not of 
benefit to any healthy person under normal conditions. 
That the habitual use of a moderate amount of alcohol, 
or the occasional use of an excessive quantity of alcohol, is ALCOHOL 
29 
damaging to the health of normal individuals. That 
while the moderate and occasional employment of alcohol 
by most persons will produce no visible harm, in others 
there is such an inherent and inborn demand for alcohol 
that it is impossible for them to take it in moderation, and 
an incurable habit results. While technically, a food, its 
intrinsic harmfulness is so great that alcohol may with 
propriety be termed a poison. It is especially damaging 
to women and children, though it may be of positive 
benefit to the aged. As a stimulant, alcohol may be used 
to advantage for its immediate effect in reflexly stimu- 
lating the heart in emergencies (through its irritation of 
the mouth and throat before absorption). Its use as a 
stimulant after absorption from the stomach has been 
given up because such action does not exist to any extent. 
It is not a stimulant, but a stupifier of the nervous system, 
and its medicinal influence in this direction is taken 
advantage of for the production of sleep and quieting 
nervous excitement and restlessness. Its frequent use 
for any reason is dangerous in establishing a vicious 
habit. 
Perhaps one of the most inpressive statements concern- 
ing the effect of a moderate use of alcohol is found in that 
made by the actuary of the New York Life Insurance Co., 
who affirms that among the deaths of 2,000,000 policy- 
holders during a period of twenty-five years the “ total 
abstainers have a mortality during the working years of 
life of about one-half that among those who use alcohol to 
the extent of at least two glasses of whisky daily.’’ 
The world-wide prohibition movement depends upon 
the exact knowledge of alcohol derived from the experi- 
ments and experience of the medical profession, and its 
altered attitude in respect to the use of alcohol, more than 
upon any other factor, 30 
THE PREVENTION OF DISEASE 
TOBACCO 
Tobacco is essentially a narcotic. In large amounts 
narcotics (as bromids, opium, alcohol) produce stupor and 
unconsciousness, but in small doses are sedative and sooth- 
ing. Thus it is with tobacco. The narcotic influence is 
exerted upon the brain. The action of tobacco upon the 
circulation consists first in slowing and strengthening the 
heart and contracting the blood-vessels, but this effect is 
soon followed by depression and increased frequency of the 
heart and dilatation of the blood-vessels. After action 
comes reaction, and long after the influence of tobacco just 
described has worn off there is a period of nervous irrita- 
bility and instability. 
This is the “morning after” phenomenon, as seen fol- 
lowing excessive smoking, more especially when the habit 
is suddenly stopped. 
The ill effects of the abuse of tobacco are well established 
ed and are briefly as follows: (1) Disturbance of the cir- 
culation. This is more commonly evidenced by pain 
about the heart and a feeling of fluttering or beating in 
this region, with shortness of breath on exertion and rapid, 
irregular pulse. In some cases the pulse may be slow and 
the blood-pressure unusually low. (2) Disturbance of 
the nervous system. Headaches, dizziness, and a 
tremulous condition of the hands are often observed. 
Lack of energy and ambition, together with nervous 
irritability and mental depression, result from overuse of 
tobacco. (3) 'Various forms of indigestion may be 
occasioned by excessive smoking, particularly that 
accompanied by increased acidity in the stomach and 
heart-burn. (4) The paralyzing action on special nerves. 
This is occasionally seen in partial blindness or deafness, 
owing to the direct action of nicotin upon the optic or TOBACCO 
31 
auditory nerves. In this form of blindness the patient 
can see better in a dim light. (5) Local action of tobacco 
smoke. Tobacco smoke irritates the throat and also 
the eustachian tubes, which connect the upper part of 
the throat with the middle ear. In this way deafness 
from catarrh of the middle ear is not infrequently pro- 
duced by excessive smoking. 
Cigarette smokers have often a loud, ringing or barking, 
dry cough, with harshness or hoarseness of voice from the 
effects of the smoke upon the vocal cords. Then, in 
so-called “smoker’s tongue” there are formed white, 
patches (leukoplakia) not only on the tongue, but also 
upon the inside of the cheeks in some cases. One of 
these patches is very prone to become cancerous after 
years unless smoking is stopped and treatment begun. 
Cancer of the lower lip, seen almost wholly in men, is 
thought to be due to pressure of a pipe-stem. Of course, 
it goes without saying that these troubles are not fre- 
quent occurrences in individual smokers, or the habit 
would soon lose favor, but, in the aggregate, there are 
great numbers of such cases. One can never tell where 
the lightning will strike. The disorders caused by 
tobacco are usually cured by complete abstention from 
its use, and by living in a healthy manner, with plenty of 
outdoor exercise and sleep. 
But, since these troubles may also be attributed to 
other causes, it will be impossible for a doctor to be sure 
that tobacco is the source of any disorder until after 
complete abstention from the weed for weeks. 
There are still other serious physical and moral dangers 
threatening the young who use tobacco. In a study of 
the students at Yale and Amherst it has been found that 
smokers are stunted in height, weight, and chest measure 
as compared to non-smoking students. Meylan, at 32 
THE PREVENTION OP DISEASE 
Columbia, concluded from a careful investigation that 
the use of tobacco among the students leads to idleness, 
lack of application, ambition, and scholarship. 
Charles B. Towns, who is the most celebrated specialist 
in drug habits in this country, insists that the harm done 
by tobacco is greater in the aggregate than that from alco- 
hol, cocain and opium, and that “nothing else at the pres- 
ent time is contributing so surely to the degeneration of 
mankind as tobacco.” 
This may seem like an extreme statement, but Towns 
finds that he can rarely cure the alcoholic unless the 
patient gives up smoking, because the smoker finds that 
alcohol is necessary to relieve the irritability and nervous 
depression caused by the excessive use of tobacco. 
The bad moral effect of tobacco upon boys is brought 
about in various ways. They are often forced to smoke 
surreptitiously, and to do this frequent the tobacco 
shop, pool, or barroom, where they obtain cigarettes 
and are naturally dragged downward by their surround- 
ings. 
A few words as to the composition of tobacco and the 
effect of different methods of using it. The chief constit- 
uent is one of the most powerful poisons known (nicotin), 
an oily, colorless, pungent, volatile liquid, existing to the 
extent of from 1 to 7 per cent, in tobacco. Virginia 
tobacco is one of the strongest. The taste and flavor of 
tobacco depend upon the development of a volatile oil in 
the curing. The injury arising from tobacco is due to 
nicotin and allied substances (pyridin and collidin), and 
also to furfurol, an ingredient of fusel oil in raw whisky, 
which causes the headache and other bad after-effects. 
But much of the nicotin is destroyed by its combustion in 
smoking, and there is said to be no furfurol in most of the 
Turkish tobacco (“London Lancet”). TOBACCO 
33 
The harmfulness of smoking depends in part upon the 
amount of nicotin in the smoke. There is least in cigar- 
ette smoke and most in pipe smoke, while the smoke from 
cigars occupies an intermediate place. It has been found 
that even when the same amount of tobacco is smoked in 
the form of a cigarette and cigar, and the cigarette 
tobacco is much the richer in nicotin, the resulting 
cigarette smoke contains considerably less nicotin than 
the smoke from the cigar. This follows because in the 
cigarette the tobacco is finer and drier and in a form to 
burn completely. In the cigar, especially if green and 
moist, the nicotin volatilizes in the damp area behind 
the flame and is inhaled in the smoke. The black, 
moist, acrid mixture of tobacco and saliva in the bowl of 
an old pipe distils off its nicotin when it becomes hot 
and produces the strongest smoke. The thinner and 
drier a cigar, the milder it is, because of its more com- 
plete combustion. 
But cigarettes are most pernicious in their general 
results chiefly because they are so mild that their smoke is 
almost always inhaled. Inhalation increases the effect 
of nicotin many times. The area with which the smoke 
comes in contact in the lungs is enormous, and the lungs 
are made for absorption of gas (air), and the action is 
extremely rapid. 
The opium habitue long ago discovered that he got 
more speedy and effective action by smoking than by 
swallowing the drug. Then, again, the cheapness and 
mildness of cigarettes causes them to be smoked at all 
available moments, when a pipe or a cigar would require 
too much time or expense. This applies particularly to 
boys, who now take more frequently to cigarettes, 
when formerly they would have had to smoke cigars or 
pipes. The danger of the overwhelming nausea and 34 
THE PREVENTION OF DISEASE 
depression, and the expense involved in the use of these, 
was a great natural preventive which has been done 
away with in the introduction of the cigarette. 
Cigarettes are most injurious, then, on account of the 
custom of inhaling their smoke and the temptation to 
smoke them continuously. There is about as much 
tobacco in one cigar as in five or six cigarettes. 
Smoking is partly a narcotic, or drug habit and partly 
a psychic habit. The narcotic effect is seen in its sooth- 
ing, comforting action, in its relieving anxiety and worry, 
and inducing a pleasant frame of mind. Its psychic 
influence is brought about by holding an object in the 
mouth (as is seen in the marvelous influence of sucking 
a blind nipple in the case of an infant), by the rhythmic 
inhalation and exhalation of the smoke, and by the hyp- 
notic effect in watching the smoke curl into fascinating 
and fantastic shapes and rings. 
The physiologic demand of the system for tobacco is 
not so great as that for alcohol, cocain, or opium in 
habitues. In other words, on stopping the use of tobacco 
part of the craving is psychic, and this may be relieved by 
chewing gum, gentian, quassia, or lovage. The actual 
demand of the system for the drug effect of tobacco can 
then be resisted without great force of will, except in the 
case of the inveterate smoker. One who smokes one 
cigar daily after dinner maybe classed a moderate smoker. 
The harmful effect of smoking is much less after a hearty 
meal. 
The most practical result of smoking is lessened personal 
efficiency. Towns goes so far as to state that smoking 
diminishes the efficiency of an individual about 15 per 
cent. Smoking is indubitably opposed to the highest de- 
velopment of vigor and energy, or “pep,” to use the pic- 
turesque slang of the day. This result must be presented OPIUM AND COCAIN 
35 
forcibly to the youth who naturally desires to succeed in 
business and sports. 
Tennis and billiard players know that smoking inter- 
feres with their accuracy of play and nervous power. 
The matter of tobacco is in like case with other harmful 
habits, for no sensible person will affirm that smoking 
improves the health. Then it simply becomes a question 
as to how much injury tobacco does. This depends upon 
the personal constitution, the amount of nicotin absorbed, 
and the occupation. Its effects may be imperceptible in 
a parent, and yet lead to defective nervous organization 
in the offspring, as is indisputably true of alcohol. If we 
are smokers, we must confess ourselves fools to our sons 
in order that they may improve upon their fathers. 
OPIUM AND COCAIN 
Prevention of the morphin and cocain habits lies 
largely with the medical profession. Morphin is taken 
by means of the hypodermic syringe in most cases. It is 
first given by physicians for the relief of pain. After 
morphin has been administered for a month the patient 
has acquired the habit and will need outside assistance 
to free himself from it, even if he is no longer in pain from 
other causes. Statutes to prevent the purchase of the 
hypodermic syringe should be enacted. Only in New 
York at present does such a law exit, owing to the 
benevolent energy of Charles B. Towns. Physicians 
should hesitate to inject morphin except for unbearable 
pain of short duration. They should never entrust a 
patient with a hypodermic syringe except under most 
unusual circumstances. There appear to be over 100,000 
opium habitues in the United States, averaging over 8 
grains of morphin as a daily dose. 36 
THE PREVENTION OF DISEASE 
The cocain habit is begun because of the exhilaration 
and relief afforded when the drug is used by doctors for 
treatment of cold in the head or other nasal troubles. 
It is very stimulating for a short time, and depression, 
which follows within about twenty minutes, excites a 
demand for more. It is the most difficult of all habits to 
break. Patent remedies containing morphin and cocain 
are also responsible for initiating the habit. 
Members of the underworld acquire the morphin and 
cocain habits from association with habitues. It is pos- 
sibly kinder to the race to let them perish as soon as pos- 
sible. Most of the other thousands of drug addicts in this 
country are to be pitied and deserve treatment at the best 
hands. Their suffering is incredible, and nobody desires 
a cure more than the patient himself. CHAPTER II 
PERSONAL HYGIENE (Continued) 
Care of the Teeth and Mouth: Pyorrhea (Riggs’ Disease). 
Hygiene of the Digestion: Causes of Indigestion, Cooking, Value 
of Food Elements, Meat, Fish, Milk, Eggs, Cereals, Fats, Vegeta- 
bles, Fruits, Vegetarian Diet, Salt, Necessity of Water, Purity of 
Water and Ice. 
CARE OF THE TEETH AND MOUTH 
The care of the teeth and mouth has taken on a new 
significance of late owing to great progress in treatment of 
abnormal conditions, and because it has become evident 
that inflammations in the mouth—including decay of the 
teeth, and inflammation of the gums and tonsils—are the 
cause of many serious remote diseases. These include 
acute rheumatism, chronic joint diseases, heart disease, 
etc. In fact, because of the importance of this subject 
a separate chapter is devoted to it in another place (see 
p. 194). 
Care of the teeth has hitherto been chiefly directed 
toward the prevention of decay, but it is of the greatest 
consequence that irregularities of the teeth and jaws 
should be avoided in childhood. 
It is thought that mouth breathing due to adenoid 
growths, so common in children, produces a narrow upper 
jaw with a high or gothic roof of the mouth, and it is 
also probable that our use of soft, prepared foods in 
modern life leads to disuse of the jaws and their muscles, 
so that the jaws are not large enough to contain the 
37 38 
THE PREVENTION OF DISEASE 
teeth. It is certainly a striking fact that the fine, large, 
impressive jaws of our ancestors are not so commonly 
seen today. The first teeth must be watched so that 
the second teeth may come regularly, or otherwise 
deformity of the jaw may be produced. Too early or 
late loss of the first teeth disturb the eruption of the 
permanent teeth. If one jaw is narrow, its teeth will 
not meet those of the other jaw, and the deformed jaw 
must be spread by the dentist. A narrowing of the 
upper jaw, with high, arched roof of the mouth, inter- 
feres with the breathing through the nose, and may 
thus lead to adenoid growth and pinched nostrils. 
Tonsils and a'denoids must be removed to prevent exten- 
sion of inflammation from them into the eustachion tubes 
which lead to the ears. Deafness in children, recur- 
ring colds, abscess of the ears, and mastoid disease of the 
bone of the skull behind the ears are usually caused by 
diseased tonsils and adenoids. 
Protrusion of the teeth of the upper jaw may be 
induced by the habit of thumb-sucking in infants. Extra 
or supernumerary teeth constitute another cause of 
irregularity of the jaws. One must pay particular atten- 
tion to the teeth during the period from the seventh to 
fourteenth years of childhood, as this is the time for the 
dentist to care for the first teeth and prevent their early 
decay, or straighten the teeth by methods which have 
reached such a state of perfection that they have become 
a specialty (orthodontia). Irregularities of the teeth 
produce spaces in which food lodges and thus favor 
decay. It has only recently been recognized by dentists 
that the prevention of decay is attained chiefly by 
regularity and perfect polish of the teeth. If the surface 
of the enamel is wholly free from irregularities and 
roughness there is no chance for food to stick to them and CARE OF THE TEETH AND MOUTH 
39 
one might almost do without a tooth-brush. The 
advance in this branch of dentistry has been so great 
that now there are dental (prophylactic) assistants who 
spend their whole time in polishing the teeth, removing 
tartar, etc. This is the ideal method of caring for the 
teeth, and the children of the present day will have their 
children treated in this way. A person should visit a 
dentist every month for this purpose, and although this 
seems a costly and onerous duty, yet the ultimate saving 
in health, suffering, and money will easily pay for the 
extra trouble required. 
The teeth should properly be brushed after each meal 
and certainly once daily, before bedtime, as that is most 
important in preventing a long delay of food on the teeth. 
The brush should be rather soft, so as not to injure the 
gums, and have bristles of varying length to reach into 
irregular spaces. The toothbrush should not be moved 
backward and forward like a saw across the closed teeth 
but, with the mouth open, strokes should be made in one 
direction downward across the gums and teeth of the 
upper jaw, both on their inner and outer surfaces. In 
the case of the lower jaw the strokes should be made 
upward across the inner and outer aspects of the gums 
and teeth. These motions do not tend to wear away 
the free edges of the gums as in the usual saw-like motion 
with the teeth closed but, on the contrary, aid in over- 
coming the tendency of the gums to draw away from the 
teeth which naturally occurs in later life. Dental 
floss and toothpicks may injure the gums and should 
only be used when absolutely required. Twice a week 
the enamel should be rubbed smooth with a soft orange 
tick and tooth powder, unless one has the teeth cleaned 
regularly by a dentist, which is preferable. For the pro- 
duction of strong teeth and good jaws in children proper 40 
THE PREVENTION OF DISEASE 
nutrition is after all the chief essential. This means 
especially an adequate supply of lime salts obtained 
most satisfactorily by giving children at least a quart of 
milk daily and an abundant supply of leavy vegetables, 
as spinach and lettuce, in addition to ordinary food 
(McCollum). 
Riggs’ Disease.—Very common in adult life is Riggs’ 
disease (or pyorrhea alveolaris), an inflammation of the 
membrane (peridental membrane) which surrounds the 
roots of the teeth beneath the gums. 
It always begins, however, as an inflammation of the 
free border of the gums where they join the teeth. As the 
mouth usually contains some fifteen varieties of bacteria 
(including the pus germs or staphylococci and strepto- 
cocci), besides many other accidental organisms, there is 
only required some mechanical injury to the gums for 
inflammation to follow. First, the essential cause, the 
pus germ; and next, the predisposing cause, usually local 
irritation or general disease with reduced vitality of the 
gums. Recently it has been claimed that Riggs’ disease 
is always due to a special germ (entameba) which may 
readily be destroyed by a special remedy (ipecac), but 
this is incorrect. 
Among the common causes of irritation of the gums, 
and so Riggs’ disease, are poor dentistry, allowing spaces 
to occur between the teeth in which food may collect; 
ill-fitting crowns and bridges; and the accumulation of 
tartar on the teeth at the edge of the gums. Constant 
preventive care of the teeth by a competent dentist 
will avert all these causes of inflammation of the gums, 
which, nevertheless, occurs in 95 per cent, of adults 
(Black). Other causes of gum inflammations are the use 
of toothpicks, hard tooth-brushes, hot soup, tea or coffee, 
and injuries from sharp teeth and hard food. Bright’s CARE OF THE TEETH AND MOUTH 
41 
disease, tuberculosis, diabetes, and old age favor 
inflammation of the gums by reducing resistance of 
the tissues. 
Some swelling of the gums occurs which give rise to a 
space or pocket between the gum and the tooth. The 
formation of a pocket in the gum is most favorable for the 
growth of germs. The gums then become red and 
swollen and more or less painful, and matter or pus may 
be pressed out from these pockets as a small, whitish bead 
on the edge of the gums. If Riggs’ disease is allowed to 
progress, the inflammation extends down along the 
membrane and hard substance (cement) covering the 
roots of the teeth, the gums recede, the roots of the teeth 
are exposed, and the teeth loosen and ultimately drop 
out. An acute and chronic form are seen. The acute 
form occurs in fevers and other special infections or may 
be excited by local irritation from any of the causes noted 
above. The chronic form is much more common from 
the irritation of food between the teeth, bad dentistry, 
etc., as noted. 
As germs may be absorbed from the inflamed gums and 
pass through the blood into most remote organs, there 
giving rise to most serious disease of the heart, joints, kid- 
neys, stomach, gall-bladder, appendix, etc. (p. 285), the 
prevention and cure of Riggs’ disease is most important. 
Prevention and cure go hand in hand. All means of 
preventing irritation of the gums are essential, and there- 
fore the avoidance of very hot food and the use of tooth- 
picks, and injury to the gums by stumps of teeth, ill- 
fitting crowns, and bridges. The constant cleaning of 
the teeth (by a dentist) to prevent the accumulation of 
tartar, and skilful dentistry to avoid spaces between the 
teeth for collection of food, etc., are essential. When the 
disease has actually appeared the dentist removes tartar 42 
THE PREVENTION OF DISEASE 
from the teeth, and if there are pus-pockets in the gum he 
must treat these so the lining of the pocket is destroyed, 
that union between it and the membrane surrounding 
the root of the tooth may occur. No tooth should be 
treated (except to remove tartar from the neck of the 
tooth) unless there is a pocket in the gum. If this were 
attempted the dentist would actually make pockets which 
did not previously exist. But, when all is said and done, 
the treatment of pyorrhea is very unsatisfactory. The 
pus-pockets may be made cleaner and the condition 
alleviated, not cured. The teeth are more or less 
destroyed and cannot be made whole again. In bad 
cases, with great recession of the gums, exposing largely 
the roots of the teeth, only extraction will cure. Preven- 
tion in treating the early inflammation of the gums by 
efficient dentistry (which means constant supervision 
of the teeth) is the chief desideratum. 
Finally, it may be desirable to treat the secondary 
infection with pus germs by the injection of vaccines 
(made from killed cultures of these germs) in bad cases 
with puspockets. 
HYGIENE OF THE DIGESTION 
Digestion should begin in the mouth; that is, the prepa- 
ration of food for absorption should begin in the mouth 
through proper chewing, thus mixing the food with 
saliva, which digests cooked starchy food. This takes 
place chiefly during the first half-hour or so after arrival 
of food in the stomach, because the stay in the mouth is 
too short. After this time the acid gastric juice saturates 
the food in the stomach and stops the action of saliva. 
The digestion of unboiled starch by saliva is slight, and 
such largely passes through the intestines unchanged 
and may produce digestive disturbance, as seen in feeding HYGIENE OF THE DIGESTION 
43 
raw bananas to infants or after eating raw chestnuts and 
vegetables. Dogs have no digestive substance or ferment 
(ptyalin) in their saliva, and it is thought that the main 
use of saliva consists in moistening food and facilitating 
chewing and swallowing. When food is swallowed in 
lumps they irritate the stomach and are not readily 
permeated by gastric juice. The x-ray has shown that 
one harm in hasty eating lies in too rapid distention of the 
stomach with food and air, which may produce pain. 
Fletcherizing of food, on the other hand, is undesirable, 
and some disorders of the stomach are attributed to too 
prolonged mastication. 
The necessity for the presence of a large proportion of 
the teeth in order that chewing may be properly accom- 
plished is usually accepted, and the loss of most of the 
opposing teeth has been considered a fruitful source of 
indigestion. One of the leading medical authorities of 
this country (Richard Cabot) affirms that he has never 
seen a case of indigestion he could attribute to loss of 
teeth. The mouth is inhabited by germs, and fifteen to 
thirty varieties have been found in it. What is much 
more important (according to Charles Mayo), pus germs 
exist in 80 per cent, of mouths (staphylococci and strepto- 
cocci), and these are usually responsible for the inflamma- 
tion of gums and tonsils and abscesses about the teeth, 
and they may enter the blood and cause serious diseases 
of the most vital organs (see p. 194). Moreover, the 
saliva should normally be neutral or alkaline, but prob- 
ably over 80 per cent, of people have mouths which are 
not healthy (presence of pus germs), and these are apt to 
have an acid reaction in their saliva. Acid secretion is 
irritating and there is even danger of cancerous growth in 
the mouth from prolonged influence of acid. The 
healthy mouth is of great importance and largely depends 44 
THE PREVENTION OF DISEASE 
upon proper care of the teeth and throat (modern den- 
tistry and removal of adenoids and diseased tonsils). 
Causes of Indigestion.-—In another place we have 
taken this matter up in detail. There we have divided 
the causes of indigestion into four categories. It is in 
connection with the cases of faulty physique, and in those 
with inherited nervous weakness, that disturbance of 
digestion from slight causes is likely to occur. These 
constitute about one-third of all cases of dyspepsia, and 
are classed under nervous indigestion, but really due 
to displacement of the stomach and intestines. 
Any extra strain borne by the nervous system, as anx- 
iety, worry, overfatigue, lack of exercise or work, abuse of 
tobacco, tea or coffee, sexual excesses, insomnia and 
emotional excitement, especially near or at meal times, 
favor the incidence of dyspepsia in such persons. 
Among causes of indigestion to which all are susceptible 
may be named overeating, irregularity in the time of 
eating, improperly cooked or unpalatable food, un- 
pleasant surroundings, hasty eating or eating alone, 
which is often the same thing, and abuse of alcohol. 
Drinking large amounts of water at meals dilutes the 
digestive juices and is undesirable. The desire for food, 
which includes appetite, palatability, and all the circum- 
stances which make eating pleasant, as attractive service, 
agreeable company, a care-free mind, etc., have the most 
important influence upon digestion. Indeed, it has been 
found experimentally that “as the mouth waters” in 
anticipation of food, so does the gastric juice flow. 
A piece of meat held before a dog which he cannot 
swallow, or a piece that is swallowed but escapes into the 
outer world through a false opening in the gullet, will 
produce as much primary flow of gastric juice as if the 
food entered the stomach. HYGIENE OF THE DIGESTION 
45 
Therefore the first phase in the secretion of gastric 
juice is brought about wholly through the nervous 
system by the desire for food. It can be readily appreci- 
ated how unpleasant emotions may have the opposite 
effect and check the nervous secretion (through the vagi) 
and so digestion. The second phase of secretion and 
digestion in the stomach is due to the presence of food in 
the stomach. There is a wonderful automatic mechan- 
ism by which the stomach contents escape and the 
intestinal secretion is regulated. As soon as a jet of the 
acid fluid contents of the stomach escapes into the small 
intestine (in which the secretion is alkaline) the acid in 
the bowel stimulates a nervous action, so that the outlet 
of the stomach closes until the gastric juice is neutralized 
by the alkali in the bowel, when the outlet again relaxes 
and another jet of stomach contents flows into the intes- 
tine. Thus, there is a continual automatic opening and 
closing of the stomach outlet during stomach digestion. 
But this is only part of the effect of the acid on the bowel, 
for each time that acid flows from the stomach into the 
bowels it causes the formation of a substance (secretin) 
in the wall of the intestine. This is absorbed into the 
blood and stimulates the secretion of bile and of the gland 
(pancreas) emptying alkaline juice into the intestine. 
This chain of events continues until the stomach is 
empty, and thus the flow of alkali is automatically 
regulated by that of acid. 
The two great factors in digestion are secretion and 
movements of the stomach and bowel pressing the con- 
tents along. The state of secretion in the stomach is 
precisely known by examination of the stomach contents, 
while the movements of the stomach and bowels are seen 
by use of the x-ray. These two methods of diagnosis are 
indispensable in chronic indigestion. Normal move- 46 
THE PREVENTION OF DISEASE 
ments of the stomach consist of wave-like contractions, 
originating every ten to twenty seconds after the food 
enters the organ, serving to mix the contents with the 
gastric juice and propel them on into the bowel. 
Intestinal digestion is brought about by the entrance 
of alkaline digestive juice from the pancreas and bile 
from the liver, through a duct about as large as a pencil, 
entering the intestines a few inches below the stomach 
outlet. The walls of the intestines themselves furnish 
an important secretion besides. Intestinal digestion is 
more important than that in the stomach, because all 
elements of food are digested by the alkaline juice here, 
while in the mouth the cooked starches are only partly 
digested and in the stomach only proteins. Moreover, 
an animal may live with a large part of the stomach 
removed. When through surgical operation an artificial 
passage exists between the small intestine and the outside 
of the body, so as to drain off its contents, death speedily 
occurs with great emaciation. 
Cooking has, of course, an enormous influence in in- 
creasing the digestibility of most food. In vegetables 
there is a large amount of starchy matter. By heat the 
enveloping membrane of the starch granules is ruptured 
and the starch thus is put in a state to be readily acted 
upon by the digestive juices. Frying food in a fry- 
ing pan (sauteing) tends to saturate it with grease and to 
make it denser and harder, while frying in deep boiling 
fat (at 200° F.) causes an instant hardening of the surface 
in a uniform coat that, with the steam generated by the 
moisture inside, keeps the food from being saturated with 
fat. When a food is saturated with fat the digestive 
juices cannot penetrate or act upon it readily, so that 
frying in deep fat is preferable to sauteing. Pastry is 
indigestible owing to its richness in fat. Broiling is, on HYGIENE OF THE DIGESTION 
47 
the whole, better than frying, therefore, and baking is 
preferable to boiling by keeping in the flavoring substances 
which may be dissolved out in boiling. When meat or 
fish are to be roasted, broiled, or fried, a high temperature 
should be applied in the beginning that an immediate 
coating be formed to retain the natural juices, while the 
cooking may be continued with more moderate heat. In 
making stews or soups the opposite course is proper. 
In making stews the meat is placed in enough cold 
water to cover it, and it is allowed to cook very slowly 
until it reaches the boiling-point, and then is removed to 
the back of the stove to simmer till thoroughly tender. 
In order to extract all the juice from meat for soup or 
beef-tea it is cut up and placed in cold water, or water at 
a simmering point, for several hours. 
If food is taken very hot or cold the activity of the 
gastric juice somewhat impaired. 
In the process of digestion the food is rendered fluid and 
soluble so that it may be absorbed by the blood-vessels 
of the intestines. There is practically no absorption of 
food or water in the stomach which pass on into the bowels. 
The undigested and unabsorbed food is gradually propelled 
by the movements of the intestines, and the watery 
portion absorbed, so that it becomes a soft solid mixed 
with cast-off cells from the lining mucous membrane and 
bacteria (composing a large proportion of its bulk) in 
the lower or large intestine. A food is as much outside the 
body when in the stomach or bowels as if it were on the 
skin, so far as its nutritive value is concerned, unless it 
becomes digested and absorbed. Four requirements are 
essential in a complete diet. 
1. Sufficient protein in amount and quality to provide 
material for growth in the young and to replace that lost 
at all ages by wear and tear of the tissues. 48 
THE PREVENTION OF DISEASE 
2. A supply of sufficient energy or heat to furnish 
that required for maintenance and work. 
3. Mineral salts to replace those lost in the feces and 
urine and to supply what are required for growth of bone 
and tissues. 
4. An adequate supply of those essential substances of 
unknown composition in food called vitamins. 
Vitamins.—In natural foods there are essential sub- 
stances, or vitamins, without which human beings and 
animals sicken and die. They are absolutely required 
by the young to aid growth (vitamin A and B), and for 
nursing and pregnant women for the same reason because 
they are only derived from food. 
If foods are made chemically pure, overheated, salted, 
dried or otherwise preserved these vitamins may be 
destroyed. Their composition is unknown. Their value 
has been discovered by their absence. That is people 
living on food lacking vitamins develop what are now 
(for past 15 years) well recognized as deficiency diseases. 
Three vitamins are known. They are distinguished 
as vitamin A, B, and C. Fat soluble vitamin A is 
present especially in whole milk, butter, eggs, and in 
fresh green vegetables. Cod liver oil is particularly 
rich in it but it is lacking in vegetable oils and skim milk. 
Water soluble vitamin B is contained in a great variety 
of food, as in the hulls and germs of grains, in meat, 
eggs and milk, but is absent in white flour and polished 
rice. Yeast is markedly rich in vitamin B. The use of 
whole wheat flour or other whole meal flour for bread 
will furnish this vitamin. 
Vitamin C or antiscurvy vitamin, occurs chiefly in 
raw fruits and vegetables. The juices of the orange, 
lemon, and tomato are notably rich in vitamin C. 
Scurvy results from its absence in food. Vitamin C is HYGIENE OF THE DIGESTION 
49 
practically destroyed by cooking, canning and salting. 
Therefore when children are fed boiled or pasteurized 
milk it is esential to supply orange juice daily to avoid 
scurvy. 
Vitamin A and B withstand cooking better, than vita- 
min C. However canned goods contain no vitamins 
owing to the intense heat used in their preparation. 
Vitamin B is not destroyed in baking bread or drying 
milk so that milk powder contains vitamin B while 
deficient in vitamin C. In addition to other food adults 
should take daily the year round one quart of milk, and 
green raw vegetables in salads, to secure sufficient vita- 
mins, lime salts, and the optimum of nutrition. When 
persons live on an unusual and narrow ration, as in 
camps, remote regions and on shipboard, in certain com- 
munities, and in the case of babies and nursing and preg- 
nant women who especially require vitamins, the matter 
becomes of importance (See Deficiency Diseases). 
The elements of food, or nutrients, as they are called, 
consist of carbohydrates (starches, sugars, and vegetable 
fiber), fats, proteins, salts, and water. Any food contain- 
ing all these in proper proportion to support life indefi- 
nitely is called a complete food. Milk is perhaps the best 
example of a complete food, but contains too much water 
for an adult. The curd of sour milk (from which the 
watery portion is squeezed) consists of casein, and is an 
example of a pure protein or nitrogenous substance. 
Butter is almost the pure fat of milk, and there is about 
as much carbohydrate, in the form of sugar, as protein 
and fat in milk (4 per cent, of each roughly). Proteins 
are represented in animal food by lean meat, the curd 
of milk, and eggs, which also contain in the yolk con- 
siderable fat. Vegetable food also contains protein, but 
not so much, in proportion to its bulk, as meat and eggs. 50 
THE PREVENTION OF DISEASE 
So to get as much protein nourishment in a vegetable 
as in a meat diet one has to consume more than is com- 
fortably possible—without the addition of cheese, eggs, 
and milk. The nearest approach to meat, in vegetable 
food, are dried peas and beans and nuts, and these contain 
approximately the same amount of protein as meat 
(about 20 per cent.). But meat is more digestible and 
less bulky than peas or beans, for the percentage of 
protein is estimated by weight. Bread contains about 
8 per cent, of protein. Boiled eggs contain about 13 per 
cent, of protein, but cheese contains 25 to 30 per cent, and 
is readily digestible. Oatmeal is also rich in protein (16 
per cent, in dry meal), but when boiled the percentage of 
protein is low on account of water (about 3 per cent.). 
The role of protein consists in supplying material to 
replace the waste of tissue in a constantly running 
machine and in forming new tissue in the growing person. 
The mechanism of the animal body is always “running,” 
and an animal at rest is like a motor-car at a standstill 
with the engine moving. Therefore the animal at rest 
requires as much protein, as at light work, for repair of 
the machine. 
Exposure to severe cold, hard work, growth, pregnancy, 
and lactation all demand an extra supply of protein. 
Protein, besides supplying material for building new 
tissue, yields heat and energy by being burnt up, chiefly 
in the muscles. It may also be transformed into sugar 
and fat, and a dog may live on lean meat for months and 
gain in weight. 
The amount of protein requisite for growth and to 
replace wear and tear of the bodily machine varies from 
3 to 5 ounces daily. Three ounces for sedentary persons, 
4 ounces for those doing moderate work, and 5 ounces for 
those performing arduous labor. HYGIENE OF THE DIGESTION 
51 
The value of proteids depends upon the various (18) 
amino acids they contain. Some amino acids are essential 
for construction of some tissues, other amino acids for 
other tissues. 
For this reason milk proteids have 3 times the value of 
cereal proteids. Even in the same article of food there 
are often several proteids. 
In milk, casein, albumin and globulin; in wheat, gliadin 
and glutenin. The most economical and therefore 
valuable combination of proteids exists in meat, eggs, and 
milk. 
Persons obtaining their chief supply of protein from 
some vegetable food are apt to suffer from one of the 
deficiency diseases. 
Meat. -Proteins constitute the most expensive element 
in foods, particularly the concentrated form in which they 
exist in meat, fish, and eggs. Looking at meat in another 
way, it is the essence of nutriment extracted from vege- 
tables. Lean meat is practically all protein, except water 
75 per cent. Comparing the different meats, we find beef 
contains the most nutriment, but its coarser fiber 
makes it a little harder to digest than lamb or mutton. 
Mutton is more unpalatable than beef as a constant diet 
because of its stronger flavor. Beef streaked with fat is 
juicier and more palatable than lean meat. Very dark 
beef has not been bled or is diseased, while pale beef is 
not sufficiently hung—both are undesirable. Veal is as 
digestible, although slightly less nutritious, than beef, 
mutton, or lamb. If veal is pale and soft it is too young 
(under a month), but if pale alone the animal has pro- 
bably been bled to death. 
Pork, although a most nutritious meat on account of its 
fat, is rather indigestible and not fit for children or those 
with weak digestion. Bacon, on the contrary, is both 52 
THE PREVENTION OF DISEASE 
highly nutritious and digestible and stimulates the appe- 
tite. It is the most suitable form of fat (with cream and 
butter) to build up thin persons and the debilitated with 
feeble digestion. 
One often hears a great distinction made between light 
(veal, chicken) and dark meat, the former being advised 
by some physicians in place of red meat in rheumatism, 
gout, Bright’s disease of the kidneys, hardening of the 
arteries, etc. 
There are certain nitrogenous bodies derived from pro- 
teins which are thought to put more work on the kidneys, 
liver, etc., and, therefore, are undesirable in disease of 
these organs. These bodies are extractives and purins. 
Extractives give flavor to meat and exist in large amounts 
in meat extract, clear soups, and broths. They possess 
very little nutritive or energy value, but stimulate the 
nervous system, appetite, secretion of digestive juices, 
and the combustion of other foods in the body. Purins 
are also nitrogenous and protein-like substances which 
arise from the cells of animals and plants. Sweetbreads, 
liver, brain, kidneys, fish-roe, caviar, meat extracts, and 
broths are particularly rich in purins. Among vege- 
tables, dried peas and beans abound in purins, but are 
free from extractives. Vegetables contain no extractives 
found in meat. As a rule, vegetables are comparatively 
poor in protein and purins, especially green vegetables 
and roots, as water is their chief ingredient. Thus, there 
is 75 per cent, of water in boiled potatoes and 97 per cent, 
in boiled cabbage. Fish is free from extractives, though 
almost as rich in proteins and purins as meat. A purin- 
free diet consists of eggs, milk, butter, cheese, sugar, 
bread, rice, macaroni, green vegetables and fruit, and 
this is the diet that is preferable where we wish to exclude 
the proteins considered most harmful in gout, rheuma- HYGIENE OF THE DIGESTION 
53 
tism, Bright’s disease, arteriosclerosis, and uric-acid 
stone. The extractives are normally the chief source of 
the principal waste-product from proteins in the urine 
(urea), and purins are normally the source of the other 
main protein waste-product (uric acid). While light 
meat of veal contains less extractives, it holds more 
purins, as does the flesh of most young animals, and the 
difference in the action of light (veal, chicken, and turkey) 
and dark meat is negligible. Fish is preferred to meat in 
some conditions as containing slightly less protein 
matter than meat, and no extractives. By many 
persons fish is considered more digestible than meat. 
In general, meat has been found more digestible by 
Chittenden. Fish containing much fat, as salmon, 
mackerel, and halibut, are more nutritious but less 
digestible than cod, haddock, flounder, and sole. For 
working men fat meat (like pork) is a most efficient form 
of protein. 
The matter of diet stands out saliently as one about 
which doctors disagree. Nevertheless, normal persons 
gain nothing by living on a purely vegetable diet. Vege- 
tables are, as a rule, less readily digestible and less stimu- 
lating to the nervous system, appetite, and digestion than 
meat and are much more bulky. The bulk, however, is 
often of great value in those disposed to constipation. 
Limiting the amount of protein (fish, meat, and eggs) is 
only permissible in adult healthy persons and should 
never be practiced in the young. Even in the life of 
sedentary people, one of the great living physiologists 
(Starling) affirms that an almost exclusive protein diet 
may be more suitable than a regimen of sugars and star- 
ches and sugars (carbohydrates), because these require 
oxidation for their combustion in the body and that is 
chiefly brought about by exercise. But proteins stimu- 54 
THE PREVENTION OF DISEASE 
late combustion of other food stuffs in the body. It is 
probable that the various diseases of middle age which 
are supposed to result partly from effect of the strain 
on the kidneys, liver, etc., in eliminating protein waste- 
products, are chiefly due to overeating and lack of exer- 
cise, for it seems unreasonable to assume that these 
organs suffer from overactivity of their normal functions 
in the elimination of natural waste-products. 
A mixed diet of meat, fish, eggs, vegetables, and fruit 
is no doubt the best for ordinary healthy persons. 
Meat is the most concentrated form of digestible food. 
It is possible for persons to live on meat and water 
alone, as well as animals, because proteids may be con- 
verted in the body into sugar and fat. 
It is difficult to lay down any definite rules for guidance 
as to the use of meat. Some of the highest medical 
authorities believe meat to be harmful in hardening of 
the arteries, yet there are vegetarian monks and natives 
of Oriental and tropical countries who develop the most 
pronounced kind of arteriosclerosis upon a strictly 
vegetable regimen. And, on the other hand, Edward 
Stewart White records that the most robust and finely 
developed tribe in eastern Africa lives almost wholty on 
blood and milk. The amount of meat for daily consump- 
tion depends upon various factors —the age, occupation, 
and climate. 
Young, growing persons, those doing hard physical and 
mental work, and those who work outdoors, especially in 
cold weather, require an abundant supply of meat, 
fish, and eggs. For most individuals leading a quiet, 
sedentary life such a regimen is unnecessary and may be 
injurious. As meat is the most expensive food and the 
most palatable it is apt to be consumed too freely by the 
well-to-do. If there is a too abundant supply of meat, HYGIENE OF THE DIGESTION 
55 
so that its products are imperfectly burned up in the 
muscles, certain diseases are thought to result, as uric 
acid, stone in the kidney, and possibly arteriosclerosis, 
while some forms of Bright’s disease of the kidney are 
most unfavorably influenced by meat. 
In disease as in health, however, a mixed diet is usually 
most desirable, and it is very rarely that a strict vegetable 
regimen is advisable (without the addition of at least 
milk, eggs, and cheese) except for temporary morbid 
conditions. As noted above, some authorities think no 
meat should be eaten in arteriosclerosis, and in some 
stages of Bright’s disease it is harmful, and the same 
applies to gout and stone. But it seldom is necessary 
that even meat should be permanently abolished from 
the diet in any disease. 
Fish.—At one time it was thought that fish exerted a 
tonic effect on the nervous system because of an appreci- 
able quantity of phosphorus it contains, but this idea has 
no basis in fact. On the contrary, it is meat that is 
somewhat stimulating to the nervous system through its 
extractives. Shellfish, as lobsters, crabs, oysters, mus- 
sels and clams, must be eaten very fresh, never after 
they have been killed more than twenty-four hours. 
Crabs and lobsters occasionally poison some people, 
causing severe indigestion and vomiting, with eruptions— 
as hives. Some cases of typhoid fever have originated 
from eating raw oysters grown in water polluted with 
sewage. This danger has been generally prevented, 
and all cooked oysters are safe food, and very digestible 
as well as nutritious. 
Milk, as we have noted, contains an almost equal 
amount (about 4 per cent.) of protein, fat and carbo- 
hydrates (milk-sugar), and about 88 per cent, of water. 
In adults milk is not so completely digested as in children, 56 
THE PREVENTION OF DISEASE 
and the bowel discharges may be rendered white from 
undigested fat. It takes about 3 quarts, or 15 glasses, 
of milk daily to support an adult at light work, and this 
large quantity of milk is apt to form curds in the stomach 
and bowels and lead to constipation, or occasionally 
diarrhea. The fact that milk in ordinary quantities is 
one of the most bland, digestible, and nutritious foods 
makes it the chief reliance in sickness. It is not generally 
appreciated, however, that a glass of milk equals in 
nourishment 2 eggs or 2 moderate-sized potatoes, or 
5 tablespoonfuls of cooked cereal, or 2 slices of bread, 
or a large helping of meat, according to Rosenau. 
Milk should be really regarded as a solid food because it 
becomes partially solid or curdled by the acid in the gas- 
tric juice as soon as it enters the stomach. To prevent 
the formation of a tough curd various means are used. 
The addition of one-third lime-water, or one-half carbo- 
nated water, or a pinch of salt aid the digestibility of 
milk. A teaspoonful of liquenzyme (Wyeth) added to a 
glass of milk may cause it to agree with persons other- 
wise unable to drink it. It is wiser not to drink milk cold 
from the ice, unless mixed with soda-water. When 
digestion is very feeble, broths, meat juice, and white of 
egg mixed with water are more appropriate than milk. 
Milk is more digestible if taken with some starchy food, 
as crackers or toast, and with the lighter meals (breakfast 
and lunch), or between meals and at bedtime. For thin 
and debilitated people the writer is accustomed to pre- 
scribe 1 pint each of thick cream and milk mixed, 1 glass 
at breakfast, 1 glass in the middle of the morning, 1 glass 
at luncheon, and 1 at bedtime. Within a few months 
there may be a gain of as much as 20 pounds. 
It is a curious fact that while milk is par excellence the 
food for infants and invalids, there is none which is so HYGIENE OF THE DIGESTION 
57 
dangerous and capable of causing the worst of diseases, 
because it is taken raw and forms such fine food for disease 
germs acquired from the cow 'and man. We have gone 
into this more fully in another place, but the only safe- 
guard no matter how carefully milk is handled in white- 
tiled dairies and parlor-like barns, is cooking—by boiling 
or pasteurizing (heat at 145° F. for thirty minutes, fol- 
lowed by cooling). The Chinese put us to shame in 
this matter by taking no raw food, not even water, and 
so escape typhoid fever, etc. 
Eggs form a concentrated food rich in protein (13 per 
cent.), while the yolk is exceedingly rich in fat (33 per 
cent.). For this reason eggs do not agree with some 
persons with weak digestions, since the fat of the yolk 
causes the sort of indigestion known as biliousness. The 
white of egg alone, which is practically pure protein (13 
per cent.) and water, is often preferred for the sick, 
giving it in milk as egg-nog or stirred up with cold water 
and flavored with lemon and sugar. It is the large 
quantity of fat in the yolk which produces distaste for a 
constant diet of eggs in some persons. When eggs are 
placed in boiling water and allowed to stand in it off the 
stove for some ten minutes (coddled eggs), or are soft 
boiled, they are much more digestible than when hard 
boiled. 
Cereals.—Vegetables are chiefly rich in carbohydrates 
or starch, although, as has been noted, dried peas and 
beans contain as much protein as meat, and, in addi- 
tion, about 50 per cent, of starch. With fat pork, baked 
beans forms' a very complete, cheap and nutritious 
food suitable for outdoor workers. Soups of peas or 
beans are also exceedingly cheap, palatable, digestible, 
and nutritious. Cereals contain from 10 to 16 per cent, 
of protein, the highest amount in oatmeal. They are 58 
THE PREVENTION OF DISEASE 
composed chiefly of starch; rice and cornmeal being 
lowest in protein (7 per cent.), and highest in carbo- 
hydrates (78 per cent.). 
Cereals are the most concentrated and nutritious of 
vegetables. The whole grain contains vitamin neces- 
sary for growth and nutrition but absent in white flour 
and polished rice. Wheat contains about 12 per cent, 
of proteins, 68 per cent, of carbohydrates, and nearly 2 
per cent, of fat, besides phosphates and other valuable 
salts. Bread consists of nearly 50 per cent, of starch 
and 7 to 8 per cent, of protein. Starch must be crushed, 
boiled, or roasted to break the cells in which it is found in 
nature and so become digestible. The new-fashioned 
already cooked, puffed, or shredded breakfast foods are 
not nearly so nutritious as the older forms of oatmeal, 
cracked wheat, hominy, graham meal, and Indian meal 
because they are too bulky. 
Whole wheat, rye, and graham bread are especially use- 
ful in overcoming constipation and do not differ much in 
composition from white bread. There is not enough pro- 
tein in cereals to form a complete food without the addi- 
tion of fat, hence the rationale of bread and butter, but 
even here the bulk required is too great. Man cannot 
live on bread alone, even if it is the staff of life. 
The products of digested starch and sugar are burned in 
the liver and muscles to produce heat and energy. Thus, 
while proteins build up the bodily machine and supply 
material to keep it in repair, carbohydrates (starch and 
sugar) act as fuel. Carbohydrates protect the more valu- 
able proteins from being burned up, and are, to a certain 
extent, transformed into fat in the body. 
Fats are two and one-quarter times more nutritious 
than carbohydrates; that is, fat produces two and one- 
quarter times as much heat in burning as carbohydrates. HYGIENE OF THE DIGESTION 
59 
Fat in the body is chiefly formed from proteins and 
carbohydrates in the food, as the fat in the food is burned 
up for immediate needs in the way of heat and muscular 
action. Fat is one of the essential structures of the body 
and acts as a storehouse, which may be called upon when 
the subject is unable to get sufficient nourishment in 
disease. Fat acts as a laxative in the bowels, and it is 
particularly valuable in nervous debility and wasting 
diseases. Fats are not usually so digestible as most 
proteins and starches, but those fluid at the temperature 
of the body are most readily assimilated, as butter and 
cream—and so is bacon. Olive oil is easily digestible for 
some persons in quantities of a teaspoonful or more 
two or three times daily, but it often acts as a laxative. 
It is most easily assimilated in French salad dressing. 
Nuts contain a large percentage of fat (40 to 60 per cent.) 
and proteins (12 to 28 per cent.), but are not particularly 
digestible. 
Green vegetables and roots are composed chiefly of 
water, and are valuable on account of vitamin C they con- 
tain. The absence of these leads to the most serious 
blood diseases, as scurvy, beri-beri, etc. Their succulence 
and indigestible residue are also useful in aiding the 
action of the bowels, while their palatibility is important. 
Boiling is the least suitable way of cooking green vege- 
tables and roots because it removes their salts, unless 
the water is used for stews or soups. Steaming or 
roasting are preferable. 
Fruits are composed chiefly of water, and their nutri- 
tive value lies mainly in the carbohydrates they contain, 
which consist of various sugars, starch, and gums. In 
addition to this, they are rich in acids which, when 
absorbed, are transformed into alkaline salts (carbonates) 
in the blood. The acids in fruit consist of citric (in 60 
THE PREVENTION OP DISEASE 
oranges, lemons, grapefruit, limes); tartaric acid (grape), 
malic acid (apples, pears, berries, rhubarb); also acetic 
and oxalic, and in some cases boric and salicylic acids. 
The amount of acid varies—in pears, 0.2 per cent.; in 
apples, grapes, plums, cherries, peaches, strawberries, 
0.7 to 0.9 per cent.; in prunes and gooseberries, 1.5 per 
cent.; in currants, 2.15 per cent.; in lemons, 6 per cent. 
Fruits also contain vitamin C that is as valuable in 
preventing blood diseases as are those in fresh vegetables 
—e.g., an infant dying of scurvy will recover almost 
instantaneously on orange juice. The vegetable fiber and 
acid in fruits account for their laxative effect upon the 
bowels. The composition of apples may stand for that 
of other fruit. They contain about 85 per cent, of water, 
13 per cent, of carbohydrates, and but 0.4 per cent, of 
proteins. A fruitarian diet has been more or less in 
vogue of late, in which fruit is combined with nuts to 
supply protein. But this diet is then very low in protein, 
and is only suitable for temporary use in persons who 
have overeaten or require a low protein diet for certain 
disorders, as intestinal fermentation, obesity, gout, 
migraine, etc. Raw fruit is often undesirable because 
it is indigestible from being underripe, or poisonous from 
the presence of germs and overripeness. Persons with 
weak digestion and children should only eat cooked 
fruit, with the exception of oranges and cherries. Raw 
strawberries are particularly harmful because they grow 
on the ground and may be contaminated with intestinal 
bacteria from animal or even human excrement. They 
should be stewed. Raw apples quite commonly disagree 
with children and adults with weak digestion. Bananas 
contain a large percentage of raw starch, and the writer 
has seen severe indigestion and even convulsions pro- 
duced in infants by raw bananas. Baked bananas are HYGIENE OF THE DIGESTION 
61 
very digestible. Salted foods are commonly considered 
more indigestible than the same food fresh, as salt 
herring, salmon, cod, salt pork, corned beef, etc. Salt 
abstracts water from food, which, therefore, becomes 
drier, denser, and harder. But some food which is cured 
by salting and smoking is quite digestible, as tender 
boiled ham; which may be eaten by persons with feeble 
digestion. 
Vegetarian Diet.—A final word as to a vegetarian com- 
pared to a mixed diet. Man was made to exist on a 
mixed diet, as shown by his teeth and digestive apparatus. 
People who live on a mixed diet are more alert, active, 
and energetic, mentally and physically, owing (probably) 
to the stimulating effect of the extractives in meat and 
to the smaller bulk of mixed food requiring less energy for 
its digestion. The same elements of food exist in both 
animal and vegetable diet, but the animal is rich in 
proteins and the vegetable in carbohydrates. Even 
those vegetables which are rich in protein, as dried peas, 
beans, and nuts, are considerably more difficult of 
digestion. The various disadvantages of meat diet are 
met by like disadvantages of a vegetable diet. The 
physical superiority of the American or European over 
the Hindu or Japanese is apparent, although the latter 
have progressed enormously since they have begun to 
eat more flesh. Ferocity is supposed to result from 
meat eating, but compare the buffalo, rhinoceros, and 
Chinese pirate—all vegetarians—with other animals 
for cunning and ferocity. The vegetarian is less energetic 
because his functions are less vital. Herbert Spencer had 
to rewrite a book first written while he was on a vegeta- 
rian diet. The physical strength of meat-eating men 
and animals is far above that of any vegetarian animal. 
No vegetarian animal can lift the weight of his own body, 62 
THE PREVENTION OF DISEASE 
Louis Cyr lifted over a ton, and a lion carrying a calf its 
own weight has been known to jump a hurdle 6 feet high 
(Tibbies). 
Vegetarians are not more healthy or long lived. The 
diseases claimed to be caused by meat, as gout, stone, 
gravel, Bright’s disease, hardening of the arteries, diseases 
of animals, ptomain poisoning, etc., are balanced by 
disorders produced by too much starch and sugar, as 
indigestion, acidity, flatulence, obesity, diabetes, cholera, 
dysentery (from germs on raw food), pellagra, and beri- 
beri, etc. Vegetarians are not generally so robust, alert, 
active, and energetic as meat eaters, but are apt to suffer 
from indigestion and anemia, and to have a poor 
circulation. 
A vegetable diet, with the addition of milk, eggs, and 
cheese, is, however, a wholly different matter, and may be 
the best regimen for some persons. It may be said that 
the well-to-do, of middle age and over, eat too much meat 
as a rule. A single moderate helping of meat once daily 
is sufficient for such persons. In many diseased condi- 
tions and for the aged total abstention from meat for a 
time, or permanently, may be desirable, but such a diet 
should be determined upon individually by consultation 
with a physician. Our newer knowledge of vitamins 
teaches that the most common faulty diet is that com- 
posed too largely of cereals, white bread, potatoes, and 
meat without fat. 
These are all deficient in vitamins and mineral salts. 
The addition to the ordinary diet of a quart of milk daily, 
and salads and fruits, whole wheat bread and fat with 
meat, furnishes the optimum of nutritive requirements. 
The mineral salts are usually present in sufficient 
amount in the ordinary diets. But phosphorus, lime 
and iodine may be deficient, especially in urbanites. HYGIENE OF THE DIGESTION 
63 
Milk will supply both phosphorus and lime. Cheese 
and eggs furnish phosphorus, and green vegetables lime. 
Iodine is found in sea water, sea food and sea air. The 
lack of it leads to goiter in children living in certain 
regions and goiter is now prevented by giving iodin to 
school children (see Goiter). 
Salt is a most important constituent of the tissues, 
gastric juice, and blood, but enough is ordinarily taken 
on and with the food. 
Water should be consumed in abundance—6 to 8 
glasses daily. It is better not to take too much water at 
meals, not more than half the daily amount, and the rest 
between meals. Too little water favors stone because 
there is not enough water to dissolve the solids eliminated 
by the kidneys. In the reduction of obesity water should 
not be taken at meals, as water increases the appetite and 
allows more food to be washed down. Only tea, coffee, 
and soup are allowed in those reducing weight. A copious 
supply of water is very essential in preventing constipa- 
tion. Water-drinking has been rather a fad and there- 
fore overdone. The drinking of several quarts of water 
daily is undesirable, as it causes inaction or atony of the 
stomach and its distention, whether the water be hot or 
cold. The consumption of ice-water at meals tends to 
check the secretion of gestric juice and digestion. 
Water-supply.—The importance of a pure water-supply 
is everywhere recognized. Surface-water and bodies of 
water which receive drainage from the surface are likely 
to be polluted with the bowel and urinary discharges of 
men and animals, which may give rise to many diseases, 
especially typhoid fever, diarrheal diseases, and intestinal 
parasites. In this category may be included springs, 
rivers, ponds, lakes, and shallow wells. The state 
chemist of Indiana has recently found in the exami- 64 
THE PREVENTION OF DISEASE 
nation of 5000 wells in thickly populated sections, 
that over 50 per cent, are polluted, and he advises that 
every surface well in Indiana be abandoned. The 
discovery of the germs normally present in the intestines 
(colon bacilli) in numerous small samples of drinking- 
water is considered a sure sign of its pollution with 
sewage. It is wise to have a domestic water-supply 
examined by a competent bacteriologist and chemist, 
such as any city health department employs. Rain- 
water is pure (except for the dust it washes from the air), 
and if the first washing from the roof is turned away from 
the conductors by an automatic device, and if the cistern 
is lined with cement and is absolutely tight—to exclude 
dirt, surface-water, and vermin—the rain-water will 
remain pure. The cistern-water should have an overflow 
pipe on the surface of the ground covered with wire gauze. 
The number of square feet in the ground plan of a house 
will constitute the roof area for collection of rain-water. 
Thus, a 40 by 40 feet ground plan (1600 sq. ft.) will give 
a roof area which will catch about 1000 gallons of water 
from 1 inch of rainfall (Harrington). 
Driven and artesian wells usually suppfy pure water 
because water from deep subsoil is ordinarily unpolluted. 
This is not always the case, however, as fissures in deeply 
embedded rocks may lead polluted water to great depths. 
The safest surface wells are those of brick or stone lined 
throughout with cement, and covered so tightly that 
surface-water and vermin are excluded. They may be- 
come polluted from drainage into the deeper layers of the 
subsoil from cesspools and privies. 
Boiling water for fifteen minutes is the simplest method 
of purification. To restore its normal taste it should be 
poured from one vessel to another, to mix it with air, 
after it has been boiled. Most filters are useless in HYGIENE OF THE DIGESTION 
65 
removing germs. The Chamberland-Pasteur filter, made 
of unglazed earthenware, through which the water must 
slowly find its way, is the only filter which prevents dis- 
ease germs from passing. It must, however, be scrubbed 
and boiled ten minutes twice a week (Harrington). It 
is fastened to the water faucet. Chlorid of lime, or 
bleaching powder, is a safe agent to use for sterilizing 
water, since it does not impart much taste or odor and is 
perfectly harmless in the amount used. Six hundred 
cities in this country and Canada use it to purify their 
public water-supplies. One teaspoonful of the following 
chlorid of lime solution is added to 2 gallons of water, 
which should then stand fifteen minutes or more before 
it is fit to drink. The solution itself is made by dissolving 
1 teaspoonful of fresh chlorid of lime in 1 quart of water, 
keeping it tightly sealed in a Mason fruit jar. 
Ice.—To avoid dangers from ice composed of impure 
water, containing possibly the germs of typhoid fever, 
diarrhea, and dysentery, one should always use clear ice 
which is made from pure water or water from which the 
germs have settled out. Clear ice is safe ice. If ice con- 
tains germs it is rarely absolutely transparent. One 
should avoid ice-water in public places when the ice is 
floating in the water. Water should be cooled by sur- 
rounding it with ice which does not come in direct contact 
with the water. The reason for this is that ice may often 
be handled by persons with hands soiled with their own 
excretions, and thus may be a means of transmission 
of typhoid fever, diarrheal diseases, and intestinal 
parasites. 
One would certainly not drink water in which such per- 
sons as servants and railway employees had dipped their 
hands, yet one does it every day unwittingly, in the form 
of melted ice. 66 
THE PREVENTION OF DISEASE 
The fashion of late dinner is based on the fact that lei- 
sure at this time favors digestion, in that blood is not 
drawn away from the stomach for mental or physical 
labor. A heavy meal in the middle of the day conduces 
to inactivity in mental workers. In the case of children 
and elderly persons it is often best that the heartiest 
meals be breakfast and at midday and the lightest in the 
evening. Candy, ices, and sweets between meals are 
the bane of children’s digestion and health. Sometimes 
only the discipline and isolation of boarding-schools will 
prevent this dissipation. The proper standing position 
is requisite for good digestion and this is considered under 
Digestive Disorders. Corsets constricting the waist 
displace the stomach downward and interfere with diges- 
tion. The straight-front corset, loose above, is the best 
type. 
In order to calculate an economic and sufficient diet 
scientifically all articles of digestible food consumed each 
day are reckoned in terms of heat value; that is, the 
value of food is considered to lie in the amount of heat it 
will produce in burning outside the body. This follows 
because food undergoes what is practically combustion 
within the body. The unit of fuel or food value or calory 
is that amount of heat required to raise 1 kilogram (about 
1 quart) of water from 0°to 1° C. The calory has become 
a household word but it is improbable that many can 
define it. About one tenth of the calories of food is lost 
by food passing out unabsorbed in the feces. Tables 
based on most elaborate experiments showing the caloric 
value of food per ounce or gram may be found in any 
work on nutrition. 
In their combustion in the body 1 gram of protein 
yields 4.1 calories, and 1 gram of carbohydrate the same, 
but 1 gram of fat furnishes 9.3 calories because it supplies HYGIENE OF THE DIGESTION 
67 
2)4 times more heat in its combustion than an equal 
weight of sugar or starch (carbohydrates). For example, 
to find the caloric value of the following breakfast we add 
together the grams of protein and carbohydrates in each 
article of diet and multiply the result by 4.1, while the 
grams of fat in each article of food we multiply by 9.3. 
Protein, 
grams 
Carbo- 
hydrate, 
grams 
Fat, 
grams 
Calories 
1 grape fruit (300 gm.).... 
2 
30 
0 
131 
1 pint of milk 
15 
22 
18 
320 
2 eggs 
13 
0 
12 
165 
4 slices bacon, 6 X 2 in.... 
10 
0 
64 
636 
2 slices bread (60 gm.).... 
6 
32 
1 
165 
1417 
The minimum quantity of food as measured by calories 
requisite to maintain life, when an individual is at rest, 
has been determined by Benedict as 1630 calories daily 
for men, and 1350 calories for women. Any sort of 
work, even digestion, demands more energy or food and 
the daily average food requirements for adults perform- 
ing their accustomed tasks vary, according to different 
authorities, from 2500 to 3500 calories, and should con- 
tain from 100 to 150 grams of protein, 50 to 100 grams of 
fat, and from 250 to 500 grams of carbohydrates (30 
grams = 1 ounce). 
The food requirements for different kinds of work vary 
all the way from 2000 calories for the sedentary semp- 
stress, to 5750 calories for the strenuous sawyer. 
It is rarely advisable for an adult to live on one article 
of food. Milk is perhaps the most suitable nourishment 68 
THE PREVENTION OF DISEASE 
for the sick but, with a fuel value of 20 calories an ounce 
or 640 per quart, a gallon would be necessary to supply 
daily the 2500 calory requirement. 
It is customary to secure the chief supply of calories 
in food from carbohydrates because of their palatability, 
digestibility and economy. CHAPTER III 
PERSONAL HYGIENE (Continued) 
Exercise: Special Exercises for Different Ages, Rationale of 
Exercise. Clothing. Baths: Outdoor Bathing, Lukewarm, Warm, 
Hot, Turkish, and Cabinet Baths. Ventilation: The Complexion: 
Sunburn, Freckles, and Acne. Care of the Hair: Baldness and 
Dandruff. Care of the Finger- and Toe-nails. 
EXERCISES 
Special Exercises for Different Ages.—From infancy- 
up to the seventh year muscular movements are not 
precise nor finely co-ordinated. The nervous and 
muscular systems are not sufficiently developed for the 
performance of accurate and co-ordinate movements. 
Thus, the baby begins kicking and moving the hands 
and legs; then picking up and dropping things; playing 
with blocks and digging and piling dirt or sand come next, 
and later running, throwing, cutting and folding, and the 
use of bows, slings, and the knife. From seven to twelve 
the outer (cortical) areas of the brain, which control 
motion and sensation, are chiefly developed, and finer 
and more complicated movements after this time are 
possible. Simple ball games, hide and seek, tag, leap 
frog, marbles, baseball, football, swimming, riding, 
bicycling, wrestling, and fishing begin in this period. 
Subsequent to this age the highest functions of the brain 
develop, as self-control, association of ideas, and judg- 
ment. It is at about twelve that the ability for team 
69 70 
THE PREVENTION OF DISEASE 
play begins, and this mental plane is equivalent to that of 
the savage. 
After twelve exercises requiring precision and accuracy 
may be undertaken, as manual training, playing musical 
instruments, baseball, cricket, fencing, tennis, boxing, 
bowling, etc. The heart is not equal to long-sustained 
competitive athletics at this age, particularly long dis- 
tance running. The heart gives out by becoming dilated 
and only short distance competitive running should be 
allowed until boys are eighteen. School and college 
athletics tend toward special and excessive development 
of the select few in competitive sports, whereas the ideal 
training consists in general physical development of all. 
To bring this about in youth there should be three half- 
hours weekly given to gymnasium class exercises, together 
with outdoor sports and walking. The special objects 
should be to overcome by appropriate exercises any 
special inherent physical weaknesses or shortcomings 
(either under- or over-development of parts), and to 
produce a fine general bodily development, and to bring 
out those special qualities so essential for any successful 
career—energy, alertness, strength, courage, and endur- 
ance. A youth should walk when he may ride, run when 
he may walk, and climb when he may be lifted (elevator). 
All the athletic outdoor sports should be his—skating, 
rowing, swimming, hunting, and fishing. Dancing is 
not to be despised. 
The various systems of home exercises by correspond- 
ence have advantages and disadvantages. They are 
very apt not to be kept up, as they are not sufficiently 
agreeable, being taken as a duty rather than pleasure. 
They resemble the use of the axe for exercise, which 
fond parents are apt to urge on their sons who are 
bursting for sport. EXERCISES 
71 
These home exercises usually consist in developing 
certain muscles by bringing into play the action of oppos- 
ing muscles. This means the resistance of the action of 
one group of muscles by an opposing group. For 
example, one has to concentrate the mind strongly upon 
bending the arm at the elbow, while at the same time 
making this movement difficult by contraction of the 
muscles opposing this action. By going through such 
exercises conscientiously for twenty minutes each morn- 
ing on rising, and following them by a shower and vigor- 
ous rub with a coarse towel, one may greatly increase the 
muscular strength. But this training has the tendency 
to make one “muscle bound” and not fit for skilled sports, 
where accuracy of movement, quickness, alertness, sup- 
pleness, and grace are desirable, as in tennis. 
The expense and secrecy attending the taking of such 
systems of physical exercise add to their allurement, and 
they are doubtless better than no exercise at all, although 
they do not favor all-round development, as do many 
outdoor sports. The systems which consist of bending of 
the body and movements of the limbs are more suitable 
for the mature business man who wishes to exercise at 
home without apparatus. (“Ten Minutes’ Exercise for 
the Busy Man,” Dr. L. H. Gulick; “Fifteen Minutes 
Invested Daily for Health’s Sake,” W. J. Cromie.) 
Walking is the cheapest and easiest form of exercise for 
those in middle life or beyond. Walking should be done 
at a brisk pace, and one should not brood over one’s self 
or one’s troubles, as mental relaxation is as important as 
exercise. This is the advantage of golf, as it is almost 
impossible to think of other things when devoted to this 
engrossing game. In walking one should “go about 
admirin’ ’ow the world was made.” When one is 
greatly taxed by mental work it is bad to burn the candle 72 
THE PREVENTION OF DISEASE 
at both ends by trying to exercise at the same time. In 
such cases rest may be found essential. Muscular 
fatigue also generates chemical substances whch may act 
as poison to the blood-vessels and induce arteriosclerosis, 
which is so synonymous with old age. One should feel 
refreshed after exercise, and not the reverse. 
The special exercises and sports suitable for the middle 
aged and elderly include golf, bicycle riding (without hill 
climbing), walking, horseback riding, bowling, hunting, 
fishing, and gardening. Violent exercises of all kinds are 
undesirable and often dangerous, such as boxing, fencing, 
mountain climbing, tennis and handball, running, rowing, 
basket-ball, and long distance swimming. The rules for 
middle age should be the reverse of those for youth. One 
should not take any unnecessary violent exertion, one 
should walk rather than run, and not lift heavy weights, as 
a trunk or articles of furniture. For the elderly the most 
suitable exercises are walking, riding or motoring, and 
billiard playing. Of course, it makes a great difference 
whether one has kept in good muscular training from 
youth onward, and such may take much more strenuous 
exercise than individuals not accustomed to physical 
exercise. Our famous Secretary of State, Mr. Richard 
Olney, was an expert tennis player well into his sixties. 
Rationale of Exercise.—Exercise or muscular move- 
ments depend upon three factors—a normal nerve impulse, 
contraction of the muscle, and an efficient supply of fuel. 
It is not sufficiently appreciated that complicated move- 
ments, such as are required by the simplest actions in 
life, are as much nervous as muscular, and by them the 
brain and nervous system are developed as well as the 
muscles. In the performance of muscular movements 
there are to be considered the origination of an impulse 
in the motor area of the outer part (cortex) of the brain, EXERCISES 
73 
its conduction along the spinal cord and thence along a 
motor nerve, and the answering contraction of the 
muscle. 
In voluntary movements the impulse travels from the 
brain at the rate of about two miles a minute. Automatic 
movements are those occurring when impulses are sent 
from the central nervous system without any conscious 
knowledge, as in the case of the beating of the heart and 
the movements of the stomach and bowels. Reflex 
action takes place when the end of a sensory nerve is 
stimulated and the impulse is carried along it to the 
spinal cord or brain, and is transformed by the nervous 
center into an impulse traveling back along a motor nerve 
to a muscle—resulting in its action. Reflex movements 
may occur in sleep and unconsciousness, and even when 
opposed by the will, as in the case of winking when the 
eyeball is touched. 
The fuel required for muscular action is chiefly derived 
from the starches and sugars of food. These are burned 
in the muscles in the form of a kind of sugar (glycogen) by 
means of the oxygen brought in the blood from the lungs. 
Thus heat and energy are produced. Sugar is, therefore, 
one of the best stimulants to muscular action and is fed 
soldiers on the march, often as chocolate, rich in both 
sugar and fat. Meat and fat may replace sugar and 
starches when they are absent from the food. 
Muscular fatigue is due to three factors—it is caused 
by nervous exhaustion, by the chemical waste-products of 
muscular contraction, and by consumption of the fuel 
which supplies muscular contraction. The nervous 
element in fatigue has been found by Crile to depend 
upon actual changes in the brain, seen microscopically 
after overuse of the muscles in animals. This fact en- 
forces the necessity of a normal nervous system for the 74 
THE PREVENTION OF DISEASE 
successful accomplishment of physical exercise. The con- 
verse is seen in the absolute loss of muscular power in 
nervous prostration, so that even talking or lifting an arm 
become a great exertion. 
The use of all drugs tending to impair the nervous 
system, particularly tobacco and alcohol, are, therefore, 
essentially inimical to the best performance of any 
athletic feats requiring endurance and the most harmon- 
ious action of various groups of muscles. 
Muscular and nervous development through exercise, 
therefore, go hand in hand. The muscles themselves 
enlarge through increase in muscle cells and grow stronger 
because more of their fibers come under the control of the 
nerves, and because the nervous impulses become more 
intense. The rapidity of transmission of the nervous 
impulse from the brain along the nerve is also increased. 
Occasionally fibers of muscles break during severe exer- 
cise, and sore spots and occasionally lumps form in the 
muscle and persist for several weeks. In the parlance of 
the trainer this is called “ charleyhorse. ” 
The effect of exercise upon the breathing and heart are 
most important. During violent muscular exertion 
more blood must be carried to the lungs in order that the 
increase of waste-products from the muscles (carbonic acid 
gas) may be there gotten rid of and replaced by oxygen, 
which is needed in excess in the muscles to burn the fuel. 
At first the breathing becomes violent, rapid, and shallow, 
and dizziness and even unconsciousness may ensue—in 
running for instance. Usually one gets his “second 
wind” in about three minutes, which means that the 
breathing has become deeper and more powerful, that 
more oxygen is taken in and more carbonic acid gas 
exhaled, and that the action of the heart is stronger. 
This forced breathing is brought about automatically EXERCISES 
75 
by increase of carbonic acid gas in the blood, which 
stimulates the center of breathing situated at the base of 
the brain. Second wind means that the body has 
adapted itself to take care of a greater amount of waste 
products by an increased power of elimination. 
Since violent exercise demands a greater supply of 
blood in the lungs, heart, and muscles, the heart responds 
by more rapid and stronger contractions. These later 
become slower and more effective, since the heart dilates 
to hold more blood and, therefore, more may be forced 
out at each contraction. Exercise excites reflexly centers 
in the brain that stimulate the heart’s action, while the 
distention of the cavities of the heart with more blood 
and the increased heat of the blood in exercise both stimu- 
late the heart. The arteries dilate during muscular 
action because with the nerve impulse sent from the 
brain to make the muscle contract there are accompany- 
ing impulses that stimulate the nerves of the arteries 
causing them to dilate. Then the demand for oxygen 
in the muscles during exercise, owing to the combustion 
of sugar in the muscles, calls for more arterial blood—a 
demand met automatically as just noted. 
The increased motion of the chest in exercise causes 
the blood to circulate more freely because the chest acts 
as a suction and force pump alternately—in its expansion 
it leads to dilatation of the great veins within it and, 
during its contraction, presses on them. Thus the 
heart’s action may be artificially kept up to a consider- 
able extent by artificial respiration. 
With every expansion of the chest (inspiration) the 
great muscle forming the floor of the chest (diaphragm) 
descends and presses on the liver and stomach and great 
veins in the belly, so that the circulation of the digestive 
organs is quickened and the movements of the stomach 76 
THE PREVENTION OF DISEASE 
and intestines accelerated, and digestion correspondingly 
improved. 
Exercise increases the supply of blood in the muscles 
and withdraws it from sexual and other organs and there- 
fore is beneficial in irritable conditions often occurring 
at the age of puberty. 
In a man in athletic condition the normal pulse of 70 
may increase to 130 or even 190 beats per minute during 
sudden and violent exertion, but soon returns to normal. 
In the man out of condition the pulse may remain high 
and somewhat irregular for some time after severe 
exercise. During the exertion of rising suddenly from a 
lying to standing position, in the normal individual, the 
heart is naturally quickened by some 12 beats to the 
minute, and if it increases by as much as 20 beats it is a 
sign of poor physical condition. Again, in rising sud- 
denly the blood tends to leave the brain and collect in 
the muscles of the lower extremities. The normal tone 
of the vessels and heart tend to prevent this. If the 
blood-pressure is taken before rising and immediately 
after rising from a horizontal to an erect position, in the 
arm of an individual with poor tone of vessels and heart, 
the pulse will be quickened more than 10 beats and the 
blood-pressure will fall in the arm after rising. In the 
highest physical condition the blood-pressure is increased 
in standing, owing to an immediate, compensatory, 
heightened tone of the vessels and heart, and the pulse is 
augmented but a few beats. 
Thus, Crampton has introduced a scale to test the 
physical condition by estimating the blood-pressure and 
pulse-rate of an individual lying and standing. A person 
getting 100 per cent, would have a rise of 10 in blood- 
pressure and only 4 in pidse-rate. If the blood-pressure 
falls when one rises into an erect position, this occurrence EXERCISES 
77 
leads to increased rapidity of the heart in its natural 
endeavor to fill the vessels. Crampton’s test is still 
sub judice. But unquestionably a quick return of a 
rapid pulse to normal after exertion is a most reliable 
sign of a good physical condition. (In 2 minutes, after 
hopping 100 times on one foot.) 
In former times it is reported that short operations 
were performed on persons painlessly by having two 
strong men lift the patient suddenly from a horizontal to 
the erect position. Partial unconsciousness or faintness 
followed, owing to the blood leaving the brain during 
this procedure. 
Dangers.—The chief danger in sound persons from 
sudden violent exercise, especially when they are not in 
training, is acute dilatation of the heart. This also 
occurs in athletes in running, rowing, football, etc., but 
in them the heart usually returns to normal within a few 
hours or days. As we have said, in getting “ second 
wind” and in all violent exertion the heart dilates some- 
what, but it is excessive dilatation of which we speak. 
This is shown by blueness of the face, bleeding nose, 
breathlessness, and dizziness. In those not in training, 
especially under fifteen and over thirty, the dilatation 
may persist for a long time or always, and a weak heart 
result. This sometimes occurs in elderly persons when 
mountain climbing after leading a sedentary life. 
In young children the volume of the heart is 
proportionately much smaller to the diameter of the 
vessels than it becomes later, for during adolescence the 
volume of the heart increases enormously (twelvefold) 
and the diameter of the arteries only threefold (Benke). 
So that overexertion in children, up to the age of fifteen 
and over, causes great strain on a heart which is not fully 
developed in size or strength, but especially in size, In 78 
THE PREVENTION OF DISEASE 
an experiment on 40 boys, from seven to fourteen, 
Riviere found that after a walking excursion which lasted 
a week, in which the boys walked five to seven miles 
daily, there was dilatation of the heart still persisting two 
and one-half months in 10 of the younger boys, and it 
seemed probable that from one to two years would be 
required before their complete recovery (McKenzie). 
Any sudden and violent effort, as in lifting, wrestling, 
and running, greatly increases the blood-pressure momen- 
tarily (from the normal, 120, to 210 in McCurdy’s tests), 
and this may lead to rupture of an artery in the middle 
aged and elderly, though never in a sound young person. 
In more moderate continuous exertion requiring endur- 
ance the blood-pressure rises, though not to so high a 
point, but falls rapidly and below normal in the sound 
individual. The pulse-rate increases more markedly and 
does not return to normal nearly so soon. Thus, in 
bicycling for half an hour Bowen found that the blood- 
pressure increased from 140 to 190 at the end of this time, 
and the pulse from 72 to 132. Within ten minutes after 
completion of the ride the blood-pressure fell to 130 and 
the pulse to 102, but only after another half-hour did 
the pulse become normal (72). 
The best exercises are those bringing into action large 
groups of muscles and developing the body as a whole. 
When a muscle contracts it squeezes the blood out of its 
veins, and at the same time in shortening it widens and 
allows more blood to flow through the arteries, so that 
three times more blood is supplied to a muscle during 
exercise than at rest. Indeed, the muscles are veritable 
hearts. The heart gets its own blood supply, both during 
contraction and in the rest periods, and when it beats 
violently during general exercise it is supplied with more 
blood than usual and develops accordingly, like any other CLOTHING 
79 
muscle. General exercises developing large groups of 
muscles and the vital organs—the heart and lungs—in- 
clude running, swimming, rowing, skating, wrestling, 
boxing, riding, fencing, and dancing. These are the 
chief developmental exercises and differ from special 
exercises which develop small groups of muscles. It is 
especially in youth and after middle age. that care must 
be taken to avoid severe, sudden, or prolonged exertion. 
We can hope to exert but little influence upon the fair 
sex in the matter of clothing, since fashion is the sole 
dictator of dress in most instances. 
One not rarely sees a wonderful combination of such 
material as a sort of refined mosquito netting and fur in 
the composition of an outer garment, and it is not unusual 
to observe the distribution of fur over remarkable portions 
of the anatomy, the remaining parts having little or no 
covering whatever. Then at another time fashion may 
demand a wholly different anatomic arrangement of the 
furs without regard to weather or season. In attempting 
to remonstrate with patients, the doctor is either met 
with fallacious arguments, on the one hand, or demure 
acceptance on the other, without any endeavor, however, 
on the part of the patient to put the advice into use. In 
the matter of night garments the physician is equally 
futile. The total exposure of the upper part of the body 
is not conducive to avoidance of rheumatic or catarrhal 
affections of this region, or to their recovery. 
In underclothing the two qualities of most importance 
are those of retaining heat and absorbing perspiration. 
Wool is pre-eminently the best non-conductor and, there- 
fore, prevents the bodily warmth from escaping. Many 
persons think they cannot wear wool because it causes 
CLOTHING 80 
THE PREVENTION OF DISEASE 
too much irritation of the skin. Merino, or mixtures of 
wool and cotton, may be used, or materials made with 
cotton on one side and wool on the other. 
Wool also absorbs perspiration readily and evaporates 
it slowly and is the best material for underwear the year 
round. Wool shrinks and becomes matted or felted by 
frequent washing; but this trouble may be averted to a 
considerable extent by washing in tepid water with fre- 
quent rinsing, but avoiding forcible wringing or rubbing. 
Cotton clothing is now worn by many indoor workers 
the year round. The fabric does not naturally absorb 
moisture so readily and cools the body more than wool 
when wet, nor does it retain heat as well as wool or fur, 
which contain so many air spaces that act as non-con- 
ductors. Yet cotton is woven loosely in such a way as 
to serve as a good substitute for wool in those not 
exposed to cold, wet, or drenching sweat. Linen is 
about on a par with cotton in absorbing moisture and 
retaining body heat. Linen garments are more expen- 
sive, but will stand more washing. The linen mesh is 
particularly appropriate for the tropics and hot weather 
in imparting a sense of coolness. Silk underwear is 
expensive and shrinks in washing, but absorbs perspira- 
tion readily, and is cool and pleasant for summer use. 
Impermeable materials, as rubber, mackintosh, and 
leather, are chiefly of value for outer garments in pro- 
tection against wind and wet. They retain the moisture 
of the body, and so are unsuitable for wear next the 
skin, or even as outer covering when one is taking violent 
exercise. Brightly dyed underwear and stockings are 
undesirable, as the anilin colors irritate the skin and 
produce eruptions. If the feet perspire freely the stock- 
ings should be changed often so as to be clean. By 
first soaking the feet in hot water, and then drying them BATHS 
81 
and dusting on a mixture of salicylic acid (1 part) 
and starch (3 parts) the perspiration will be much 
reduced. The same treatment is useful in troublesome 
sweating of the hands or armpits and to prevent its 
attendant bad odor. If the clothing is damp the growth 
of bacteria and parasites of skin diseases is favored, so 
when perspiring freely the underclothes should be 
changed and put into the wash or well aired and dried 
before wearing them again. White cotton or linen outer 
garments are worn in the tropics because dark colors 
absorb heat rays of the sun more readily and because 
cotton or linen do not retain bodily heat like wool. 
Many persons wear too heavy underclothing in winter. 
For those exposed to severe outdoor weather in their busi- 
ness thick underclothing may be essential, but is apt to 
make indoor workers sensitive to cold and subject to colds. 
The more sensible way is to wear but little heavier 
underclothing in the house in winter than in summer, 
and to dress very warmly in ulsters, furs, etc., when 
going out into the cold. 
Hats should not be made to fit the head exactly, as 
they are not comfortable and do not afford proper 
ventilation. The shape of shoes most desirable is of 
importance and is discussed in another place (page 407). 
BATHS 
Baths are not by any means of use solely for cleansing 
purposes. A cold plunge is not particularly cleansing, 
yet has a marked influence upon the body. A daily cold 
bath (50° to 70° F.) tends to render the skin less sensitive 
to cold, and so prevents colds, and has a pronounced 
stimulating effect upon the circulation, respiration, and 
nervous system. This action is seen when cold water is 82 
THE PREVENTION OF DISEASE 
dashed upon the face and chest in fainting, or in failing 
respiration, and is relied upon to resuscitate newborn 
infants, when they fail to breathe, and to restore persons 
in a fainting condition. The cold bath is customary 
among the better class of English and Americans, and 
the ruddiness, robustness, and fine complexions of our 
insular cousins may be due in no small measure to this 
habit. 
A daily cold bath should be taken by all healthy youths 
and adults under middle age if they are able to secure the 
reaction or warm after-glow which should succeed the 
bath. The bath should be taken in a warm room, to 
favor reaction, and be followed by vigorous rubbing with 
a coarse (linen mesh is best) towel. In case a person 
suffers from chilliness after the bath it may often be 
obviated by standing or sitting in hot water while 
cold water is used by sponging or by a shower. Cold 
sponging with salt and water while standing in warm 
water is a good method for delicate children when fol- 
lowed by brisk rubbing with a coarse towel. 
Persons not habituated to cold baths should begin them 
in summer, and then may continue them through the 
winter months without discomfort. In taking cold 
baths, plunges, or showers the water should not come 
in contact with the body more than a minute or two. 
Cold baths are undesirable and often harmful for young 
children, persons with kidney disease or hardening of 
the arteries; or elderly individuals, unless they have been 
habituated to them all their lives. Also colds baths are 
inadvisable for women during menstruation and in the 
later months of pregnancy, and for both sexes when much 
fatigued or very hot after exercise. A cold plunge is 
not injurious, however, for healthy persons perspiring 
mildly after moderate exercise. BATHS 
83 
Outdoor Bathing.—Sea-bathing (60° to 75° F.) has 
the beneficial action of the cold bath plus the salubrious 
effects of one of the best forms of exercise in the fresh 
air, the stimulating influence of the waves and salt upon 
the skin, and the pleasure and sunlight. The tempera- 
ture range is considerable, and the proper duration of 
the bath depends upon this—anywhere from two to 
twenty minutes. Two minutes is too long in many 
parts of the Northern New England and Pacific coasts, 
whereas twenty minutes is almost too short in the shallow 
and warm waters of Cape Cod and the middle and south- 
ern Atlantic shores of the United States, where the water 
reaches a temperature of 72° to 75° F. or more. There is 
great harm done children and delicate persons through a 
prolonged stay in cold water. A warm reaction should 
follow sea-bathing, as after the cold bath indoors. One 
so frequently sees persons blue and shivering loitering 
about on the shore or knee-deep in cold water instead of 
taking a plunge and then out. There is immense loss 
of heat and combustion of food or tissue in the body to 
supply this. The result is a great drain upon the 
vitality, exhaustion, and often loss of weight after a 
prolonged course of cold sea-bathing. 
Especially pernicious is the habit children have of 
playing out of the water in wet bathing suits (thus 
cooling the body by evaporation), or of wading in cold 
water while their bare heads are exposed to the burning 
sun—a most favorable procedure for sunstroke. The 
same remarks apply to swimming pools and the great 
frequency of colds, and serious sinus, ear and mastoid 
troubles in bathers, is due largely to lowered resistance 
of the body by prolonged chilling. To stay in cold 
water long one must be stout, since the layer of fat 
under the skin acts as a non-conductor, keeping heat in 84 
THE PREVENTION OF DISEASE 
and cold out. Women have more subcutaneous fat 
than men, and their greater ability to stand around in 
cold water, as compared to males, is notorious. Long- 
distance swimmers must be fat to withstand the cold 
and exhaustion. 
It is always wise to wet the head before entering cold 
water, and it is unwise to bathe when excessively hot, but 
it is safer when moderately warm from exercise than 
when beginning to cool off. It is the custom not to 
bathe until three hours after meals, because the action 
of cold water alters the distribution of the blood to the 
digestive organs and other parts of the body. From 
bathing soon after eating persons have suffered from 
nausea, vomiting, cramps in their bowels, and even 
death. 
Cold applied to the skin drives the blood into the inter- 
nal organs and to the head by contraction of the external 
blood-vessels. This is the reason for first wetting the 
head. To those used to cold baths sea-bathing may 
be indulged in before breakfast. The rule in all cases 
should be never to stay in water until one has blue fingers 
and lips and is shivering and chattering with cold, for one 
should always feel warm after the bath. 
Sudden and unexpected deaths occur in swimmers and 
bathers from fainting, overexertion, and cramps. Swim- 
ming is tremendous exercise, since it brings into play 
most of the muscles in the body. If one is swimming at 
top speed and in rough water the strain is extreme on even 
the healthy heart. The writer watched a professional 
athlete in pink of condition give out through making 
extraordinary efforts in swimming to catch a drifting boat. 
Seeing a sudden pallor come over his face, the Swimmer 
was rescued just in time. If the heart is naturally weak 
the exertion of swimming may easily cause it to fail. BATHS 
85 
Sometimes a weak heart will momentarily stop when a 
person jumps into cold water. The author has known 
this to happen twice in the case of a patient jumping into 
a swimming pool. Drowning will result unless help is 
directly at hand. From a long experience in swimming 
the writer believes that the dangers of death from cramp 
are somewhat exaggerated. Long swims are dangerous 
unless a person is in first-rate physical condition. The 
author had an impressive experience in the water with a 
swimmer fresh from sedentary occupation in the depres- 
sing heat of a city who undertook a considerable swim 
and gave out when half the distance. Those who faint 
readily, who have palpitation or other disturbance of the 
heart, the elderly not habituated to cold water, and 
persons who do not react satisfactorily to cold bath 
should refrain from outdoor bathing. Diving removes 
mucus and chills the membrane of the nose lowering its 
resistance to germs. Water may enter the eustachian 
tubes through the nose. 
An authority, Skillern, advises divers to stuff both 
nostrils with cotton to avoid dangerous sinus, ear and 
mastoid troubles. 
A word as to swimming tanks—eye, ear, throat, and 
sexual infections are sometimes contracted from water in 
common use by bathers, even when care is taken to 
require a preliminary shower, etc. Intestinal germs are 
not infrequently found in the water. Disinfection with 
chlorid of lime, copperas, or other agent, together with 
frequent change of water, are imperative. 
The lukewarm bath (80° to 90° F.) with the aid of soap 
has merely a cleansing effect in removing dead, scaly par- 
ticles and fatty secretions of the skin, dirt, and sweat. 
The functions of the skin in eliminating waste matters 
in the sweat are thus favored and the work of the kidneys 
relieved to this extent. The common pimples (or acne) 86 
THE PREVENTION OF DISEASE 
of youth are prevented to a considerable degree by daily 
cleanliness. The lukewarm bath is suitable for the 
elderly or those who do not react or are endangered by 
cold baths. It may be taken at any time, but preferably 
not directly after meals. 
The Warm Bath (90° to 100° F.).—This may also be 
used for cleansing purposes, and is not likely to cause dis- 
turbance after meals, the temperature being so near that 
of the body. Warm baths conduce to sleep if taken 
before bedtime and followed by a glass of hot milk. The 
activity of the skin is favored, and persons with chronic 
kidney troubles and hardening of the arteries should have 
warm baths daily. After severe exertion warm baths 
tend to remove muscular soreness and stiffness of the 
joints. One should not go outdoors in cold weather 
soon after a warm bath. 
The Hot Bath (105° to 110° F.).—The layman is often 
advised not to take hot baths except by professional 
advice. This is rather absurd, as takes them 
whether or no. But there is considerable danger, never- 
theless, in hot baths for persons with weak hearts. The 
heat is depressing to the heart and dilates the blood-vessels 
of the skin, taking the blood away from the brain. This 
is just what occurs in fainting—lack of blood in the 
brain—and fainting may occur in the bath. Hot baths 
should not be taken after meals (blood is drawn away 
from the digestive organs) nor before going out into the 
cold. Hot baths are useful in preventing colds after 
exposure to cold and chilling. They relieve intense pain, 
as in renal colic caused by the passage of stone from the 
kidney, and will stop convulsions in children. Hot 
baths are also used to cause sweating in many cases of 
poisoning from insufficient action of the kidneys; but 
where patients are weak in such conditions hot blankets BATHS 
87 
are usually wrapped about them in bed. In taking a 
hot bath before bedtime a cold cloth should be worn on 
the head to prevent insomnia. 
The Turkish Bath and Hot-air Cabinet Baths.—Boxes 
or cabinets are often used in public bath places and at 
home in which a person sits tightly enclosed (in a nude 
state), with the head out in the air of the room. These 
cabinets are heated by dry air from electric lights or 
steam pipes, or moist air is used by the evaporation of 
boiling water over a lamp, as in folding cabinets for home 
use. The object is to produce excessive sweating for the 
prevention of cold, treatment of Bright’s disease of the 
kidneys, rheumatism, etc. A cold cloth should be worn 
on the head. A person may remain in the cabinet for 
twenty or thirty minutes, providing the heat is not too 
oppressive. An attendant should always be at hand. 
In a Turkish bath a hot-air bath is given at 120° to 170° 
F., the subject breathing the air. This is followed by a 
hot shower and massage in a room filled with hot, moist 
air (100° to 110° F.), and then by a warm shower changing 
to cold, with thorough rubbing and drying. Turkish 
and Russian baths are depressing to the circulation, as 
are all hot baths, and should not be taken by very stout 
persons or those with weak hearts. Exposure to cold is 
dangerous after such baths, and for that reason hot 
baths are best taken at home. If taken elsewhere in 
cold weather one should return home in a closed convey- 
ance. Some forms of rheumatism and stiffness of the 
muscles and joints after severe exercise are much bene- 
fited by hot baths, but the dry, hot air of a cabinet is 
less depressing and exhausting than the moist air, 
especially where one has to breathe it, as in the Turkish 
bath room. 88 
THE PREVENTION OF DISEASE 
VENTILATION 
A word about ventilation may not be amiss. The 
older ideas concerning ventilation have been gradually 
slipping away, especially the belief that the exhalation of 
carbonic acid gas from the lungs, and corresponding con- 
sumption of oxygen by occupants of a room, is the chief 
cause of bad air is crowded apartments. Leonard Hills’ 
startling experiment with a group of persons in an air- 
tight chamber, in which the oxygen was used up until 
matches would not burn, should be sufficient to shatter 
the carbonic acid poisoning theory. The occupants 
laughed and chatted while vainly endeavoring to light 
cigarettes, but remained perfectly comfortable so long as 
the air was kept cool. 
Modern conceptions of ventilation are based on two 
fundamental experiments: “First, that subjects immured 
in close chambers and exposed to the heat, as well as the 
chemical products found therein, are not at all relieved by 
breathing pure outside air through a tube. Second, that 
they are completely relieved by keeping the air artificially 
cooled without changing the air at all, and are relieved to 
a considerable extent by the mere cooling effect of the 
electric fan.” The stale air of crowded and ill-ventilated 
rooms is chiefly air which has become overheated and 
oversaturated with moisture through radiation from its 
human occupants. Good ventilation means primarily 
and essentially constant movement of cool air. 
The matter of the best degree of moisture in air is at 
present unsettled. Very dry air, as from hot-air furnaces 
containing an insufficient amount of water from evaporat- 
ing pans, is notoriously harmful to the mucous membranes 
and predisposes to catarrh. A temperature over 65° or 
70° F. lessens the comfort and efficiency in work and THE COMPLEXION 
89 
causes slight increase in body heat and rise in pulse-rate. 
There is still another element in connection with ventila- 
tion, and this is the exhalations from the mouths, bodies, 
and clothes of individuals in crowded rooms, which aid in 
making the air stale and unpleasant. Of just what these 
emanations consist is unknown, but, while they are often 
not perceived by occupants of a room, they become very 
objectionable to the outsider entering a crowded apart- 
ment. Bad air of ill-ventilated rooms resolves itself 
chiefly into overheated and overmoist air having insuffi- 
cient movement. It is corrected by reducing the tem- 
perature below 70° F. and by affording some means of 
generating a current of air. Emanations from many 
individuals also play a less important part in the produc- 
tion of a stale or foul atmosphere. 
THE COMPLEXION 
There is a vast deal of nonsense in the idea fostered 
by advertising that great discrimination is necessary in 
the selection of a toilet soap. As a matter of fact, it is not 
best to use soap at all, habitually, on the face unless the 
skin is oily or soiled. One toilet soap is about as good as 
another if it is a pure soap. Soaps are made by boiling 
fats of different kinds with alkalies. The cheaper soaps, 
as yellow laundry soaps, contain an excess of alkali which 
is useful in removing dirt from clothes, but irritates, 
roughens, and dries the skin by removing its natural 
oily secretion. Plain castile soap or any of the more 
expensive soaps have little or no free alkali and are equally 
serviceable. Medicated soaps have not much value 
because the soap is in contact with the skin such a short 
time. Some persons find special soaps agree with their 
particular skins more than others, as the French Societe 
Hygienique soap (plain), for instance. Cold water 90 
THE PREVENTION OF DISEASE 
should be used on the face, as it gives color, improves 
tone, and tends to prevent wrinkles. Warm water 
relaxes the skin and favors chapping on exposure to cold. 
The various proprietary toilet preparations for applica- 
tion to the face are usually harmless, and may afford 
much satisfaction to the users and peculiar profit to the 
maker, but, as a rule, are wholly unnecessary. The 
application each night of cold cream to the face by 
thorough rubbing will preserve the complexion clear 
and free from wrinkles better than any other applica- 
tion, and the same is useful to prevent chapping of the 
skin of the face or hands in winter. In summer the use 
of rice powder on the face will tend to absorb perspiration 
and prevent sunburn. The proprietary face powders are 
much more expensive and no more effective, while the 
same remarks apply to the face creams as compared to 
cold cream. 
Freckles due to a deposit of pigment in the skin may 
be caused by exposure to the sun, when they go away 
spontaneously. Then there are permanent freckles, 
more often in blondes, owing to some inborn peculiarity 
of the skin. To prevent freckles the skin must be pro- 
tected from the sun by some covering as a hat, veil, or 
gloves, or covered with brown grease paint. For the 
removal of freckles white precipitate ointment may be 
applied each night. To prevent and cure sunburn noth- 
ing is better than an application of calamine lotion, and is 
more agreeable than the brown grease paint, also efficient 
as a preventive. Both the precipitate ointment and 
calamine lotion are kept by all druggists. 
Acne.—In acne there are pin-head and larger sharp- 
pointed pink or reddish pimples with a central opening 
often containing a black speck. These are accumulations 
of the naturally greasy secretion in the pores of the skin, THE HAIR 
91 
causing irritation of the surrounding integument. Some- 
times the pimples contain matter and become as large as a 
pea. Acne pimples occur on the face, shoulders, chest, 
and back. The disease first appears somewhere between 
the twelfth and fifteenth years, and usually disappears 
between the twenty-third and thirtieth years. General 
care of the health does much to prevent and cure the 
disease. The bowels should move daily (see Consti- 
pation, page 319). A cold bath should be taken daily, 
followed by vigorous rubbing, or a warm bath for those 
not able to take a cold one. 
Regular exercise outdoors is also imperative in play or 
sports, as bicycling, riding, horseback, rowing, etc. Diet 
is of great importance. Candy, pastry, cakes, and pies 
should be forbidden, also tea and coffee. If the patient is 
thin or debilitated and pale, he must be built up with good 
nourishing food, as cream, milk, and butter. Cereals are 
valuable, with the exception of oatmeal, which sometimes 
seems to favor acne. Green soap and water should be 
applied to the face every night, and after the face is 
dried the writer has found that the application of a 
proprietary preparation, Dermatone, is very effective 
in curing the disease. 
Alkaline mineral water is also useful and a quart bottle 
of Vichy Celestins may be taken daily. In place of this, 
six or eight glasses of water, with a pinch of salaratus in 
each, may be drunk to advantage each day. 
THE HAIR 
Baldness and Dandruff.—Dandruff is the commonest 
cause of baldness. Dandruff is a germ disease in itself 
(Seborrhea sicca) which is contagious. After a period 
of two to seven years of dandruff and dryness of the hair, 
occurring between the twentieth and thirtieth years, 92 
THE PREVENTION OF DISEASE 
baldness begins. As the baldness increases, usually at 
the top of the head, the dandruff diminishes. Not every- 
one with dandruff becomes bald, but baldness is the prob- 
able result, especially in men. In dandruff the germ 
ultimately destroys the roots of the hairs, which then fall 
out. Prevention is most important. One should not 
wear other people’s headgear or use their brush and comb 
so as to convey the germ from diseases scalps to one’s 
own. Lassar reproduced dandruff in guinea-pigs by 
rubbing the scales from a diseased human scalp into the 
backs of these animals. 
To cure baldness it is first essential to prevent or cure 
dandruff, and the baldness will then be cured or will fail 
to progress. A hair wash should be used with which to 
thoroughly shampoo the scalp night and morning until the 
dandruff disappears. If the dandruff returns, the wash 
should be again applied. It is possible that dust may 
transmit the germ of dandruff. The wash is composed of 
mercury bichlorid, 10 grains; glycerin, 1 dram; alcohol 
(70 per cent.), 8 ounces. This is poisonous if swallowed. 
If the skin of the scalp becomes too dry, a little sulphur 
ointment may be rubbed in night and morning in place 
of the wash. The scalp may occasionally be washed with 
tincture of green soap. Most hair tonics and pomades 
are of no value, being founded on the older idea that the 
scalp needs stimulating in baldness. Of course, there are 
other causes of baldness than dandruff, but it has been 
authoritatively stated (Jackson) that 70 per cent, of all 
cases of baldness result from dandruff, although there 
is undoubtedly an inherited lack of resistance to this 
infection. 
Constant wetting of the hair is undesirable. Frequent 
cutting stimulates the growth of hair, but does not 
increase the number of hairs. Barbers are prone to FINGER- AND TOE-NAILS 
93 
advise singeing to make the hair grow thicker, but it has 
no action of this kind. 
There is undoubtedly danger of contracting serious 
infections from the barber shop. Syphilis may be com- 
municated from a razor not thoroughly sterilized. 
Several germ and parasitic skin disease may be conveyed 
from patients by barbers to other customers through the 
medium of the razor, scissors, brush and comb, and moist 
towrels. These include the germ disease dandruff from 
brush and comb, also barber’s itch, an eruption on the 
bearded chin and upper lip of inflamed pimples containing 
matter or pus. This disease is contagious by means of pus 
germs (staphylococci). Ringworm of the face is due not to 
a worm, but to a vegetable fungus. It occurs as circular, 
partly bald patches on the chin, or as scaly or weeping 
reddish lumps arranged in a circle, on which the hair 
is more or less wanting. This disease may be contracted 
from the barber. Besides dandruff, barber’s itch, 
and ringworm, it is possible that boils and carbuncles 
may be transmitted by the barber’s appliances from one 
person to another. The only way to surely avoid these 
troubles at a barber shop is to furnish all one’s own 
materials—razor, soap, brushes, and comb—and to 
have only a clean dry towel used on the face. 
It is not safe to rely upon barber’s methods of steri- 
lizing their utensils. 
While the finger-nails should be cut so that they will 
follow in outline the contour of the fingers, it is best to 
trim the toe-nail in a straight line across the ends of the 
toes to better prevent the effects of pressure on them by 
the boots, 
FINGER- AND TOE-NAILS CHAPTER IV 
GERM DISEASES 
Vaccination, Small-pox, Chicken-pox, Typhoid Fever, Asiatic 
Cholera, Dysentery, Diphtheria, Hydrophobia, Lockjaw, Scarlet 
Fever, Measles, Mumps, Whooping-cough, Bubonic Plague. 
VACCINATION, SMALL-POX AND CHICKEN-POX 
For the prevention of disease is it extremely important 
in communicable disorders that the patient be isolated. 
In most of these fever is the first symptom and, in the 
eruptive contagious disorders the characteristic rash 
does not appear for from one to four days. Children are 
more commonly attacked and so when they have a fever 
or cold, or both—they should be kept apart from other 
children in a room with closed doors. 
It is also advisable for the attendant always to wash 
the hands after handling a fever patient, and see that the 
eating and drinking utensils and napkins be boiled before 
they are used by others. Also, in the case of sore throat, 
colds in the head and cough, it is well that the attendant 
avoid close proximity to the patient as far as practicable. 
With the appearance of any rash in the course of fevers 
the services of a physician are urgently demanded and the 
same necessity arises when there is sore throat with fever, 
in order that an early diagnosis be made. 
The failure of parents and guardians to secure medical 
aid in contagious diseases is regarded in law as criminal 
neglect and those responsible may be held liable to 
punishment. 
The most successful examples of vaccination against 
germ diseases at the present time include vaccination for 
94 VACCINATION, SMALL-POX AND CHICKEN-POX 
95 
small-pox, typhoid fever, diphtheria, lockjaw, hydro- 
phobia, dysentery, cholera, plague, and cerebrospinal 
meningitis. It might at first sight appear disheartening 
to find many persons and sects still actively opposing 
vaccination for smallpox after considerably more than a 
century’s absolute proof of its efficacy. But this very fact 
is a natural result of the success of vaccination in almost 
eradicating one of the most fearful scourges of mankind 
(Magna Pesta), responsible formerly for nearly half a 
million deaths in Europe alone. In 1760 it was estimated 
that small-pox carried off from one-thirteenth to one- 
fourteenth of each generation, and but one person in 
twenty escaped the disease before the days of vaccination. 
So that at the present time the foolish may safely combat 
vaccination without being punished for their folly by 
taking small-pox. But the deluded are not be any means 
always born idiots, for Herbert Spencer late in life wrote 
an essay attempting to prove vaccination a fallacy. 
Lady Wortley Montagu, in 1718, introduced from Asia 
into Europe the practice of inserting matter from the 
small-pox eruption into scratches made in the skin of sus- 
ceptible persons, and by so doing reduced the death-rate 
to 1 per cent., but at the same time greatly increased the 
prevalence of the disease in a mild form. It had long 
been known in England and elsewhere that accidental 
inoculation with cowpox while milking would render the 
inoculated person safe from small-pox. 
Acting on this knowledge, in 1774 Benjamin Jesty, a 
Dorsetshire farmer, who had himself escaped small-pox 
by acquiring the cow disease, proceeded to rub some of 
the matter from the cow eruption into scratches in the 
skin of his wife and his two infants, who remained proof 
against small-pox. This is the first recorded instance of 
vaccination. Again, in 1791, Peter Plett, in Holstein, 96 
THE PREVENTION OF DISEASE 
haying seen doctors inoculate small-pox into people, and 
knowing the accepted tradition that milkers who had 
acquired cowpox were safe from small-pox, tried the 
experiment himself of inoculating cowpox. Being tutor 
in a family, he had the temerity to transfer the matter 
from the eruption of cowpox into incisions, made with 
a pocket knife, on the back of the hands of his three pupils. 
But so successful was this rough-and-ready experiment 
that three years later these vaccinated children were the 
only ones spared in an outbreak of small-pox. 
Jenner is given the credit of being the orignator of vac- 
cination, but while this is not so, he is justly regarded 
as the author or father of vaccination because it was he 
who first introduced it to mankind, and his was the con- 
ception that by this method small-pox might be abolished 
from the world and to it he devoted his life and strength. 
His first successful vaccination was in 1796. 
Cowpox is generally regarded as a form of small-pox 
modified by passing through the cow. The disease 
attacks chiefly young cows, is mild, and the eruption, 
similar to that seen on the vaccinated arm of a man, is 
commonly confined to the udder. The vaccine matter 
is obtained by inoculating the bellies of calves with 
vaccine matter taken from other calves or from vacci- 
nated human beings, which has been examined micro- 
scopically to prove its absence from harmful germs. The 
matter having been rubbed into scratches on the clean 
skin of the calf, the eruption is scraped off between the 
fourth and sixth day, and this material is then ground in a 
machine and mixed with glycerin to kill all germs, except 
those of cowpox. 
The calf is killed and examined carefully to prove its 
healthy condition. A successful vaccination will in- 
variably afford protection against small-pox after eight 97 
VACCINATION, SMALL-POX AND CHICKEN-POX 
to eleven days from the time of vaccination. As small- 
pox requires from ten to twelve days to develop, one may 
avoid small-pox if vaccinated within the first six days 
after exposure, and even if vaccination be delayed till 
the eighth day the small-pox will be of a mild character. 
But if vaccination is delayed till after the eighth day 
following exposure of a person to small-pox it is useless in 
preventing the disease. Practically nobody is immune 
to vaccination, but it is not safe to infer that because a 
vaccination or re vaccination does not “take,” the person 
is immune to small-pox. 
It will naturally be asked. How long does vaccination 
protect one from small-pox? This cannot be answered 
by any stated period, because it is variable, from months 
to many years. Usually from five to seven years. The 
safest method to pursue is that in which children are 
vaccinated between the ages of six months and two 
years; again, when they enter school; and a third time 
within a period of ten years, and after this whenever there 
is special danger. A simple test has recently been used to 
show if a person is immune to small-pox at any period fol- 
lowing successful vaccinaton. A drop of vaccine is 
rubbed into a single small scratch in the skin. If the 
person is immune, a red area will surround the scratch 
within twenty-four hours, which may increase within 
forty-eight hours, and then rapidly fade away. This 
is called the “immunity reaction.” Compulsory vacci- 
nation and revaccination should be required in all states, 
and has been upheld by the Supreme Court of the United 
States. 
The dangers of vaccination are frequently exaggerated, 
and “compulsory school attendance is far more dangerous 
than compulsory vaccination.” In ten million people 
vaccinated in the Philippines between 1905-15, there was 98 
THE PREVENTION OF DISEASE 
not a single death, accident or serious complication caused 
thereby. Almost all the severe cases of complication 
after vaccination are avoidable, being due to local infec- 
tion from carelessness of the doctor or patient in caring 
for the wound. Vaccination is a surgical procedure and 
should always be carried out as such. The arm should 
be vaccinated and not the leg, unless the patient remains 
in bed during the course of the vaccination, since inflam- 
mation of a serious character will often follow. The 
arm should be washed with soap and water, and then 
with alcohol, and the skin allowed to dry before the 
vaccination is done. 
Three scratches a quarter of an inch long and three- 
quarters of an inch apart, but not deep enough to draw 
blood, are made with a sterilized needle. Cross scratches 
near together are undesirable, because a scab will then 
form, which causes irritation, scratching, and infection. 
After the vaccine matter has been rubbed into the 
scratches with the side of the sterile needle, and has dried, 
a light dressing of six layers of sterile gauze should be 
kept over the vaccination by strips of adhesive plaster 
to protect it from unclean clothing. 
It may be superfluous to give facts which may be used 
to refute the unbelievers in vaccination, but as more than 
40 per cent, of adults are unvaccinated in some states 
and a large proportion of the remaining 60 per cent, are 
not properly vaccinated, it should not be amiss. The 
classical example in this country is that of Benjamin 
Waterhouse, Professor of Physics at Harvard, wrho on 
July 8, 1800, first introduced vaccination into the United 
States by vaccinating seven of his own children. In 
Boston, in 1802, 19 boys were vaccinated, and almost 
two months later 12 of these boys were inoculated with 
small-pox; nothing followed. At the same time 2 VACCINATION, SMALL-POX AND CHICKEN-POX 
99 
unvaccinated boys were inoculated with small-pox and 
both took the disease. Finally, the whole 19 vaccinated 
children were again inoculated from matter taken from 
the fresh eruptions from the two boys with small-pox, 
but small-pox did not follow in any single case. 
“This is one of the most crucial experiments in the 
history of vaccination, and fully justified the conclusion 
of the (Boston) Board of Health—‘cowpox is a complete 
security against small-pox’” (Osier). There is not the 
slightest danger for one recently and successfully vacci- 
nated in caring for small-pox patients, and newspaper 
heroism is thus easily acquired. A modern instance of 
the success of vaccination is seen in the Philippines 
since our occupation. After 1907 systematic vaccination 
in the six provinces near Manila (with a population of 
over a million, and having from time immemorial a death- 
rate of over 6000 from small-pox) has resulted in no 
death in the successfully vaccinated and but a few 
scattered cases of small-pox. Between 1915-19 vaccina- 
tion of newborn children in Manila was not carried out 
and 700 deaths from small-pox were reported there 
during the summer of 1918. Small-pox attacking a 
person who has been vaccinated within five or six years 
is usually of a mild type and is called “varioloid.” Pit- 
ting rarely occurs in these cases, but occasionally small- 
pox appearing within a few years after vaccination is 
severe and even fatal. 
Vaccination is, then, the chief preventive means 
against small-pox. In addition, isolation of the sick in 
a guarded house or in a hospital, and vaccination of 
exposed persons, who should be isolated and watched 
daily for three weeks, are essential. The patient’s 
discharges should be covered with 1 part of chlorid of 
lime in 8 parts of water, and the attendants not be 100 
THE PREVENTION OF DISEASE 
permitted to leave the premises. After the disease has 
terminated the mattresses should be burned and the 
bedding and clothing boiled for half an hour. It is 
being generally accepted by medical authorities that the 
contagious eruptive skin diseases, as scarlet fever, measles, 
and small-pox, are chiefly communicated by the secretions 
of the eyes, nose, skin and throat, and by direct contact of 
persons with these secretions—not through the air by 
means of scales or some imaginary emanation fron the 
skin. If every one were properly vaccinated small-pox 
would disappear, and an adult acquiring the disease now- 
a-days should rather be regarded as an object of shame, 
and might not unfairly be subject to fine or punishment.. 
A word may be said about the recognition of small-pox. 
As influenza or grip is usually more familiar and common 
and, as the early symptoms of small-pox are very similar, 
small-pox is ordinarily mistaken for grip during the first 
three days of fever, headache, backache and vomiting. 
But after that time the fever and illness often subside 
and on the fourth day the eruption of small-pox appears, 
first on the forehead, face and front of the forearms. 
This occurs as red spots, like flea bites, soon becoming 
hard, shot-like pimples. On the second or third day 
these are tipped with little blisters with depressed centers, 
Three days later the blisters become filled with matter 
or pus, and are surrounded by a red area, and the skin is 
tight and swollen. A period of 10 to 12 days elapses 
after exposure before small-pox begins. Rarely from 5 to 
20 days. 
Of late years many cases of small-pox have been very 
light and in some it has been difficult to distinguish 
small-pox from chicken-pox. 
In chicken-pox there may be 24 hours of grip-like 
symptoms, rarely longer, before the rash appears. The VACCINATION, SMALL-POX AND CHICKEN-POX 
101 
eruption occurs on the body, rather than on the face, 
and pustules never form, that is pimples with matter in 
them. Adults rarely have chicken-pox and persons 
recently and successfully vaccinated do not have small- 
pox. The long period of invasion (3 days) before the rash 
appears, its greater severity, the formation of pustules, 
the location of the rash on the face rather than on the 
body, all speak for small-pox rather than chicken-pox. 
Also if many adults are affected the disease is more apt 
to be small-pox. There is now a laboratory test for small- 
pox in which a rabbit previously vaccinated against 
small-pox is injected with the contents of the eruption 
from a person. If the case be small-pox swelling and 
redness of the skin appears on the rabbit, but not so if 
the material be taken from a case of chicken-pox. 
In chicken-pox a period of 13 to 16 days elapses 
after exposure before the disease begins. 
This period of incubation may vary between 11 and 
24 days. 
Some fever, chills, pains in the back and legs may 
precede the eruption of chicken-pox for 24 hours. The 
rash appears first on the back or chest as red pimples 
which soon develop into pearly blisters surrounded by a 
red area. There may be a dozen or several hundred of 
these blisters and they do not run together as in small- 
pox. After 3 or 4 days they dry up and are covered with 
a dark brown crust which later drops off leaving a red 
spot. 
Several crops of these blisters form in the first few 
days so that as some are drying up new ones may be 
seen. Matter or pus does not form in these pimples, 
as in small-pox, unless they are scratched and infected. 
On the other hand, the eruption does occasionally first 
appear on the face in chicken-pox as in small-pox. 102 
THE PREVENTION OF DISEASE 
When a small-pox patient is well, and free from all 
scabs he may reenter the world in new or disinfected 
clothes after a period of 6 to 8 weeks, or even months. 
Vaccination against typhoid fever is now the most im- 
portant means of prevention, but one which has not yet 
been popularly appreciated and accepted. The prin- 
ciple of vaccination is that by the injection under the 
skin of dead germs of typhoid fever there is a production 
in the patient of antibodies, thus affording an active 
immunity to the disease such as occurs after an attack 
of typhoid fever. 
It is rare that persons have typhoid fever more than 
once, but occasionally second and third attacks occur. 
In 1897 Sir A. E. Wright vaccinated 17 persons against 
typhoid fever, and was the first at this time to recom- 
mend the method as a general preventive measure 
against typhoid fever. In the preparation of this vac- 
cine the typhoid fever germs are grown on suitable 
media, and then mixed with salt solution and killed by 
exposure to heat (129.2° F.) for one hour, when they are 
further diluted with salt solution to a standard strength, 
a small amount of antiseptic is added, and doses of 
500,000,000 and 1,000,000,000 dead germs are put 
up in hermetically sealed glass tubes. The vaccine is 
tested to show its freedom from living germs, and by 
injection into animals to prove its immunizing strength 
and freedom from harmful germs, especially those of 
lockjaw. Three doses are injected under the skin at 
about the site of ordinary vaccination of the arm, at 
intervals of seven to ten days, using a dose of 500,000,000 
the first time and 1,000,000,000 of the dead germs at 
each of the later injections. There is some swelling 
TYPHOID -FEVER TYPHOID FEVER 
103 
and redness at the site of the injections, and there may 
be fever, headache, nausea, and a feeling of weariness for 
a short time after the injections, but no dangerous or 
fatal result has occurred in the millions of persons so 
treated. In about two-thirds of the cases there are no 
general symptoms produced. The injection is made in 
the late afternoon, and neither alcohol nor violent exercise 
should be taken thereafter. 
Typhoid fever has often been more fatal than bullets in 
war. Thus in the Boer War over 7000 died through 
wounds and over 8000 by typhoid. Of our troops in 
the Spanish-American War, 243 died of wounds and 1580 
perished of typhoid fever. 
Before typhoid vaccination began there were 10,759 
soldiers at camp at Jacksonville in 1898, and over 2000 
cases of typhoid with 248 deaths 
After vaccination there were 12,801 troops at San 
Antonio, under approximately the same conditions and 
length of time, with only 2 cases and no deaths. Since 
1911 vaccination has been compulsory throughout the 
United States Army in persons under forty-five years of 
age. Among 80,000 to 90,000 persons thus vaccinated 
there were but 3 cases of typhoid fever in 1913 and no 
deaths, as against several hundred cases in previous 
years, with from 22 to 74 deaths. Owing to vaccination, 
for the first time in 1913 in any army no deaths from 
typhoid fever occurred in the United States troops. 
Typhoid vaccine is now supplied free in many states, 
and its use in civil life should become general and 
customary. 
All children and young adults should be vaccinated, 
as typhoid fever is a disease of the young, and vaccination 
is less disturbing to children, rarely keeping them from 
school or play. The dose is regulated by their weight. 104 
THE PREVENTION OF DISEASE 
Vaccination is especially indicated for all colleges, insti- 
tutions, and boarding schools, and particularly in hospi- 
tals and dispensaries for doctors, nurses, and attendants. 
Travelers in the country and in unsanitary cities, in- 
habitants of typhoid-ridden regions, and for all campers 
the use of vaccination as a preventive for typhoid should 
be the rule. 
At present it is not known how long the protection 
against typhoid fever, conferred by the vaccination, will 
last. The protection may last for months, years or 
for life, but there is no means of foretelling in any given 
person how long it may persist. The majority of people 
will be certainly immunized for a year. In the Army 
vaccination against typhoid fever is required on enlist- 
ment and again three years later, and it is hoped that 
these two vaccinations will protect an individual for 
life against typhoid. Typhoid vaccination is as impor- 
tant as vaccination against small-pox, and there is suffi- 
cient evidence to recommend it for all healthy children 
and adults under 45 in any part of the United States. 
In the Army vaccination is not required in persons over 
forty-five but, while unusual at this age, typhoid fever 
may attack much older persons. If individuals are to 
live in a region infested with typhoid vaccination is 
advisable at any age. The final test and triumph of 
typhoid vaccine came in the Great War when, among 
2,121,396 vaccinated men in the A. E. F., there were but 
213 deaths from typhoid fever. 
If the men had been unvaccinated, and the same death 
rate had prevailed as in the Spanish-American War, 
there would have been 68,164 deaths from typhoid 
fever. It is now customary to combine with the typhoid 
vaccine the dead germs of paratyphoid fever, A and B, 
750 million with every 1000 million killed typhoid TYPHOID FEVER 
105 
bacilli. ‘This mixed vaccine will prevent paratyphoid 
fever which is a milder allied infection and often mistaken 
for typhoid fever. Sometimes only two injections of 
typhoid vaccine are given, 8 to 10 days apart, instead of 
three doses. 
How We Take Typhoid Fever and Means of Avoiding 
It.—While the prevalence of typhoid fever in the United 
States is perhaps half what it was forty years ago, yet 
it is two to five times higher than it is in enlightened 
European countries today. As every case of typhoid 
depends, in the last analysis, upon the direct or indirect 
transmission of typhoid germs from the excrement or 
urine of patients (or carriers of germs) by “food, fingers, 
or flies,” to a susceptible person, the disposal of excretions 
becomes of chief importance. In cities this is the main 
object of a public sewage system since not only the germs 
of typhoid fever but those of dysentery, diarrhea, cholera, 
and (rarely) tuberculosis, together with the eggs of round- 
worm, tapeworm, and hookworm are transmitted to man 
by means of the excrement. Indeed, if typhoid germs were 
kept out of every human body for eighteen months it is 
probable that the human disease would forever disappear. 
In the country districts the care of human excretions is 
in the hands of individuals. Here human excreta may 
contaminate wells by leaking out of privies into surface 
soil and thus into loosely capped wells. It may be dis- 
seminated by the feet of humans and animals when on the 
surface of the ground, and it may pollute milk and other 
food through soiled fingers and flies, or by direct contact, 
when human excrement is used for manure in growing 
vegetables eaten raw, as strawberries, lettuce, radishes, 
etc. 
The proper construction of privies becomes then of 
prime importance. They should be fly-proof and tlie 106 
THE PREVENTION OF DISEASE 
receptacle for the excreta should be water-tight. The 
privy must have a tight roof, sides, door, and floor to 
exclude flies. Air holes for ventilation, in the sides near 
the top, should be screened for the same reason. On the 
tight floor is erected the seat. The front of the seat is 
hinged so as to open. Through this opening is placed a 
large galvanized iron pail under the hole in the seat. The 
front of the seat is then closed and fastened until it is 
necessary to empty the receptacle. The hole in the seat 
must be always tightly covered when not in use, to keep 
flies from contact with the excretions. This is accom- 
plished by causing the cover to automatically fall when 
not resting against the back of the occupant. A projec- 
tion from the back wall of the privy will hold the cover 
forward so as to rest upon the back of the occupant of 
the seat. When the person rises the cover, therefore, 
falls by gravity, and a careless individual cannot leave the 
seat uncovered. The contents of the receptacle may be 
kept fairly odorless by scattering dry earth on it each 
time the closet is used. When the pail is full of excre- 
ment it should be buried more than 18 inches deep and 
covered with lime. Human excrement should not be 
used for manure. 
The germs of typhoid fever enter the body through the 
mouth in food and water contaminated writh excrement or 
urine of typhoid patients. 
Typhoid fever is not communicated from the sick to 
persons merely entering the room of the patient, but 
attendants who handle the patient’s body, his clothing, 
and vessels containing his discharges often acquire the 
disease by soiling their hands and thus their food. By 
sterilizing everything after contact with the patient, even 
boiling his bath water, by covering the discharges with 1 
part of freshly slaked lime in 8 parts of water for an hour, TYPHOID FEVER 
107 
and by the attendants wearing rubber gloves and long- 
sleeved aprons, communication through contact with the 
patient may be averted. 
Water and milk are the chief sources of typhoid fever. 
The Chinese never drink raw milk or unboiled water and 
rarely have typhoid fever, while the disease is common 
among the white people living in China—a commentary 
on our civilization. Milk is the most common cause of 
typhoid fever in cities having a good water-supply (see 
page 345). Typhoid germs are conveyed to milk by 
patients or “carriers,” persons who have recovered from 
the fever, but excrete germs in their urine and excrement 
for months or years afterward. One per cent, of typhoid 
convalescents become “ carriers.’’ 
Typhoid germs enter water from sewage, privies, and 
surface-water contaminated with the discharges of 
typhoid patients. Typhoid fever germs usually perish 
in filthy water within two days or a week, but may live 
in still water in reservoirs and wells for several months, 
and in ice as long as three months. Most large cities in 
civilized countries have an unpolluted water-supply, 
otherwise one must only drink boiled water. 
Raw vegetables soiled by contaminated water or 
human excrement or by handling, and raw oysters taken 
from beds polluted by sewage are occasional sources of 
typhoid fever. Flies are common carriers in camps and 
elsewhere, flying directly from typhoid discharges to 
alight on food. They were the great sources of the 
disease in the southern camps of our troops in the 
Spanish-American War. In camps where large amounts 
of contaminated dust may settle on the food we have 
another possible source of typhoid infection. Then 
there are the human “ carriers/’ noted above, who live 
among us for years unsuspected and innocent of their 108 
THE PKEVENTION OF DISEASE 
malign influence until some energetic health officer traces 
an outbreak of typhoid fever to the unfortunate cook, 
waiter, or dairy employee or other “carrier” engaged in 
handling food. 
It has recently been stated by Lumsden (United States 
Public Health Service) that the use of typhoid vaccine 
lessens the susceptibility to typhoid fever by 75 per 
cent, or more, yet persons so protected may succumb 
to an enormous number of typhoid germs such as may 
be found in milk contaminated by the infection. There- 
fore typhoid vaccination cannot wholly supplant sanitary 
preventive measures. The susceptibility to typhoid 
fever differs in the same individual at different times and 
does not depend upon general robustness. When 
numbers of persons drink the same water containing 
typhoid germs perhaps only 1 in 10 or 1 in 100 will take 
typhoid fever, so that susceptibility is an important 
factor. 
The early recognition of typhoid fever is very important, 
especially to protect others. A little blood (Widal test) 
is commonly sent to the laboratory to test its action on 
the germs of typhoid fever, causing their clumping 
together. But this test is operative in only 20 per cent, 
of typhoid cases during the first week. On the other 
hand, if the doctor sends a larger amount of blood for 
a blood culture, and identification of the special germs 
of typhoid fever, the germs may be found during the 
first week in 90 per cent, of cases of typhoid fever. In all 
fevers, when the diagnosis is doubtful, a blood culture 
should be done within a few days after the onset of the 
fever. 
Cholera is a disease in which the infecting germ always 
enters the mouth in food or drink, inhabits the intestines, 
ASIATIC CHOLERA ASIATIC CHOLERA 
109 
and passes away in the bowel discharges. It is similar in 
these respects to dysentery and typhoid fever, and, in 
fact, cholera is no more contagious than typhoid fever, 
according to Osier. India has been the home of the 
disease from time immemorial, and not until the nine- 
teenth century did it invade Europe. While cholera is 
frequently brought to seaports in the United States and 
Great Britain, it is easily kept from spreading by modern 
methods of sanitary control. Within recent times cholera 
has been prevalent in the near and far East, India, 
Russia, Italy, North Africa, Asia Minor, Arabia, and 
Turkey. While cholera was one of the most common 
diseases in the Philippines after the American occupa- 
tion, it has been almost extinguished by our Public 
Health Service. 
The disease is transmitted by the germs escaping in the 
bowel discharges of the sick, convalescent, and the 
apparently healthy, who may act as “carriers.” Eight 
per cent, of 376 healthy persons were found to be carriers 
in Manila. Here, again, cholera infection is transmitted 
precisely as in typhoid fever, water being the commonest 
medium of infection; then raw food of all kinds which has 
become contaminated with infected water, flies from 
bowel discharges, or fingers soiled by handling patients, or 
from the personal discharges in carriers. Unboiled milk, 
cheese, and butter are frequent sources of infection; also 
raw fruits, salads, and vegetables, as lettuce, water cress. 
Cholera germs may live on butter, bread, or fresh meat 
for a week, so that the eating of recently cooked food and 
drink (including water and milk) must be insisted upon 
during cholera epidemics. The boiling of all utensils 
used to prepare, hold, or serve food is also essential. 
Some thick-skinned fruits and vegetables may be eaten 
with safety after immersing them in boiling water a few 110 
THE PREVENTION OF DISEASE 
moments, as oranges, apples, tomatoes, and mangoes. 
The hands must be frequently washed and always before 
eating, and the same care should be observed by cooks 
and waiters. All food should be carefully screened from 
flies. 
Infection through air does not occur because cholera 
germs are readily killed by drying. Mineral waters 
obtained from cholera-free regions and boiled water, or 
milk, tea, coffee, and chocolate are, of course, allowable. 
The use of alcohol favors cholera infection and any food 
which irritates the digestive tract and leads to diarrhea. 
Indigestible food, an excessive amount of fruit, fruit 
juices, or cream are thus harmful in cholera-infected 
regions. Constipation may be relieved by rectal injec- 
tions. Chilling of the body, worry, overexertion, and 
fright make persons more susceptible to cholera. 
A flannel bandage should be worn continually about the 
abdomen to prevent diarrhea. There is not much danger 
to persons during a cholera epidemic if they can follow 
out these precautions. Even doctors and nurses who are 
constantly exposed to cholera do not frequently take it, 
while those handling soiled clothes in laundries are 
especially prone to infection. 
Vaccines, consisting of both living and dead cholera 
germs, are injected under the skin to prevent the disease 
and diminish the mortality in those of the inoculated 
who do acquire it. The vaccines appear to greatly lessen 
the chances of infection in cholera epidemics, and also 
very considerably lower the mortality in the inoculated, 
but produce considerable local and general disturbance. 
They have, however, been used quite extensively and suc- 
cessfully in the Philippines, India, Russia, and in 
Iioumania during the Great War, where a vast cholera 
epidemic was evercome by vaccination alone without DYSENTERY 
111 
the aid of any other preventive measures. Haffkine’s 
vaccine, consisting of the killed cholera germs, has about 
halved the liability to take cholera and diminished the 
death rate in vaccinated persons from 75 to 42 per cent. 
The immunity conferred by the vaccine lasts about one 
year. After taking cholera germs into the digestive tract 
from two to five days are required to develop the disease. 
In many cases no symptoms are produced, and these 
vary from the mildest diarrhea to the constant draining 
away of rice-water discharges and collapse. Isolation of 
those sick with cholera and the most careful disinfection 
of their discharges and clothing and cleanliness of the 
hands are practiced precisely as recommended in the 
care of typhoid patients (see page 105) to prevent conta- 
gion from cholera patients. Microscopic examination of 
the bowel discharges of suspicious persons with diarrhea 
will determine the existence of the cholera germs. 
To prevent cholera entering this country requires 
constant surveillance of emigrants from cholera infested 
districts. Vessels are held in quarantine and emigrants 
detained five days while their bowel discharges are 
examined for the cholera germs or vibrios. 
Thus at Ellis Island in New York in 1912, 34,000 such 
examinations of feces were made from persons coming 
from cholera regions and 28 cases of cholera were dis- 
covered and 27 healthy carriers. 
DYSENTERY 
Dysentery is acquired like typhoid fever through water 
or food containing the dysentery germs (Bacillus dysen- 
teriae) escaping from the bowels of patients. Again, like 
typhoid fever, it may be acquired by persons who handle 
the patient’s body, clothing, and vessels holding his 112 
THE PREVENTION OF DISEASE 
discharges. More often the disease is taken by drinking 
contaminated well-water in the country or other polluted 
drinking-water, or by bathing in polluted streams. 
Dysentery is the great destroyer of life in the tropics 
and is common in summer in temperate regions, particu- 
larly in military camps and institutions, and as the 
“summer diarrhea” of children. In the tropics dysen- 
tery destroys more lives than cholera, it has been more 
fatal to armies than shot and shell, and has caused more 
invalidism and death than any other disease (Barker). 
The laity often call any severe diarrhea dysentery, but 
true dysentery begins with diarrhea or loose movements 
of the bowels, together with fever, loss of appetite, 
weakness and pains in the bowels, and then the true 
dysenteric symptoms are seen. These consist in painful 
straining and the passage of slime and blood. 
Milk is a common means of transmitting the disease 
through polluted water used in washing milk utensils. 
Flies also carry the germs directly from the bowel move- 
ments of patients to food. Then, again, persons who 
have dysentery in a very severe form and recover may 
harbor the germs in their bodies for a long time and even 
carry them over from one warm season to another. In 
other words, we have dysentery carriers as well as 
typhoid carriers. Patients with dysentery should be 
isolated and screened. 
Persons nursing patients should not cook or serve 
food. Flies are as dangerous carriers of germs to 
food as in typhoid fever. The bowel discharges of all 
patients, convalescents and persons in contact with 
them (contacts) should be frequently examined until 
known to be free from dysentery germs. Healthy 
carriers should not handle food. The means of convey- 
ing the germs of dysentery are the same as in typhoid DYSENTERY 
113 
fever; food and water, fingers and flies. Raw vegetables 
may also be sources of infection when saturated with 
polluted water. The means of prevention are precisely 
those outlined for typhoid fever; that is, the drinking of 
boiled water and milk, and the avoidance of raw vege- 
tables and fruits growing on the ground, as strawberries, 
the observance of the same care in the handling of 
dysentery patients and their bowel discharges, and, 
finally, the use of vaccine in epidemics in the case of 
those much exposed. The vaccine is made from cultures 
of the dysentery germs in the same manner as typhoid 
vaccine and administered in the same doses subcutane- 
ously. It will, however, only protect the individual 
for from eight to ten weeks against infection with 
dysentery. 
We have been speaking of the more common form of 
dysentery, or bacillary dysentery, as it is technically 
called. There is another form, the amebic dysentery, 
common also in tropical countries, in India, Egypt, 
the Philippines and Southern United States, and rarely 
throughout this country. This form of dysentery is 
more apt to be chronic and is not so prone to occur with 
the suddenness and fever of the more common tropical 
or bacillary dysentery; but the disease is produced by 
the lowest form of animal life—the ameba (entameba 
histolytica)—which can readily be seen in the bowel dis- 
charges under the microscope, and this test is the only real 
means of separating the two forms of dysentery. Liver 
abscess is one of the common complications of the amebic 
form of dysentery. Amebic dysentery is more common 
in the northern and middle portions of the United States 
than formerly believed. There are attacks of diarrhea 
containing mucus and blood, with soreness, tenderness 
and rigidity of the abdominal muscles. 114 
THE PREVENTION OF DISEASE 
After a few weeks the trouble may cease and the pati- 
ent appear well, except for some intestinal distress, and 
months may elapse (occasionally a year or two), before 
another attack of diarrhea ensues. 
With a history of previous diarrhea, obscure abdominal 
discomfort, and even constipation, it is always advisable 
that the fresh bowel discharges obtained by enema be 
examined microscopically for entamebae. In Seattle 
30 cases have been thus discovered in one of the hospitals 
in the past two years, many suffering from constipation 
at the time of examination. Liver abscess is not a 
common complication outside of the tropics. 
After swallowing the parasite from 20 to 95 days may 
elapse before diarrhea occurs. 
Patients may harbor the amebae in their bowels for 
years without symptoms. In active cases there are 
ulcerations in the upper part of the large bowel often 
causing appendicitis. Amebic dysentery can usually be 
distinguished from the other form (bacillary) by being 
milder and chronic, with long periods of normal health 
or constipation intervening. The treatment by subcu- 
taneous injections of the active ingredient of ipecac 
(emetin) is quite different from that for bacillary dysen- 
tery. Emetin is injected into a muscle once daily for 12 
days and about % of the cases are permanently cured, 
the other quarter relapsing after a few weeks and requiring 
a second course of treatment. Emetin is a specific 
poison for the entameba and a most successful remedy for 
amebic dysentery. As water appears to be the chief 
carrier of the ameba, the precautions to be adopted in 
the prevention of amebic dysentery are the same as those 
for typhoid fever and bacillary dysentery. It is important 
to avoid agents which may irritate the bowel, and so 
offer a favorable field for the growth of dysentery germs. DIPHTHERIA 
115 
in warm weather; these include the small fruits and unripe 
fruits, coarse cereals, and rye or whole wheat bread, and 
powerful cathartics. 
DIPHTHERIA 
It has been found that persons are much more resistant 
to diphtheria at some ages than at others. Thus, by 
means of the Schick test, it appears that at birth 90 
per cent, of infants are immune, and as high as 80 per 
cent, of adults, while of children from one to five years 
but 25 to 60 per cent, are immune.1 Since its discovery 
antitoxin has been used in an enormous number of cases 
to prevent diphtheria. The protection afforded by anti- 
toxin lasts but about ten days to three weeks, however, 
and so its use must be repeated every three weeks, or it 
may be only given to exposed persons or to those who are 
about to be exposed. 
It will be seen that young children are particularly 
susceptible and, therefore, those who most require such 
protection. 
Briefly, antitoxin is the liquid portion of the blood (or 
the blood-serum) of horses which have been made im- 
mune against diphtheria. 
Diphtheria germs are grown on the surface of broth, the 
germs are killed by adding an antispetic, and then the 
filtered broth containing the poison (toxin) produced by 
1 Immunity of persons at different ages as determined by the 
Schick test in over 20,000 individuals (Park). 
Percentage Immune 
At birth, 90 per cent.; 4 to 6 months, 70 per cent.; 6 to 9 months, 
40 per cent.; 1 to 2 years, 25 per cent.; 2 to 3 years, 35 per cent.; 
3 to 5 years, 60 per cent.; 5 to 19 years, 60 per cent.; 10 years, 
75 per cent.; over 20 years, 80 per cent, immune. 116 
THE PREVENTION OF DISEASE 
the growth of the germs is injected into healthy young 
horses every few days in gradually increasing doses. 
After several weeks of this treatment the animal is bled, 
the red cells are allowed to settle, and the clear, straw- 
colored serum is drawn off after the blood has stood 
awhile. This is antitoxin and must be tested as to its 
strength, which is stated in units. A unit is the smallest 
amount of this serum which will protect a guinea-pig 
from death after receiving a minimum fatal dose of diph- 
theria poison. To protect children from diphtheria 
a dose of antitoxin containing 1000 units should be 
injected under the skin, but in adults is safer to inject 
some 3000 units for this purpose. In the actual treat- 
ment of diphtheria the dose is 5000 units in ordinary cases 
in children and 10,000 units in severe cases. For the 
treatment of diphtheria in adults the average dose is 
10,000 units, and in severe cases 30,000 units, which is 
increased to 50,000 or 150,000 units in advanced and 
desperate cases. In either children or adults antitoxin is 
injected under the skin for protection or in the treatment 
of mild cases; in more severe cases it is injected deep into 
a muscle, and in serious cases it is injected immediately 
into a vein. It is rarely necessary to repeat doses of anti- 
toxin when they are given in proper dosage at the onset. 
There is considerable prejudice against antitoxin as a 
preventive in diphtheria, which, however, has but slight 
basis. 
In the first place, it is practically a sure preventive of 
diphtheria after exposure if given at any time before the 
disease is manifest, and in larger doses an almost sure 
cure if given within the first hours after the development 
of diphtheria. Thus, in New York, of 80,000 persons given 
antitoxin to prevent diphtheria, but 2 in 1,000 developed 
the disease and but 1 died. The disadvantages of anti- DIPHTHERIA 
117 
toxin are as follows: In from seven to ten days after its 
injection (rarely from one to twenty-one days) various 
forms of itching rashes appear in some cases, and they 
may be accompanied by weariness, fever, vomiting, pain 
in the joints, and some swelling of the glands (serum 
disease). These symptoms are usually not severe and dis- 
appear in three or four days. But rarely death has been 
caused by antitoxin under certain conditions, as when 
persons have previously received antitoxin after an inter- 
val of a week or any length of time greater than a week. 
Also in the case of persons subject to asthma, or those 
affected by the smell of horses (see asthma) and in some 
children with enlarged glands. Only one person in every 
10,000 injected with diphtheria antitoxin develops any 
serious symptoms, while only one death occurs in every 
50,000 people thus injected (Park). 
But harm from the use of antitoxin may always be pre- 
vented by injecting but 1 drop and waiting three hours 
for any unpleasant symptoms, as this dose cannot be 
dangerous. After this time the regular dose may be 
given, or if the small dose caused unpleasantness, the 
antitoxin may be injected in gradually increasing 
amounts. Such a course should always be pursued in 
persons who have formerly taken antitoxin, in those 
subject to asthma and sensitive to horses, and in any 
who may fear the treatment. The concentrated serum 
now used is much less likely to produce any rashes, as it 
is the amount of the horses’ blood that causes trouble. 
In children’s hospitals it has been the custom to give 
all the patients antitoxin at regular intervals, to prevent 
the occurrence of diphtheria, and in the Boston Children’s 
Hospital this was done for years without any untoward 
result. While antitoxin is not usually regarded as a 
vaccine, yet any material inoculated into persons to 118 
THE PREVENTION OF DISEASE 
prevent disease is a vaccine. Now permanent immunity 
is secured by the use of the toxin-antitoxin method. 
In cases of diphtheria the patient should remain in a 
room from which all the movables, as rugs and carpets, 
etc., have first been taken. 
Dogs and cats should be excluded. Cats occasionally 
have the disease and dogs can carry diphtheria. The 
attendant should gargle her throat frequently with a 
saturated solution of boric acid or with listerine, but there 
is no preventive so sure as antitoxin. The nurse should 
have her hair covered with a cap and her dress by a long- 
sleeved gown, which should be left in the room when she 
leaves it. Everything taken from the room should be 
first boiled or soaked for an hour in 5 per cent, solution of 
carbolic acid. A person is more likely to catch the 
disease if the patient coughs or sneezes in his face. The 
disease is chiefly communicated by convalescents who go 
about before the germs have left their throats (conval- 
escent carriers) or by exposed but healthy persons 
(healthy carriers) who may carry the germs in their 
throats without taking the disease. Quarantine is not 
removed nor the patient permitted to go abroad until 
officially released by the Board of Health when the 
throat is free from diphtheria germs. 
Finally, the question arises, shall every person who has 
by any possibility been exposed to diphtheria, or is likely 
to be exposed, be given a preventive dose of antitoxin? 
Most of the leading health authorities advise such a 
course, and this has been mjr rule unless special reasons 
to the contrary exist. In cases of unsanitary and crowd- 
ed buildings, and in institutions for children, hospitals, 
asylums, and schools, when an epidemic of diphtheria 
threatens, all the inmates should be immunized. In 
private practice among the well-to-do it has been the DIPHTHERIA 
119 
custom of some leading physicians not to give antitoxin 
to adults who may have been exposed to diphtheria, and 
to keep exposed children under close observation taking 
smears from their throats for cultures, and to withhold 
antitoxin unless sore throat appears in them. Diphtheria 
requires from two to seven days to develop after exposure, 
more often only two days. But it seems to the writer 
that the safer course is to give antitoxin to all persons 
who may have been exposed to diphtheria; the only 
objection is the inconvenience, there being no danger if the 
precautions already described are followed. 
The new Schick test may allow us to forego the injec- 
tion of antitoxin in adults slightly exposed, and is useful 
in institutions where large numbers of persons may need 
protection against an outbreak of diphtheria. 
The Schick test informs us as to the susceptibility 
of a person to diphtheria. By its use, as stated above, 
some 80 per cent, of adults, a varying percentage of per- 
cent. of children, and perhaps 90 per cent, of infants 
appear to be immune. Infants inherit antitoxin from 
their mothers, it passing into their circulation before 
birth. The antitoxin disappears to a considerable degree 
after the age of two or later, and so children then become 
largely susceptible to diphtheria. In later life there is 
again often immunity established by a previous mild and 
unrecognized attack of diphtheria. Carriers of diphtheria 
germs always give a negative Schick test and are always 
immune because of the large amount of antitoxin in their 
bodies. In active diphtheria the Schick test is always 
positive, owing to a lack of antitoxin in the patient. The 
Schick test is valuable in persons who may be dangerously 
susceptible to antitoxin. But if it is negative in such 
persons, there will be no need for them to be given anti- 
toxin since they are not susceptible to diphtheria. In the 120 
THE PREVENTION OF DISEASE 
Schick test 3 drops of dilute diphtheria toxin are injected 
into the skin of a person. Directly a white spot appears 
at the site of the needle puncture, and if the individual 
is susceptible to diphtheria, some redness, swelling, and a 
pimple will appear at this point within twenty-four to 
forty-eight hours. 
In persons not susceptible to diphtheria the antitoxin 
in their bodies neutralizes the irritant effect on the skin 
of the toxin injected, and so no local inflammation occurs 
at the site of the injection. The toxin used in the test 
is a poison developed in the growth of diphtheria germs. 
It is standardized for the test, so that the human dose is 
equal to one-fiftieth of a fatal guinea-pig dose. 
In children exposed to diphtheria it is safer to wipe off 
secretions from the throat for examination for the pre- 
sence of the diphtheria germ. This is called taking 
cultures from the throat. In adults not greatly exposed 
the Schick test may be used. By it about four fifths 
of exposed adults will be found not to need antitoxin 
(Park). If a person has not recently been exposed to 
diphtheria, but is liable to future exposure, he may be 
given vaccine treatment which affords permanent 
protection against diphtheria while antitoxin gives im- 
munity for only ten days or so. The vaccine is a strong 
solution of diphtheria toxin neutralized by antitoxin, 
and is injected into the skin of the back. 
The toxin in this mixture causes the person to develop 
his own antitoxin and so probably permanent immunity, 
although this has not been definitely determined as yet. 
No harm to any individual results from this method 
of securing immunity against diphtheria. 
After 3 injections one week apart of about 15 drops 
of this toxin-antitoxin mixture 90 per cent, of previously 
susceptible persons are found to be immune. DIPHTHERIA 
121 
The use of the Schick test is first required in order to 
determine whether the individual is susceptible to 
diphtheria. 
This method of producing immunity by the diphtheria 
toxin-antitoxin mixture has been largely practiced in 
institutions to prevent outbreaks of diphtheria and 
should be employed in private practice to protect children 
against this dread disease. When a period of 2 to 3 
months has elapsed after injection of the last dose of 
diphtheria toxin-antitoxin mixture the Schick test should 
be again done to be sure that immunity to diphtheria has 
been established. 
Owing to the short period of development of diph- 
theria—two to seven days after exposure—it is safer 
not to wait for the results of the Schick test, but to give 
a protective or immunizing dose of antitoxin as soon 
after exposure as possible, except in adults slightly 
exposed. But in those individuals subject to asthma, 
and in those who have had antitoxin on a previous occasion, 
and, therefore, may be poisoned by a second dose, the 
toxin-antitoxin mixture may be used as a safe and effec- 
tive substitute for antitoxin as a protective agency against 
diphtheria. 
While this work does not attempt to enable the lay- 
man to diagnose disease yet, in order to prevent infec- 
tion in others, the early recognition of diphtheria is 
most essential. The presence of sore throat, moderate 
fever, and the appearance of white spots or patches on 
the back of the throat, are most suggestive, and should 
arouse suspicion and call for immediate professional at- 
tention. Such appearances are most common in acute 
tonsillitis but the trained ability of the physician is essen- 
tial for diagnosis. It may not be exceeding professional 
etiquette to add that it is always wiser, in the event of any 122 
THE PREVENTION OF DISEASE 
white deposit in the throat or mouth, to have a specimen 
sent to a laboratory for examination. The elect may be 
mistaken at times in the diagnosis of such a white deposit 
which may be due to the germs of ordinary inflammation 
(streptococci), to diphtheria, to Vincent’s angina, 
syphilis, or leukoplakia. 
HYDROPHOBIA 
Rabies, from the Latin, formerly applied to the dis- 
order in dogs, is the name now more often used to 
discribe the disease in both man and dogs. Rabies 
means literally madness. Hydrophobia, is derived from 
the Greek, “fear of water.” This is partly a misnomer 
because there is a great desire for water in subjects of 
the disease but swallowing water in man is so difficult 
that convulsions are induced, and the patient comes to 
dread either water or food because of the suffering caused 
by attempts to swallow. The name hydrophobia has 
been retained here because more popular. 
While hydrophobia is a comparatively rare disease in 
man, it would be much more common were it not for the 
Pasteur vaccination. The disease is greatly more fre- 
quent in dogs, and outbreaks have occurred in most states 
in the Union—and for the first time, recently, on the 
Pacific coast. In 1911, 4625 persons were treated for 
hydrophobia, that is, given the preventive treatment; 
and there were 98 deaths from the disease in the whole 
United States. It is curious that although hydrophobia 
has been known to exist since 300 b. c., there are many 
deluded persons who still deride its entity, and not so 
long ago an English writer stated that hydrophobia was a 
disease which attacks man and impels him to kill dogs. 
Anyone who has observed hydrophobia in man or 
beast could as easily doubt its existence as one seeing HYDROPHOBIA 
123 
a case of small-pox. The germs of the disease have not 
yet been isolated. There are certain microscopic 
appearances or inclusions found in the large cells of the 
brain (Ammon’s horn and Purkinje cells of the cere- 
bellum) in the form of almost invisible dots and larger 
irregular bodies (Negri bodies) only seen in rabies. 
These Negri bodies (so called from their Italian 
discoverer) may be the causative germs (protozoa) 
of the disease, or may be only the effects of the germs 
in producing degeneration of tissue, or special reaction to 
their presence. Finding Negri bodies in the brain is 
positive proof of rabies or hydrophobia. The germ, or 
virus, is almost invariably communicated from the rabid 
animal in the saliva by biting; a mad dog may however 
transmit the disease by simply licking one’s hand, if 
there are abrasions on it, and who can be sure there are 
not. The virus or contagium is found in the brain and 
spinal cord and in various organs in the body. It must 
also be present in the blood because dogs occasionally 
inherit madness. 
That is the germ in the mother’s blood must infect the 
young in the womb because dogs that have not been 
bitten may become mad several months after birth. 
This has been proven by laboratory experiments and 
may account for rare and hitherto inexplicable cases of 
madness in dogs. 
The mother of the rabid young may remain free from 
the disease until long after the madness has developed 
in the offspring. The contagium is present in the saliva 
of a mad animal before any signs of the disease are present 
(from 3 to 14 days or longer). 
One should know in a general way the symptoms of 
madness or rabies in dogs to avoid the disease. The 
animal is altered in disposition and habits which are 124 
THE PREVENTION OF DISEASE 
the opposite of the normal. He is sullen or very friendly, 
nervous, and restless, sees imaginary objects, and may 
snap at them, or at any object held toward him, and 
often shuns the light and hides. He frequently licks 
and swallows all kinds of objects and is subject to vomit- 
ing. Frothy saliva often drips from his jaws. Later 
he has difficulty in swallowing, and quite commonly 
he is thought to have a bone in his throat. Attempts to 
swallow water are constant and, in the later stages of 
the disease, this is impossible. In the second stage the 
animal leaves home and travels great distances, biting 
men, animals, and inanimate objects, often returning to 
die. The worn, thin, bruised or wounded animal is a 
pitiable object and endangers the owner in the natural 
desire to pet the sufferer. The voice is changed into 
a hoarse howl, the tail droops, the head is depressed, with 
staring, glazed, bloodshot eyes, and the animal is insen- 
sible to pain, persons, or surroundings; the gait is un- 
steady and the dog becomes emaciated and repulsive. 
Periods of excitement and biting occur in the presence of 
noises, animals, and men, alternating with exhaustion 
and quietude if the dog is not disturbed. The third 
stage is shown by exhaustion and paralysis of the hind 
parts and the lower jaw. The latter happens early in 
what is known as dumb rabies and the lower jaw drops, 
the tongue is dry and covered with stringy saliva, and 
there is inability to either bite, howl, or swallow. If the 
dog truly has rabies, death is almost invariably certain 
in from four to ten days, except in dumb rabies, when death 
may be more delayed. This form, known as “drop jaw,” 
leads owners to think dogs have a bone in the throat. 
While they cannot bite, it is exceedingly dangerous to 
handle their mouths, for the saliva may infect the slightest 
abrasion of the hands, as about hang-nails. HYDROPHOBIA 
125 
When persons are bitten by a dog supposedly rabid a 
diagnosis is imperative. The surest way is to keep the 
animal caged for inspection where this is possible. His 
death and the examination of the brain will settle the 
diagnosis absolutely if the result is positive. If the sus- 
pected dog is alive and in good health after fourteen 
days rabies is highly inprobable. 
If the suspected animal runs away, dies, or is killed 
inside of fourteen days the Pasteur treatment is advis- 
able unless laboratory examination of the brain of the 
animal can be made and is negative. Even this is not 
to be wholly relied upon in early stages of the disease, and 
if the animal has bitten several persons, or its actions have 
been suspicious, the treatment should be taken. It has 
been found that in 3 per cent, of truly rabid dogs the 
examination of the brain will not show evidences of 
the disease. Persons whose hands have been licked by 
rabid dogs should also take the Pasteur treatment, as 
Park records 8 cases in which hydrophobia has been 
acquired in this manner. 
The head and neck of a suspected animal should be 
sent on ice to a laboratory for examination if the dog has 
been killed or dies, or the brain and upper part of the 
spinal cord may be sent in glycerin and will keep much 
longer than if sent on ice. 
The writer was able to locate by advertising the body 
of a dog which had been killed and buried a week after 
biting six persons, and examination of the animal’s brain 
and inoculation of it into rabbits proved the disease to be 
rabies. Most of the bitten persons had already begun 
the Pasteur treatment and none developed hydrophobia. 
The laboratory tests consist in making smears of the 
brain (Ammon’s horn and cerebellum to detect Negri 
bodies), and examining sections of the brain (Gasserian 126 
THE PREVENTION OF DISEASE 
ganglia) for destruction of ganglia cells and inflammatory 
infiltration. These tests may be made without any 
loss of time. But it is also advisable to inject into the 
covering of the brain (dura) of a rabbit and guinea pig 
an emulsion made from the brain of the supposedly 
rabid dog. If the dog was truly rabid the rabbit will 
die with paralysis of the hind legs in from 7 to 30 days, 
or within 90 days. The bitten person cannot of course 
wait for the completion of the rabbit innoculation test 
for protection against rabies is not established until 
36 days after the beginning of the Pasteur treatment. 
Moreover, it is absolutely unwise for a bitten person to 
rely upon cauterization for protection against rabies. 
Many individuals have developed hydrophobia after 
cauterization alone, and the Pasteur treatment should 
always be taken if there is any probability that a bite 
has been inflicted by a rabid animal. Cauterization 
lessens the liability to infection from a bite but does not 
surely protect one against rabies. The finding of all 
sorts of unusual objects in a dog’s stomach after death 
is suggestive of rabies but not positive evidence. 
Whenever a person is bitten by a dog that disappears 
and cannot be traced the Pasteur treatment should be 
taken. When there is the slightest doubt as to whether 
a person has been bitten by a rabid animal it is safer not 
to wait more than a few days before taking the Pasteur 
treatment for every day is valuable in order that immu- 
nity be established, before hydrophobia has time to 
develop and this time is always problematical. 
The period required for development of the disease, 
after infliction of a bite, usually varies from two to twelve 
weeks in man, and two to eight weeks in dogs or, on the 
average, forty-nine days in man. In rare instances 
hydrophobia may not develop until a year or more after HYDROPHOBIA 
127 
infliction of a bite in man or animals. The bites of 
rabid animals should be immediately burned with a 
hot iron or cauterized by fuming nitric acid, followed by 
a strong solution of saleratus in water and then by alcohol. 
Nitric acid is the preferable agent. 
Or the tissue surrounding the bite should be cut away. 
Either of these methods is of value, even if it must be 
deferred as long as twenty-four hours, but the sooner 
Pasteur treatment is begun the better. Of all those 
persons bitten by supposedly rabid dogs (including those 
cauterized) but 15 per cent, develop hydrophobia. 
If the bare skin is bitten the chances of acquiring 
hydrophobia are much increased. Ninety per cent, of 
those bitten on the face have hydrophobia unless taking 
the Pasteur treatment, and 63 per cent, of those 
bitten on the hands. The hands are sometimes protected 
by gloves and bites are readily sucked and washed. 
The Pasteur treatment should be begun as soon after 
receiving the bite as possible, and it is successful in pre- 
venting hydrophobia in 99 per cent, of persons recently 
bitten. The vaccine matter is prepared from the spinal 
cords of rabbits which have been given the disease, the 
virulence of the germs is greatly lessened by drying the 
cords for varying periods of time. The cords which have 
been longest dried are weakest and are first used, rubbed 
up with a little water, and injected under the skin. 
Another advantage secured is that, by passing the disease 
from rabbit to rabbit, the time of development of the 
disease (incubation) is much shortened (6 to 7 days, 
after the fiftieth to the ninetieth passage). 
The treatment is given daily for three weeks. Half a 
dozen manufacturing firms and the Hygienic Laboratory 
at Washington send out the vaccine by mail. Glycerin 
and carbolic acid are added as preservatives. 128 
THE PREVENTION OF DISEASE 
No harmful effects whatever follow the use of vaccine 
in the vast number of cases. Rarely local paralysis has 
been caused by the treatment, which may later disappear. 
In 4282 persons vaccinated for rabid dog bites by the 
New York City Health Department there were 7 cases 
of paralysis and 2 deaths attributable to the treatment. 
The latest figures are those of Simon, who finds paralysis 
occurs in 1 case in every 2177 persons treated. Since 
but 1 person in 200 treated develops hydrophobia, 
and since 30 untreated persons in 200 who have been 
bitten by mad dogs contract the disease and always 
die, the disadvantages of treatment are negligible. 
Animals who have been bitten by supposedly mad dogs 
should be immediately destroyed. The muzzling of 
dogs for six months within a radius of 20 miles from the 
location of the first case of rabies will stamp out the 
disease. 
Hydrophobia sometimes begins in man with numb- 
ness and pain about the old bite. The patient is irritable 
and depressed, and often has a sense of impending 
danger, with headache, sensitiveness to light, insomnia, 
hoarseness and difficulty in swallowing. 
Attempts to swallow cause the most intense pain and 
spasm of the muscles of the throat, and feeling of suffoca- 
tion. Even the suggestion or thought of food or drink 
may bring on these spasms in the throat muscles, and 
general convulsions. In these attacks the patient may 
become delirious and maniacal, and, owing to the dry, 
paralyzed condition of the larynx, may utter strange 
sounds, likened to the barking of dogs by the supersti- 
tious. Between the attacks the patient may be quiet 
and intelligent. Fever is usually present. 
This condition may last from one to three days and 
then the third and last stage ensues. The patient ceases LOCKJAW 
129 
to have spasms, and may even be able to swallow, but 
paralysis begins in the lower limbs and gradually ascends, 
with unconsciousness and death from failure of the heart. 
Nobody is known to have recovered from hydrophobia. 
There is, however, an hysterical condition seen in 
persons who have been bitten by dogs (normal or rabid) 
which very closely resembles true hydrophobia. The 
patient is irritable, depressed and sure he is going mad. 
He thinks he cannot swallow, clutches at the throat, 
and becomes greatly excited in attempts to do so. But 
the disorder does not grow worse, fever is absent, and 
the patient responds to treatment and recovers. Re- 
ported recovery from hydrophobia is recovery from this 
false or imaginary hydrophobia. 
LOCKJAW 
Lockjaw, of tetanus, is a rarp disease, so that a physi- 
cian seldom sees more than a case or two in a lifetime 
unless practising in a region in which the disease is in- 
digenous. In this country lockjaw more frequently 
occurs in Long Island, Connecticut, the Hudson River 
Valley, and the Atlantic States. The germs naturally 
live in the intestines of horses, cattle, and dogs, and so 
dust and dirt contaminated with droppings from these 
animals are dangerous when they soil a wound. Lockjaw 
sometimes arises without the presence of any wound, but 
in that case it is thought that some slight unperceived 
abrasion may have led to the infection. The germs and 
their spores are most difficult to kill, and live for years 
and years on inanimate objects. They exist in the soil, 
and especially in stable dirt. Then there are certain 
wounds which offer a favorable field for their entrance 
and growth. The germs of lockjaw do not grow well 
when exposed to air, so that punctured wounds, which 130 
THE PREVENTION OF DISEASE 
are not freely open to the air, are most dangerous, 
especially if made by a nail or sharp object entering the 
foot which has been contaminated with manure or stable 
dirt, or soil of any kind. The entrance of foreign bodies 
into the wound, as clothing, the wad of blank cartridges, 
or simply dirt, adds greatly to the likelihood of lockjaw. 
All wounds in which there is much bruising or tearing of 
the tissues and punctured wounds or those penetrating 
deeply, especially when contracted in the streets or 
about stables, are chiefly liable to lockjaw, and tetanus 
antitoxin is indicated. 
Therefore persons with lacerated or punctured or 
gunshot wounds, with wounds contaminated with 
street dust or manure, wounds containing foreign bodies, 
as bullets, clothing and splinters, should always be 
treated with tetanus antitoxin. Its use is harmless and a 
fatal and dreadful disease will be surely averted thereby. 
Before the general suppression of the Glorious Fourth- 
of-July an extraordinary number of cases of tetanus 
occurred from toy pistol wounds on these occasions. 
From 1 to 21 days (more often 9 to 10 days) elapse 
after the infliction of the wound before the first symptoms 
of tetanus occur. If this period is longer than a week the 
disease is apt to be of a milder type. The sooner tetanus 
appears after the inception of the wound the more 
malignant is it likely to be. The germs of tetanus remain 
in the region of the wound and set free a poison or toxin 
which has a great affinity for the cells of the central 
nervous system. The poison affects chiefly the motor 
ganglia of the spinal cord making them more sensitive to 
stimuli. 
Tetanus begins with restlessness, irritability, outbursts 
of temper, violent headache, pain in the muscles of the 
neck and back and, after a few hours, there are stiffness LOCKJAW 
131 
of the jaws (lockjaw) and pain and difficulty in swallow- 
ing. The head is drawn back and there are stiffness, 
rigidity and twitching of the muscles generally, or con- 
vulsions. Any unusual noise or even draught of air 
may bring on a convulsion. There are fever, difficulty 
in breathing and swallowing and insomnia. Sometimes 
the rigidity and spasms are limited to the wounded 
limb. Tetanus is a very fatal disease. If antitoxin is 
given within the first few hours of the beginning of the 
disease it may save the patient’s life. When given 
later it has little benefit. 
The toxin is neutralized by the antitoxin during the 
first few hours of the disease, but later the toxin becomes 
fixed in the nervous tissue and is not antagonized by 
antitoxin. The mortality of tetanus in the British 
Army was reduced by very early treatment with tetanus 
antitoxin from 58 to 19 per cent. 
But as a means of preventing lockjaw, or tetanus, 
antitoxin is practically invariably successful. It was 
used as a routine measure in the Great War as soon as 
possible after all gunshot wounds in the American and 
British forces. 
The entrance of other germs in wounds favors the 
tetanus infection. (Gunshot wounds were practically 
always infected with other bacteria in over 97 per cent, 
of all gunshot wounds examined in the Great War!) 
Also bruising of tissue favors lockjaw and general infec- 
tion. In clean cut sword wounds only 25 per cent, were 
found infected. 
There are three essentials in the treatment of such 
wounds. The first is thorough swabbing wound and 
surrounding skin with tincture of iodin, removal of 
loose tabs and shreds of tissue, foreign bodies, dirt, 
clothing, etc., and wide excision or cutting out of bruised 132 
THE PREVENTION OF DISEASE 
and devitalized tissue and swabbing out of the wound 
with half strength tincture of iodin; second the thorough 
opening of deep punctured wounds, swabbing them with 
iodin and keeping them open with strips of sterilized gauze. 
When this is done, and a surgeon should always attend 
the case if possible, and may have to give an anesthetic, 
there is less danger of lockjaw. The third essential, 
especially in regions where lockjaw is known, is a dose of 
antitoxin given within a few hours after the injury, and 
it will almost invariably prevent the occurrence of the 
disease. Fifteen hundred units is the preventive dose 
injected under the skin and repeated every 7 days, four 
doses in all, as the neutralizing effect of the toxin wears 
off after 7 to 10 days. This was the rule in all wounds 
in the British Army. In 2 million doses of tetanus 
antitoxin given soldiers in England during the Great 
War there were only 11 cases in which unpleasant im- 
mediate effects were experienced (hypersensitiveness to 
foreign protein, allergy, see page 387), and all recovered. 
These unfortunate symptoms occur with injection of 
any horse serum (see Diphtheria Antitoxin). 
In the treatment of tetanus by antitoxin not an hour 
must be lost ater the diagnosis is made. The antitoxin 
is injected into the spinal canal so as to come in direct 
contact with the central nervous system. About an 
ounce of spinal fluid is first removed and 15,000 units 
are injected intraspinally daily while at the same time 
10,000 more units are injected under the skin. 
As typhoid vaccine has removed the chief source of 
death from disease in war, so has tetanus antitoxin 
annihilated the chief horror of wounds. 
Tetanus antitoxin is made by injecting horses with 
gradually increasing doses of the poison developed by the 
germs of this disease, and at the end of four or five months SCARLET FEVER, SCARLATINA 
133 
some of their blood is withdrawn and, after the red por- 
tion settles, the upper, pale, straw-colored serum is 
removed and is called antitoxin, because it possesses 
antibodies elaborated in the horse which will neutralize 
the poison of lockjaw in man. 
Colonel Roosevelt was given a dose of tetanus antitoxin 
almost immediately after the attempt on his life, during 
one of his public addresses, because of the greatly bruised 
character of his wound produced by the impact of the 
would-be assassin’s bullet on his spectacle case, and thus 
on his chest. 
SCARLET FEVER,SCARLATINA 
Scarlatina is another name for scarlet fever and not a 
milder form of the disease, as the layman often appears to 
believe. Persons are not so susceptible to scarlet fever 
as to measles and many escape infection. Scarlet fever 
usually begins suddenly with vomiting, sore throat, 
chilliness and fever and within 24 hours a fine scarlet 
rash appears, first on the neck and upper chest, and 
spreading all over the trunk and limbs during the next 
2 days of the disease. 
The disease is more fatal than measles, although not so 
much so in children as most persons think. The death- 
rate in 1000 cases at the Boston City Hospital was about 
10 per cent. Most of the fatal cases occur in children 
under six years of age, and 90 per cent, under the age of 
ten, so that every protection must be afforded children. 
Infants at the breast are rarely attacked, however. The 
safest method is to send children who have not had the 
disease out of the house as soon as a case of scarlet fever 
develops. Thus, Chapin found in Providence that, while 
over one-quarter of the children in houses containing a 
case of scarlet fever took the disease when they remained 134 
THE PREVENTION OF DISEASE 
in their home, but 7 per cent, were affected when they 
were sent away. That is, some 50 of 1000 children sent 
from infected homes developed the disease when away, 
and 19 more came down with it when they returned. 
The disease requires for its development—from time of 
exposure to the first appearance of sickness—from one 
to eight days, oftenest two to five days. 
Formerly the scales of skin during peeling were thought 
to be the medium for conveying the germs of scarlet 
fever. Now the secretions from nose, throat and ears 
(when these run, as often happens from ear abscess) are 
considered the most important sources of contagion. 
Injection of the mucus from the nose and throat of scarlet 
fever patients under the skin of ten children reproduced 
severe cases of the disease in every child. But, the germ 
having not yet been identified, it is uncertain that the 
peeling skin is not also a medium for its transmission. 
Many persons have such mild attacks that they go about 
unsuspected and spread the disorder, while others 
communicate it during the last few days before they come 
down with the disease, and still others convey it during 
convalescence. 
Such individuals may contaminate milk, and large out- 
breaks in cities have been traced to milk infected in this 
way. In Boston, in 1910, some 842 cases of scarlet 
fever suddenly occurred from drinking a contaminated 
milk in which the germs flourish. The only sure pre- 
ventive is to drink milk properly pasteurized in the bottle, 
or boiled milk (see page 346). One epidemic was traced 
to a milkman who had a discharging sore on his finger 
following an attack of scarlet fever, and the discharge 
had evidently contaminated the milk supply. Isolation 
of the patient in a room connected with an anteroom is 
the best precaution against spread of the disease. How SCARLET FEVER, SCARLATINA 
135 
long he shall stay there is at present uncertain—any- 
where from three to nine weeks according to different 
authorities. Four to six weeks isolation are more com- 
monly required in practice, or until all peeling and dis- 
charge from the nose, throat, ears, or other parts cease. 
All unnecessary articles should be first removed from 
the sick room, especially such as cannot be readily dis- 
infected, as books, curtains, rugs, upholstery, etc. There 
is slight danger of communication of the disease by the 
attendant if the case is well managed, but Chapin’s 
figures show that this is not usually practicable. If the 
nurse wears a washable cap and gown covering her 
clothing, burns cloths on which secretions from the 
mouth, nose and throat of the patient are collected, and 
thoroughly washes her hands and clothes, and removes the 
gown and cap in the anteroom on leaving the patient, 
there is little danger of contagion. The father of the 
family under such conditions may go to business as usual. 
Thorough disinfection of the sick rooms with formalin 
and scraping off the wall paper and repapering, with 
burning of all unnecessary infected articles, should be 
done after the patient is well. Children who have been 
sent away should not return until at least two months 
from the beginning of the scarlet fever, and later if there 
is any likelihood of infection from catarrh in the nose or 
throat or discharge from the ear of the patient. Where 
disinfection cannot be done by a proper health board the 
formalin candles sold by druggists may be used, but 
at least twice the quantity recommended should be 
employed, and the room must be sealed tight (by pasting 
strips of paper over all cracks) for twelve hours while the 
fumigation is going on. Everything which comes out 
of the room must be first disinfected, either by boiling 
or soaking in 1:1000 solution of corrosive sublimate, or, in 136 
THE PREVENTION OF DISEASE 
the case of metals, a 5 per cent, solution of carbolic acid. 
Mattresses, pillows, and carpets are hard to disinfect 
except in municipal steam-sterilizing plants. Persons 
rarely have scarlet fever more than once, and many 
adults, as doctors who are constantly exposed, escape it 
altogether. 
MEASLES 
Measles is a disease every one is supposed to have, but 
this need not necessarily be the case if attempts at preven- 
tion were general. It is, indeed, true that no person and 
no age are immune, but more care should be taken to avoid 
exposure. This remark particularly applies to children 
who are made by measles much more susceptible to 
pneumonia, tuberculosis, rickets, etc.; but there appears 
to be a feeling among parents that it is just as well to 
allow children to acquire measles, because they will have 
it any way, and since it is more severe in adults. The 
contrary is actually the case, it having been shown that, 
in the same region and in the same class of people, the 
mortality from measles was 8.1 in children and but 1.3 
among adults (Fiirbringer). It is true that infants under 
six months are less often sufferers, but this is probably due 
to the fact that they are kept more secluded and not so 
apt to be exposed. 
The period of development, from exposure to the begin- 
ning of the disease, is from “seven to eighteen days;often- 
est fourteen days.” Therefore, children who have been 
exposed should keep away from school for two weeks, and 
children living in the vicinity of measles should be sent 
away to avoid the contagion. Measles is peculiar, in that 
it is most contagious during three to four days before the 
eruption occurs, and the contagion dies out within three 
or four days after the appearance of the eruption. Whether MEASLES 
137 
there is any contagion from the patient during peeling is 
questionable. Experiments indicate there is not. 
If parents isolated children just so soon as fever and 
other signs of any sickness appeared, on general principles, 
the opportunity for taking contagious diseases would be 
much curtailed. 
This is notably important in measles, which comes on 
like a feverish cold, with running at the nose, sneezing, 
fever, cough, and sore eyes. The eyes are more red 
and watery and more sensitive to light than in ordinary 
colds. On the evening of the fourth day the rash usu- 
ally appears on the brow, face, under the ears and then 
on the chest, body and limbs. The rash is bright red 
and blotchy and the face is swollen, the cough hoarse 
and incessant and fever and general sickness at their 
height. The essential feature is the long period of 
invasion (four days) before the rash appears which dis- 
tinguishes measles from scarlet fever or German measles. 
Contagion may be spread to others from the very onset 
of the disease before the rash appears. No disease is 
more contagious and a person may acquire measles 
through sneezing of a patient ten feet away. Whereas 
half of susceptible children may escape scarlet fever, if 
the patient is isolated in the same house, it is rare that 
susceptible children escape measles with a case isolated in 
the same dwelling. Usually in 7 to 10 days after the 
disappearance of the rash the patient is incapable of 
giving measles to others but it is wise to quarantine 
children two weeks after the rash appears, and adults 
ten days. The germs of measles live but two hours 
after they leave the body, so that disinfection of the 
sick room is unnecessary. Bathing of the patient and a 
twelve-hour airing of the room and its contents are suffi- 
cient protection to susceptible persons. 138 
THE PREVENTION OF DISEASE 
Second and even third attacks of measles are more com- 
mon than in the case of any other contagious disease. 
The great fatality of measles among the natives of islands 
in which the disease is not indigenous is well known, as 
seen in Fiji, where over a quarter of the population died 
in four months from this disease, and in the Faroe Islands. 
This disease is generally made light of by everybody 
except the patient. It differs from the other contagious 
diseases in having a long period of development— 
fourteen to twenty-four days,' more usually about three 
weeks. Rarely the first symptoms have not shown 
themselves for thirty-six to forty-two days after exposure. 
Patients may give the disease to others for a few days 
before they become sick, and afterward for two to four 
weeks from the beginning of their sickness, so that it is 
safer to isolate children for at least three weeks. Mumps 
is communicated by the secretion from the mouth of the 
patient and articles soiled by it, eating and drinking 
utensils, handkerchiefs, towels, etc. 
The disease begins with chilly and aching sensations 
in the body and limbs, loss of appetite, dryness and 
soreness of the throat, and slight fever (99°-100° F.), 
and sometimes nausea and vomiting. Within 48 hours 
the parotid gland (on one side usually) begins to enlarge 
and become painful. This is shown by swelling under 
and in front of the ear, and there is difficulty in opening 
the mouth and swallowing. The swelling lasts five to ten 
days and, as the swelling on one side of the face begins 
to subside, the gland on the other side often commences 
to enlarge, or they may be both swollen at once. The 
most important complication of mumps is swelling and 
pain (inflammation) of one or both testicles which some- 
MUMPS WHOOPING-COUGH 
139 
times occurs in males over fifteen years five to eight days 
after the onset of mumps. Likewise the ovaries are occa- 
sionally affected in females. 
This condition commonly lasts only three to five days 
but rarely the testicles remain permanently enlarged. If 
this happens in both testicles the individual may be 
sterile but possess the desire and ability to perform the 
sexual act. 
Again, very rarely, following swelling of the testicles 
in mumps they may begin to shrink after two months and, 
if both testicles become thus small and atrophied, the 
patient may be both sterile and impotent. This is a 
very unusual result and generally mumps is the mildest 
of infections, and complete recovery the rule. 
But in order to avert inflammation of the testicles in 
mumps the patient should remain in bed until fever is 
passed and keep quiet in the house for ten days. 
Little treatment is needed in mumps. The swollen 
face may be covered with a thick layer of sheet cotton or, 
if there is much pain, hot or cold compresses of many 
layers of gauze, covered with oil silk and bandage, may 
be applied. 
Prevention lies in isolation of the sick for three to four 
weeks from susceptible children and watching exposed 
children (contacts) for earliest signs of the disease. 
Disinfection of the sickroom is not practiced because 
only the clothing and articles in direct contact with the 
patient are contaminated. 
WHOOPING-COUGH 
The public needs instruction concerning the prevention 
of whooping-cough more than in any other contagious 
disease. This follows, first, because less pains are taken 
to isolate patients than in the case of any other of the 140 
THE PREVENTION OF DISEASE 
infectious disorders, and, second, because both the laity 
and profession appear to think and act as though whoop- 
ing-cough were a mild and comparatively inconsequential 
disease. 
As a matter of fact, whooping-cough is more fatal than 
either measles, scarlet fever, or diphtheria, if we include 
its complications, in children under five years of age. 
Nine out of every ten deaths from whooping-cough are 
due to pneumonia, and the severe coughing occasionally 
leads to death from bleeding into the brain (apoplexy) 
and starvation from vomiting, while deaths from heart 
failure and convulsions are not uncommon. Parents are 
shamefully responsible for permitting their children, 
suffering from whooping-cough, to play with other 
healthy young people. The reason this lapse is more 
frequent and possible than in the case of other contagious 
diseases is that patients with whooping-cough are usually 
about and outdoors. 
The whooping-cough germ (Bacillus pertussis) has only 
recently been discovered and isolated. It lives in the 
mucus in the air-passages, where it may be found during 
the first few weeks of the disease. One attack protects 
an individual from another. Almost every one is sus- 
ceptible and has the disease at some period of life. One- 
half the cases are under six years of age, but infants under 
six months are not so liable to the disease. There are 
about 10,000 deaths a year from whooping-cough, on the 
average, in the United States, and the death-rate is 
5 to 15 in 100. 
After exposure one to two weeks elapse before the 
symptoms begin. If more than two weeks pass after 
exposure without development of the disease there is 
little danger of its occurrence. Whooping-cough starts 
like an ordinary cold and cough, although the cough is WHOOPING-COUGH 
141 
more constant than usual at night. Unless whooping- 
cough is prevalent it is not possible to make a diagnosis 
until the second stage begins, after one or two weeks more. 
Then there are severe spells of coughing, four to twenty 
or more daily, which are often followed by vomiting. 
The child in one of these gives fifteen or twenty short 
coughs, grows blue, and appears to be suffocating, and 
then draws a long breath with a crowing sound (the 
whoop), and often ends by vomiting. The whooping 
stage may last an uncertain number of weeks. Violent 
fits of coughing, which end in either whooping or vomiting, 
are most characteristic of whooping-cough as distin- 
guished from other diseases with cough. While children 
are best kept outdoors with the disease, they should not 
be permitted to play with well children until after eight 
weeks or until one week after all whooping and coughing 
of phlegm has ceased. They should have a separate 
room to sleep in, and all material which is vomited or 
coughed up should be burned at once. Paper napkins 
and old clean cloths may be used for collecting secretions 
from the nose and mouth. While direct contact with 
the sick is usually the cause of contagion, yet the germs 
are sprayed into the air in coughing and carried about on 
clothing. There is a classical case in which clothing 
from a patient on a ship in St. Helena conveyed the 
disease to the children of a laundress on shore. 
Handkerchiefs, towels, pencils and toys often convey 
the disease from child to child where isolation of 
the sick and disinfection are not carried out. The 
disease is not communicated during the period of develop- 
ment from exposure to the beginning of the first symp- 
toms (one to two weeks,) but from this time on until two 
weeks after the whoops begin, the disease is most contag- 
ious. After this the communicability gradually lessens, 142 
THE PREVENTION OF DISEASE 
Under six months infants are usually immune owing to 
inherited immunity, but from the age of six months to 
five years, the susceptibility is greatest. Carriers convey 
the disease, they are healthy people who carry the germ 
in their respiratory secretions and transmit it to suscep- 
tible persons over long periods. 
The germ is difficult to isolate so that diagnosis is not 
commonly made from the sputum of the sick but may be, 
done in well-equipped laboratories. It is well for young 
children with colds who have been exposed to whooping- 
cough to remain in bed until the period of development 
(one to two weeks) is passed. If they have the disease 
they may thus avoid complications and communication 
of it to others. 
Quite recently a vaccine has been used made in much 
the same way as described for use in typhoid fever; 
consisting of the dead germs of whooping-cough and 
injected under the skin. This appears to be of con- 
siderable value in protecting those exposed to whooping- 
cough from taking the disease. Hess (1914) reports that 
with the use of vaccine protection, in an epidemic of 
whooping-cough, 1 in 12 took the disease, while without 
it almost 3 out of 4 children became sick with the disorder. 
It is without danger and should be tried. The New 
York Health Department has ardently advocated 
vaccination against whooping-cough. 
The best time to give the whooping-cough vaccine for 
treatment is as early as possible after the diagnosis is 
made. The vaccine is made not only of the specific 
causative germ but of others (streptococci and staphylo- 
cocci) which are factors in the infection. If the doses 
injected under the skin are large enough (250 million for 
children under a year, 500 million over a year, and a 
billion for adults, to begin with) and the vaccine is fresh, PLAGUE. BUBONIC PLAGUE 
143 
and contains the same strains of the whooping-cough 
germ as those attacking the patient, the disease is reduced 
in severity and duration. 
The same vaccine will afford immunity and prevent 
disease in 90 per cent, of susceptible persons. Just how 
long the immunity lasts is unknown, but if vaccination 
will protect children for the first four years of their life, it 
will prevent most of the fatality. Vaccination should 
be done if possible before exposure as it is said from ten 
to twenty days are required to secure immunity after the 
first injection of vaccine. 
Disinfection of the room should be done after the 
patient has recovered. The chief danger of pneumonia 
is during early convalescence. 
PLAGUE. BUBONIC PLAGUE 
Plague has been known from the second century, and 
in the fourteenth it destroyed one-fourth of the people of 
Europe, and was known as the “ black death.” It 
ravaged Europe again in the seventeenth century, but 
gradually died down, until it appeared again in Hong 
Kong in 1894. 
There have been enormous losses from plague in India, 
some five and one-half millions dying of it in the United 
Provinces, Bombay, and the Punjab between 1896 and 
1911. Since that time the disease has occurred in the Far 
East, in Persia, Turkey in Asia, Java and Sumatra, 
and in Egypt and Japan. 
There have been a few cases in England and the United 
States within the past few years, notably in San Francisco 
(121 cases in 1907-08), and a few cases in Seattle, and 
there was an outbreak in New Orleans in 1914. With 
the modern manner of handling the disease in the most 144 
THE PREVENTION OF DISEASE 
civilized communities there appears to be little danger 
of a large epidemic of the plague. 
Several forms of the disease occur. The most common 
begins with fever, headache, pain in the back and stiffness 
of the limbs, and enlarged glands (buboes), especially in 
the groins, appear from the third to fifth day. Some 
patients are so overwhelmed by the germs that they die 
within three days before the buboes form, and in the 
pneumonic type the disease is evidenced by a rapidly 
fatal form of inflammation of the lungs. In order to 
make a positive diagnosis of plague the swollen gland 
should be punctured and the fluid exuding should be 
examined to discover the plague germ, and cultures of the 
germs from the gland juice should be injected into guinea- 
pigs. The sputum from suspected plague pneumonia 
should be likewise examined. 
Plague is contagious in less than 3 per cent of cases, and 
the contagion is seen only in the pneumonia cases crowded 
together in unsanitary conditions. 
Bubonic plague is transmitted to man from rats and 
ground squirrels entirely by rat- or squirrel-fleas, and 
from rat to rat or squirrel to squirrel by the same insect. 
The disease germ (Bacillus pestis) is carried from place 
to place by rat-fleas on persons or their belongings. 
The rat-fleas may live a week when starved, but on 
human beings they may subsist three or four weeks. 
Rat-fleas do not naturally take to humans or other 
animals, and it is only when they are starved that they 
change their habitat, except in the case of ground 
squirrels, chipmunks, and a few other animals. 
A single rat-flea may harbor as many as 500 plague 
germs in its body, and human epidemics usually follow 
severe outbreaks in rats, as the terrible mortality in rats 
drives their fleas to the human host. The finding of PLAGUE. BUBONIC PLAGUE 
145 
many dead rats in a seaport is the first sign of the 
approach of plague. The infected rats are brought to 
the United States in vessels, chiefly from the Orient. 
It will be noted that the plague is but accidental in man. 
It is only when the disease kills rats, ground squirrels 
and other rodents, that their fleas desert, because starving, 
and attack man. 
After the flea leaves the dead rat about three days 
elapse before it attacks man, and three to five days after 
man is bitten by the infected flea he develops plague. 
The cat- and dog-flea are apparently not invaded by 
the plague germ and so are not dangerous to man. On 
the contrary, in the Punjab it has been shown that where 
there are from 30 to 75 cats for every 100 houses, there is 
no plague, owing to the destruction of rats, and this 
method of fighting plague is prescribed by the scriptures 
of the Mohammedans and Hindus. 
The modern way of fighting plague consists in poison- 
ing and trapping rats and examining dead rats for plague 
germs, in disposal of food and garbage in rat-tight vessels, 
general cleansing and destruction of shacks, out-houses, 
and stables affording nests for rats, but particularly 
enforcement of rat-proof buildings, to make life impossible 
to rats through starvation. These measures have been 
splendidly carried out in the United States through the 
agency of the Public Health Service, often hampered as 
much as possible by the state and municipal lay authori- 
ties who were most concerned, as in California and Seattle. 
The appearance of dead rats in a seaport should imme- 
diately excite suspicion, and cultures from their bodies 
will decide the existence of plague germs, together with 
inoculation of guinea-pigs. Segregation of the sick, 
fumigation with sulphur of the premises and ships to 
destroy rats and fleas, and shields on the hawsers to 146 
THE PREVENTION OF DISEASE 
prevent rats from boarding ships are essential. To 
protect individuals against plague there is Haffkine’s 
vaccine, consisting of the dead bodies of the plague germs 
and harmless in itself. One injection of this reduces 
the chances of getting the disease four-fifths, while those 
who have had the injection and acquire the disease 
have two and one-half times the expectation of recovery 
as compared to the uninoculated (Martin). The protec- 
tive effect of the Haffkine vaccine lasts six months or 
longer. 
The Yersin-Roux Antiplague serum has been used in 
the treatment of plague but is only effective in the very 
earliest stages of the disease. CHAPTER V 
GERM DISEASES ONLY COMMUNICATED BY THE 
BITES OF MOSQUITOES 
Malaria, Yellow Fever, Dengue 
MALARIA 
Malaria is now known to be due to animal parasites 
(plasmodia) which are only transmitted to man by a par- 
ticular kind of mosquito, the genus Anopheles, eight 
species of which act as hosts to plasmodia. The mos- 
quitoes, in their turn, get the malarial parasite into their 
Fig. 1.—Various mosquitoes in attitudes of repose: a, Culex pipiens 
or common mosquito; b, Myzorrhynchus pseudopictus; c, Anopheles 
maculipennis or malarial mosquito (Manson). 
bodies by biting a person who has the malarial parasites 
in his blood. Therefore the prevention of malaria may be 
summed up, first, in destroying mosquitoes; second, in 
avoiding mosquito bites; third, in taking quinin to kill 
the parasites in the body. In the avoidance of mosquito 
147 148 
THE PREVENTION OF DISEASE 
bites the individual is protected against malaria and the 
community also, because only in this way do the mosqui- 
toes become dangerous. Thus, malaria was practically 
unknown about Boston some years ago, but the advent 
of Italians, who were employed in large numbers in the 
Metropolitan Sewage System, introduced malaria to the 
region by infecting mosquitoes which had previously 
been harmless. The disease thus became indigenous in 
the neighborhood. 
The female mosquito lays about 100 eggs on the surface 
of fresh water, and preferably in the presence of grass and 
scum of algae. After eight days the insect becomes full- 
grown, does not fly great distances, and avoids wind, 
but seeks protection in grass, undergrowth, and brush. 
The greatest danger threatens from mosquitoes bred 
within 300 feet of a house, although they may fly much 
greater distances. Within this area, at any rate, all 
agencies favoring the breeding of mosquitoes should be 
abolished. Tall weeds, shrubs, grass, and undergrowth 
of all kinds should be gotten rid of, and trees near the 
house are also inadvisable in a malarial region. Collec- 
tions of stagnant water are particularly dangerous. Thus, 
disused wells, springs, empty cans, bottles, watering 
troughs for animals, roof-gutters, rain-water barrels, or 
depressions in the soil, or even in the hollow of leaves, 
where water may stand a week, are prolific breeding 
places. 
The water should be changed in these places daily, or 
the receptacles should be screened, or kerosene may be 
kept on the surface of standing water, or the collections 
of water should be gotten rid of. One ounce of kerosene 
will cover 15 square feet of water. A constant drip from 
a partly opened stop-cock of a can is the best method of 
application. Brooks should be kept clear of weeds, so MALARIA 
149 
that there may be no standing water, and ponds should be 
covered with petroleum, drained away, or stocked with 
various kinds of minnows. The filling in or drainage of 
marshes are essential. 
Mosquito bites may be avoided by staying in a 
screened house except during the hours between sunrise 
and sunset. In case this is not practicable the head 
should be protected by a head net, the hands and wrists 
by gauntlets, and the ankles by leggings, especially in 
the tropics. 
The house should be absolutely screened with wire 
netting of No. 16 mesh. In the tropics the bed should 
also be protected by a special netting, as described under 
Yellow Fever. In sitting after dark, women should 
cover their ankles with high shoes and their necks with 
scarfs. A bedroom well off the ground is safer from 
mosquitoes. 
Where there are many mosquitoes in a room they may 
be killed by burning broken pieces of roll sulphur in a 
deep pan placed on bricks on sand, or floating in water 
inside a larger pan, to avoid setting fire to the premises. 
Cracks about doors and windows should be made tight 
by pasting strips of paper over them. 
In a reasonably well-built house this is unnecessary. 
Three pounds of sulphur are suitable for a room 10 by 10 
by 10 feet. Eight ounces of wood alcohol are poured on 
the sulphur and ignited, and the door of the room is 
closed at once and not opened for twelve hours. 
A word may be said about screening houses. Where 
the inmates sit outside after sunset the veranda must be 
wholly screened. Mosquitoes are only active during the 
night, and will enter a house through the smallest crevices 
such as keyholes and chimneys. These must be stopped 
by wads of paper placed in the throats of chimneys, in 150 
THE PREVENTION OF DISEASE 
fireplaces, and in keyholes. If the smallest holes are not 
stopped a house will act as a trap for mosquitoes, which 
may enter but not find their way out. Wire screens 
should cover every door and window in the house which 
may be opened. 
Window screens should not be movable, but the frames 
should fit tightly against the lower part of the upper sash 
and be fastened by screws. The upper sash must not be 
opened. The netting should not be larger than a No. 18 
for the yellow-fever mosquito nor larger than a No. 16 for 
the malarial mosquito. The number means the number 
of meshes to the inch. A coat of thin paint will convert 
No. 14 into No. 16 mesh. 
The taking of quinin to kill parasites in the body is the 
most practical measure of all, although not so useful as 
thorough screening, together with the taking of quinin. 
Thus, in Italy, where quinin is supplied free of cost to the 
poorer part of the population, the inroads of malaria have 
been tremendously reduced by daily consumption of 
quinin. Celli reports that the mortality from malaria 
has there been lowered 75 per cent., and in the malarial 
region about Rome the number of annual cases has been 
reduced from 11,653 to 2974 by this means. 
In our farming population, where elaborate methods of 
screening and draining are not practicable, the daily use 
of quinin is the most satisfactory method of preventing 
malaria. Quinin does not, however, always kill all the 
malarial parasites in the blood, because in some persons 
the parasites may still exist, but the quinin keeps down 
their numbers sufficiently to prevent an attack, and the 
individual may feel perfectly well, the disease remaining 
latent in his system. No harm is done by taking the 
necessary preventive amount of quinin daily the year 
round, as was shown by the higher officials at Panama, MALARIA 
151 
who took 2 grains three times daily at each meal. In 
some persons this dose may cause buzzing in the ears and 
discomfort, but this usually wears off within a week. 
Quinin might only be taken during the mosquito 
season, but in case of persons who have had malaria the 
parasites may remain in sufficient numbers in the blood 
to produce an attack of fever before they are again bitten 
by mosquitoes the following summer. Such persons 
should being to take quinin in March, and other persons 
should start to take it in June and continue it daily to 
November in this country. In the tropics it is necessary 
to take quinin the year round. The dose for adults 
should be 2 grains of quinin sulphate in capsules with 
each meal three times daily. For children under ten, 5 
grains of the tannate of quinin in chocolate tablets are 
given thrice daily. This form of quinin does not contain 
half as much of the drug as the sulphate, and hence the 
larger dose. In children under five, 2-grain tablets three 
times daily will suffice. While capsules of quinin are the 
most soluble containers and preferable, yet, where the 
cost is important, quinin sulphate may be bought much 
more cheaply by the hundred in tablets. If these are 
properly made, they should begin to crumble in a glass 
of water within ten minutes. In this case they are 
suitable for use. The only objection to pills or tablets 
of quinin is that they are frequently so insoluble that they 
pass through and out of the intestines just as they were 
swallowed. In tropical countries, where malaria is 
severe, it is advisable to take more than 6 grains daily if 
it can be done without much discomfort. Thus, 3 
grains should be taken three times daily, or even 10 
grains daily is safer. After a healthy person has been 
bitten by a malarial mosquito the parasites multiply in 
the blood until from the fifth to fourteenth day they 152 
THE PREVENTION OF DISEASE 
produce malarial symptoms in the patient. The attack 
begins with a shaking chill, headache and fever which 
last from one to several hours and end with sweating. 
These attacks are repeated every 48 to 72 hours. The 
attacks coincide with the formation of spores in the blood 
and they may last for a fortnight and gradually subside, 
or be cut short by quinin. 
Quinin is one of the few remedies that kills parasites 
in the body without poisoning the individual. 
FOR PERSONS ACTUALLY HAVING MALARIAL ATTACKS 
Quinin sulphate should be given in 5 grain tablets to 
adults. In children over 8 years 2 to 3 grain tablets may 
be given. Adults should take 10 grains 3 times daily for 
3 days and then 10 grains each night for 2 months. The 
dose of quinin sulphate for children is as follows: under 1 
year, grain; for 1 year, 1 grain; for 2 years, 2 grains; 
for 3 to 4 years, 3 grains; from 5 to 7 years, 4 grains; from 
8 to 10 years, 6 grains; and from 11 to 14 years, 8 grains; 
and over 15 years, 10 grains. In children these doses 
should be given 3 times daily for 3 days, and then one dose 
each night for 2 months. If the person is infected, but 
not having an acute attack, only one nightly dose for 2 
months is required. 
Children taking 4 grains of quinin at a dose, or less, 
may be given it in aromatic syrup of yerba santa. 
In children under one year the quinin is dissolved in 
half a teaspoonful, and in children over one year the 
dose is dissolved in one teaspoonful of this syrup. 
It should be understood that while chills, fever and 
sweating occur in a typical malarial attack only fever 
may be present and simulate fevers from other causes. 
A positive diagnosis can only be made by finding the 
malarial parasite or plasmodium in the blood of the YELLOW FEVER 
153 
patient. The parasite can practically always be found, 
especially directly after a chill, unless large doses of 
quinin have been taken. 
A patient suffering from malarial fever should be 
especially well protected by mosquito screening to pre- 
vent infection of mosquitoes which might bite him and 
thus transmit the disease to others. For this reason white 
persons avoid the neighborhood of the native quarters in 
the tropics, as the mosquitoes are more apt to be infected 
there. 
Of course, the precautions against malaria are only 
required in regions in which the disease exists; that is, in 
which the mosquitoes are infected with it. Malaria is 
common in the United States throughout the South and 
central Atlantic states, especially in the fall, also in 
southeastern New York and parts of Rhode Island, 
Connecticut, and Massachusetts, and in California in 
the Sacramento and San Joaquin valleys. In the north- 
western states and on the northern Pacific coast it is 
almost unknown. 
Malaria is much less common about New York City 
and Philadelphia than formerly. The disease is only 
found in the Great Lake region about Lake Erie and 
St. Clair. 
YELLOW FEVER 
The prevention of yellow fever is the most interesting of 
any similar attempt in the history of medicine, on account 
of the heroism involved, the ingenuity practised, and the 
wonderful success attained. Yellow fever has been 
shown not to be contagious through contact with a patient, 
his surroundings, or discharges, but to be only trans- 
mitted through the medium of a certain species of 
mosquito, the Stegomyia calopus. The great discovery 154 
THE PREVENTION OF DISEASE 
was made in Cuba by United States Army surgeons in 
1900 following the American occupation. As early as 
1881 Dr. Carlos Finlay of Havana had suggested that 
yellow fever was due to mosquito bites, and the work of 
Dr. Ross in India had proved that .malaria was only 
caused by the bites of mosquitoes, and these facts and 
theories stimulated the American Commission to experi- 
ment in regard to yellow fever. This body was made up 
of the following United States Army surgeons—Drs. 
Walter Reed, Carroll, Lazear, and Agramonte. The 
experiments were done at Camp Lazear in Cuba, in a 
frame house with a screened vestibule, and so constructed 
as to shut out sunlight and fresh air. Previous to this 
time, in September, Dr. Lazear had permitted himself to 
be bitten by a mosquito in a yellow-fever ward and he 
sickened in five days and died a week later of the disease. 
Two months later fifteen mosquitoes which had bitten 
yellow fever patients were allowed to bite one of the 
volunteers at camp Lazear, and he became ill with the 
disease five days later, while two other susceptible persons 
slept in the same room for eighteen nights separated 
only by a mosquito screened partition from the patient. 
These latter remained perfectly well. Many other 
volunteers knowingly permitted themselves to be bitten 
by mosquitoes (which had bitten yellow fever patients a 
sufficient time previously) and they all took the disease. 
To prove that there was no danger of contagion from the 
clothes or discharges of yellow fever patients, two soldiers 
and a surgeon slept for twenty-one consecutive nights in a 
mosquito-screened house in which were boxes containing 
clothing of yellow fever patients soiled with their blood, 
urine, and bowel discharges. Each night the men 
handled these by unpacking them and hanging them on a 
line in the room, and each morning they packed them up YELLOW FEVER 
155 
again in the box. Moreover, two other soldiers slept 
twenty-one days in the night-clothes and sheets just as 
they had been taken from patients recently dying from 
yellow fever, and one of these men actually slept on a 
towel soiled with the blood of a yellow-fever patient. 
None of these volunteers took the disease. The outcome 
of all these experiments proved: (1) That yellow fever 
was only transmitted by the bites of a certain species of 
mosquito. (2) That the mosquito is harmless for a 
period of eight to twelve days or longer after biting a 
yellow fever patient, but that then the mosquito is 
dangerous to man as long as it lives, in one case fifty- 
seven days following the biting of a patient. (3) That 
a period of two to six days after a person is bitten by a 
mosquito, which has previously bitten a yellow fever 
patient, must elapse before the patient begins to sicken. 
(4) That the injection into a susceptible person of even 
2 drops of blood taken from a yellow fever patient in the 
first three days of his sickness will produce the disease in 
one who has not previously had it. (5) That the mos- 
quito to be dangerous must bite a patient during the 
first three days of his sickness. (6) That there is no 
danger from contact with a patient, his clothing or 
discharges, but only from mosquitoes which have bitten 
patients. 
Owing to this knowledge that hotbed of infection, 
Havana, which had been a pest-hole of yellow fever for 
130 years was cleared of the disease by Gen. Gorgasin 1901 
by interfering with the breeding of mosquitoes, by 
destroying mosquitoes which had bitten yellow fever 
patients, and by preventing mosquitoes from biting 
patients. So, again, in Panama Gen. Gorgas stamped 
out the disease absolutely within sixteen months of the 
American occupation in 1904, with no return since, and 156 
THE PREVENTION OF DISEASE 
upon this result did the success of the canal construction 
largely depend. 
Yellow fever is indigenous in Vera Cruz, Rio, and 
Spanish-American ports; it appears periodically in 
tropical Atlantic ports of America and Africa, and 
occasionally between the 15th and 35th parallels of north 
latitude. Where it is prevalent the taking of the tem- 
perature on the slightest feeling of illness will arouse the 
first suspicion of the disease if there is fever. The 
disease begins in a person who has been bitten two to six 
days before by a particular kind of mosquito, which has 
itself bitten a yellow fever patient some eight to twelve 
or more days previously. 
Yellow fever may be divided into 3 stages. The 
first begins suddenly, like many other infections, with 
headache, chilliness, pains in the back and limbs and 
fever (102°-104° F.). On the morning of the second or 
third day the symptoms and fever abate with sweating 
and, in very mild cases, patients may go on to recovery. 
Ordinarily comes now the second stage on the third day 
when the fever and all the other symptoms again increase 
and remain more or less stationary for four to seven days. 
The headache, backache, chills, pain in the limbs 
and fever return with soreness and pain in the stomach 
and perhaps vomiting. Jaundice also appears in this 
stage with yellow tinge of the whites of the eyes, and 
dark scanty urine, with yellow foam, when shaken in a 
glass bottle. 
The jaundice is the most diagnostic symptom of the 
disease and gives it the name of yellow fever. There 
may be bleeding from the nose, mouth and womb. 
Albumin is found in the urine. Next the third stage 
begins with gradual recovery, shown by increase in the 
amount of urine and decrease in fever, vomiting and YELLOW FEVER 
157 
albumin in urine and sleep or, in the fatal cases, the jaun- 
dice increases, the fever remains high, the urine is very 
scanty, there are black or bloody vomiting, hiccups, 
delirium, stupor and perhaps convulsions and death. 
Malignant cases die in two or three days and exhibit 
but one stage. They begin with intense headache, pains 
in back and limbs, chills and high fever (105°-107° F.), 
pain and soreness in the stomach, and black vomit, 
unconsciousness and convulsions. 
One attack of yellow fever usually confers permanent 
immunity or protection against the disease. 
The mortality varies from 10 to 25 per cent, in the 
United States; from 45 to 80 per cent, in Africa. 
Only in 1919 did Noguchi discover the probable 
specific germ or spirochete (leptospira icteroides) which is 
the direct cause of yellow fever. It is so minute as to 
pass through an earthenware filter and lives in the body 
of the mosquito, and blood of the human patient for the 
first three days of yellow fever. Noguchi has prepared 
an immune serum for treatment, and a vaccine for 
prevention in exposed persons, as quarantine officers 
and employees. It is too early to determine the value 
of these but they may well do away with all the terror 
associated with yellow fever. It is of course essential to 
keep patients under a mosquito net to avoid infection of 
mosquitoes from them. Vessels from yellow fever ports 
should be quarantined and sulphur disinfection used to 
kill any infected mosquitoes. Exposed non-immunes 
from the ship must be quarantined six days ashore under 
observation and in screened quarters so that mosquitoes 
may not be infected from them. 
To personally avoid the disease, one should only go out- 
doors in well-lighted places (the Stegomyia may frequent 
darkened woods) between the hours of 9 a. m. and 3 p. m. 158 
THE PREVENTION OF DISEASE 
as the mosquitoes are not active during this period. 
After 3 p. m. one should either seek elevations, where 
there are no mosquitoes, or remain in a thoroughly 
mosquito-screened veranda or room and sleep in a room 
high above the ground under a mosquito bar. 
Mosquitoes already in a room should be killed by fumi- 
gation with sulphur, as advised under Malaria. If it is 
essential to be outdoors in the evening one should wear 
head nets, gauntlets, and leggings. 
Screening of the house is even more important than in 
the case of malaria, where the method is described. A 
mosquito bar for beds should be made of fine bobinet, 
hung from an oblong frame above the bed. 
The frame is better a little higher than the bed, and 
may be made by tying upright posts to the bed-posts and 
running a cord about the top of these on which the net is 
hung. It should not be slit on the side, but be made of 
one piece, which should hang from the inside of the 
frame, so as not to be interfered with by the posts, and 
be tucked in at the head, foot, and sides of the bed at 
night and also by day. 
The beds should be three-quarters size, because if one’s 
body projects against the mosquito net in narrow beds a 
mosquito may bite through the net. 
DENGUE, BREAKBONE FEVER, DANDY FEVER 
Dengue is transmitted from one individual to another 
by the yellow fever mosquito, Stegomyia calopus, and 
this is the only known method of communication, as it is 
not contagious in the ordinary sense. The special germ 
which is the cause of the disease has not yet been certainly 
identified. The disease occurs in tropical and subtropical 
countries, as in India, China, and the Philippines, and in 
our Southern States, as far north as Virginia. Except in DENGUE, BREAKBONE FEVER, DANDY FEVER 
159 
the tropics, it always appears during the warm season. 
Dengue attacks a large part of the population, and when 
the writer was a youth he acted as understudy for the 
medical profession in St. Augustine in carrying about 
medicine and advice for the doctors who were bedridden, 
together with everybody else, during an outbreak. 
Three to six, or five to nine days according to recent 
studies, after exposure the patient comes down with high 
fever, chilliness, and excruciating pains in the head, back, 
legs, and joints, especially the knees. These symptoms 
continue for three or four days, and then the fever departs 
for two to four days, only to reappear again for a few days 
longer, although the disease does not usually last much 
more than a week. When the fever returns, more often 
on the fifth day, it is accompanied by a bright red rash 
appearing first on the hands and spreading rapidly 
to arms, trunk and legs. Besides the eruptions there 
mayor may not be swelling in the painful joints. Persons 
may have second and third attacks of dengue but they 
are much less severe than the first. 
The writer attributed his escape from dengue to pre- 
vious dosage with 10 grains of quinin daily, but this 
means of prevention is denied by some of the leading 
medical authorities. The only known opportunity of 
escape is by avoiding all mosquito bites by means 
suggested under Malaria and Yellow Fever. Fortu- 
nately, while dengue is exceedingly painful it is not- a 
fatal disease. CHAPTER VI 
GERM DISEASES (Continued) 
Tuberculosis, Colds, Influenza, Pneumonia, Cerebrospinal Menin- 
gitis, Infantile Paralysis 
Tuberculosis is the chief destroyer of the human race. 
Yet the deaths from it are steadily declining; so much so, 
that while it has been estimated that one-fourth of all 
deaths in Europe in the last century were due to the dis- 
ease, at the present time it produces but one-tenth of all 
deaths in the most enlightened communities. 
This result has been accomplished by methods of pre- 
vention, depending upon our increasing knowledge of the 
disease and the various means by which persons become 
infected. Our exact knowledge of the contagiousness of 
tuberculosis dates from the discovery of Koch (in 1882) 
that it is caused by a special germ; in fact, this epoch 
marks the beginning of our knowledge of germ diseases, 
since the germ of consumption was the first to be thor- 
oughly studied and proved to be the one and sole cause of 
tuberculosis. 
There are some astonishing facts which we must first 
consider before we can have a rational conception of the 
disease. While the name “tuberculosis’’ strikes terror in 
those afflicted with it, yet the really important matter is 
not so much whether one has tuberculosis as whether one 
has it in a serious or active form. Or, in other words, 
whether the disease is in an active state, or whether 
TUBERCULOSIS 
160 161 
TUBERCULOSIS 
it is inactive or healed. Now for the facts: Over 90 
per cent, of city dwellers show signs of tuberculosis in their 
bodies after death from any cause; 60 per cent, show 
signs in the lungs. The tuberculin test, which is used in 
living patients, is so delicate that it will not only show 
active and serious tuberculosis, but the presence of 
minute and even practically healed small, diseased areas 
in any part of the body. By this test 90 per cent, of all 
children are proved to be tuberculous by the age of 
twelve, and 60 per cent, of healthy young adults. If the 
whole population of city and country are considered, it is 
estimated that from 50 to 70 per cent, are tuberculous in 
some degree. It will thus be seen that while 1 in every 
10 persons dies of tuberculosis, 8 in every 10 become 
infected with the disease and recover—in most cases the 
disease being so slight that the patient is never aware 
of any disturbance caused by it. 
To prevent tuberculosis one must know how it is 
acquired. The disease is not directly inherited from 
either parent; that is, the germ does not pass from either 
parent into the embryo (child) at the time of conception. 
If either parent is tuberculous the disease may be 
communicated to the child soon after birth. A certain 
susceptibility may be inherited (recent research rather 
points to the existence of some immunity against the 
disease in the offspring of the tuberculous) and a peculiar 
build may predispose to consumption. In some families 
various members succumb to the disease at a certain 
age, as from eighteen to twenty-five. Among the children 
of 1000 families tuberculosis was found to be 10 per cent, 
more common in the offspring of tuberculous parents. 
This does not necessarily show heredity or susceptibility, 
but is what would be expected in the case of children 
exposed to a contagious disease. 162 
THE PREVENTION OF DISEASE 
It is now generally accepted that childhood is the 
age in which tuberculosis is more frequently acquired, 
although it may lie dormant until adult life and 
then become active as consumption. The supposedly 
inherited build suggesting greater susceptibility to 
tuberculosis is that represented by pale, thin, blond, 
delicate-skinned persons with sloping shoulders, pro- 
jecting shoulder-blades, and long, narrow, and flat or 
rounded chests. It is probable that these persons are 
already sufficiently infected with tuberculosis to cause 
their inferiority in physique. 
Consumption in children—that is, tuberculosis of the 
lungs—is comparatively rare. Tuberculosis in them be- 
gins in enlarged glands of the neck, the bones and joints, 
and brain. Ninety-four per cent, of children have en- 
larged glands in the neck and 80 per cent, of these are 
tuberculous. The germs enter the system by three 
paths, either through the mouth and throat, from the 
intestines, or in the air taken into the lungs. The latter 
pathway was formerly thought the most frequent one, 
but it has been shown that tuberculosis germs swallowed 
by calves or injected into their tails enter the blood and 
may only lodge in their lungs and not cause disease at the 
site of entrance into the body. 
What is the most common path by which the germs 
enter the human body? This is still a debated point. 
The germs arise from patients with consumption who 
have the disease in an active form; that is, the lungs are 
ulcerating, and the broken-down tissue, containing 
millions of germs, is coughed up. 
The germs soil the fingers, pillow, handkerchief, and 
various objects, food and utensils handled by the patient, 
and enter into the dust of the room. Children crawling 
around, placing all kinds of objects in their mouths and TUBERCULOSIS 
163 
sucking the fingers, toys, and other contaminated objects* 
are thus apt to get the germs into their mouths, which are 
absorbed into the blood from the mouth or digestive 
tract. Then there is great danger from consumptives 
with germs in their sputum (expectoration), when one is 
in close proximity to them during coughing, from the 
minute droplets sprayed into the air. Children run 
great danger from the milk of tuberculous cows. This 
disease is extremely frequent in cattle-—in some herds as 
many as 90 per cent, are affected; among 24,000 cows in 
Massachusetts 50 per cent, were tuberculous, and 
throughout the whole country 10 per cent, of the milk cows 
are tuberculous. Taking at random samples of mixed 
milk on the market it has been shown that one in every 
ten will contain the germs of tuberculosis and will commu- 
nicate the disease to animals. Even the milk from 
certified herds, which are tested for tuberculosis, is not 
absolutely safe, as animals develop the disease between 
testing times, and the writer has known of one instance 
where 20 per cent, of the animals in a certified herd were 
tuberculous through carelessness of the management. 
The most glaring example of the danger sometimes 
inherent in the (apparently) best and cleanest milk which 
money can buy was that (1915) brought to light 
in the case of one of the leading certified milk farms in the 
United States. In a herd of over 600 cows considerably 
more than one-third of this number were suddenly found 
to be tuberculous by the health authorities through an 
accidental occurrence. Certified milk is the best raw 
milk procurable as a general proposition, but it is far 
from infallible in even the protection against tuberculosis, 
which is the danger most readily avoidable. Proper pas- 
teurization will make milk perfectly safe. It is estimated 
by leading authorities that 15 per cent, of the deaths 164 
THE PREVENTION OF DISEASE 
from tuberculosis in children (under five) are due to 
cows’ milk, and that from 20 to 25 per cent, of all cases 
of tuberculosis in children arise from drinking cows’ 
milk. Milk causes 8 per cent, of the total deaths from 
tuberculosis and kills over 10,000 children annually in 
this country. Consumption or pulmonary tuberculosis 
is not caused by the bovine germ, but is always derived 
from a human source, unless the bovine germs become 
altered by growth in the human so as to simulate the 
human tuberculosis organism. 
In children especially, diseased tonsils lead to enlarge- 
ment of the glands in the neck, and these are frequently 
tuberculous, as we have seen. 
Diseased tonsils often act as paths of entrance for 
tuberculosis germs, and in 100 tonsils removed at Ann 
Arbor one-fourth were found to contain such. The 
average of all examinations by many doctors shows that 
only 15 per cent, of removed tonsils are tuberculous 
(Ravenel). Adenoid growths in children (see page 207) 
and enlarged tonsils both interfere with breathing, and 
thus favor consumption by reducing general vitality and 
by interfering with the proper ventilation of the lungs. 
To summarize, it may be said in children the greatest 
danger of tuberculosis is from food, especially raw milk 
and food and other objects placed in the mouth, infected 
by handling, by coughing, and by dust; while in adults 
there is more danger from exposure to coughing and 
dust. That the germs pass more often through the 
mucous membrane of the mouth and intestines into the 
blood, and less often lodge in the lungs directly from 
the air. That consumption in adult life often follows 
tuberculosis of the glands in children. 
That infants and children are most susceptible, and 
possibly the children of tuberculous parents possess less TUBERCULOSIS 
165 
resistance to the disease, but this appears to be doubtful. 
That adults are comparatively insusceptible to tubercu- 
losis either because they actually have it in a latent 
form, or have recovered from it, and they do not retake 
the disease (i-. e., the reopening or “lighting up” of former 
tuberculosis or the entrance of a fresh supply of tuber- 
culous germs into the body) unless through long exposure, 
or circumstances which greatly lower their general 
vitality or local resistance, as by the presence of colds, 
bronchitis, and influenza. Consumption is never 
communicated to attendants in well-regulated hospitals, 
and in the case of 64 throat specialists constantly exposed 
to the breath and coughing of consumptive patients for 
years not one developed the disease. 
On the other hand, when proper precautions are not 
adopted the danger of communication to adults living or 
working in the same rooms with consumptives is consider- 
able. This is so well recognized that in life insurance 
applications one is asked if he has lived or worked with a 
consumptive. 
Thus, Lampson, of Minneapolis (in 1913), examined 
173 persons living in 33 families, in each of which there 
was a known case of open consumption; that is, one in 
which the tuberculous germs were expectorated. He 
found that 100 of these 173 individuals (exclusive of the 
known cases) also showed evidences of tuberculosis, and 
in all the (54) members of 10 families signs of th6 disease 
existed. Whereas, in 15 families, in which no case of 
tuberculosis was known to exist, there were 80 persons, 
and only 2 of these gave evidences of tuberculosis. 
Nevertheless, the consensus of medical opinion is that 
9 in every 10 adults are immune to tuberculosis. This 
is based on the fact that having once had tuberculosis 
one rarely wholly recovers. Small areas in the body 166 
THE PREVENTION OF DISEASE 
contain living germs of tuberculosis, and although they 
are .enclosed by inflammatory tissue, yet the germs are 
often found circulating in the blood of apparently healthy 
persons. Therefore, as 9 out of 10 adults have tuber- 
culosis, they cannot take it again. An active tubercu- 
losis in adult life means a breaking down of old latent 
trouble. An extra dose of germs derived from exposure 
to a consumptive will rarely harm the adult already 
suffering from a latent form of the disease. The belief is 
then prevalent among the leading authorities that 9 in 
every 10 adults may be exposed to active consumption 
with impunity. But a child, or the tenth adult who has 
not been protected by a previous mild tuberculous in- 
fection from milk or from human beings, will probably 
have the most fatal form on exposure to the disease— 
as the aborigines succumb to it and other contagions. 
Consumption is one of the less severe forms of tubercu- 
losis dependent upon a partial immunity existing in the 
subject. This is not a plea for unnecessary exposure to 
tuberculosis, because an individual does not usually 
know whether he is susceptible or not, and children must 
be protected at all costs. 
Certain occupations favor the incidence of tubercu- 
losis. Some of these produce irritation of the membrane 
lining the air-passages, as the dusty trades—stone- 
cutting, metal grinding, working in wood and certain 
textiles, mining. Glass-blowers, cigarmakers, hat and 
cap makers, printers, and bookkeepers have been found 
especially susceptible to the disease. While glass- 
blowing may mechanically irritate the lungs, yet in many 
of these occupations the chief harm is done by ill-venti- 
lated quarters, lack of sufficient space, overheating, over- 
work, and underpay. Industrial workers constitute 
about one-third of the population, and furnish about half TUBERCULOSIS 
167 
the deaths from tuberculosis in this country, and by 
removal of the dust, through properly controlled sani- 
tation of factories, the number of cases and deaths from 
tuberculosis may be reduced by one-half, as has been 
accomplished in the cutlery industry in Germany (Kober). 
It is thought that persons who develop sudden and 
acute tuberculosis late in life are those who have escaped 
the disease in childhood, for with a mild form of tubercu- 
losis, such as most of us have, one acquires a certain 
degree of immunity, as in the case of individuals 
recovered from measles or scarlet fever. In calves the 
injection of small doses of living, non-virulent (human) 
tuberculosis germs produces an immunity which persists 
for an uncertain period. The germs of tuberculosis may 
live for years in an apparently healthy person and may 
even be found in their blood. In healed areas in a 
lung or gland the germs become so surrounded by scar 
tissue that they cause no sign or symptom because they 
are shut off from the circulation. But let a person be- 
come “run-down” and his resistance lowered, and partial 
immunity caused by a mild infection with tuberculosis in 
childhood no longer protects him; the tissues about the 
germs break down and the germs escape into the blood 
to cause active, serious disease in some part of the body. 
In most cases we are wholly ignorant of the presence of 
tuberculosis germs until many years after their entrance 
into our bodies. Every cause tending to lower the 
general health—as disease, overwork, undernourishment, 
dissipation, bad habits, overcrowding, and poverty— 
favor tuberculosis, which causes one-third of all deaths 
between the ages of twenty and forty, the time of greatest 
stress and strain from work or dissipation. 
A large portion of consumptives do not cough up 
matter containing the germs because the diseased area 168 
THE PREVENTION OF DISEASE 
is not connected with the air-tubes and is surrounded by a 
wall of inflammatory tissues. If there is no expecto- 
ration, or if frequent examination of the expectoration 
shows that it is free from germs, the patient cannot 
transmit the disease to others unless his condition 
changes. 
What are the early signs of tuberculosis in adults? 
Loss of weight, loss of energy and ambition, and a tired 
feeling; digestive disturbances; frequent and prolonged 
colds; pleurisy or spitting of blood; pain about the shoul- 
der-blades or between the shoulders; hacking or tickling 
cough in the throat, hoarseness; fever and night-sweats. 
The existence of one or more of these symptoms should 
cause the subject to seek medical advice. 
A proper medical examination will include taking tem- 
perature at two-hour intervals for several days, examina- 
tion of the expectoration, if any, tuberculin test and x-ray 
examination, besides the ordinary tapping on the chest 
and listening to the breath sounds with the stethoscope. 
It is often impossible to make a positive diagnosis because 
the symptoms and signs are indefinite. The x-ray and 
tuberculin test may indicate tuberculosis, and yet the 
disease may not be in an active state. 
But in all doubtful cases the treatment is never doubt- 
ful. The same upbuilding which is most suitable in 
tuberculosis will be indicated in debility from other 
causes. 
Now in regard to the preventive measures to be 
adopted in the case of children of tuberculous parents. 
The danger to infants nursing tuberculous mothers is 
slight from the milk, but there is more danger to the 
child from soiling of the breast and other objects by the 
mother’s fingers, and she would very probably be too 
much debilitated to undertake nursing. (In cows the TUBERCULOSIS 
169 
milk is chiefly infected from the germs in manure, which 
commonly contaminate their milk.) So that nursing 
a tuberculous mother is undesirable, and the child should 
be brought up as much apart from tuberculous parents as 
possible and should stay outdoors the greater part of the 
time. A separate room is advisable for a nursery, with 
no unnecessary furniture, curtains, or carpet to catch the 
dust, and every effort should be made to keep children 
from placing toys, pencils, and various objects in their 
mouths. 
Great care should be taken to wash their faces and 
hands three times daily before eating and to brush their 
teeth at least twice daily after meals. Separate eating 
and drinking utensils, handkerchiefs, table, bed and body 
linen must be provided for children, and all objects 
coming in contact with consumptive parents or other 
persons should be avoided. The effect of crowding is 
seen in the observation of Knopf, that 42 per cent, of all 
cases of tuberculosis occurred in families living in one 
room, while but 6 per cent, of all cases were seen in 
families living in four or more rooms (Berlin). Parents 
whose expectoration is filled with tuberculosis germs had 
better themselves be removed to a hospital to prevent 
infection of children. This applies more especially to the 
poor. Advanced cases of consumption, when bedridden 
and unable to care for themselves, are the chief source 
of danger in spreading germs and tuberculosis. What is 
worth doing for animals is certainly worth doing for 
children. It is generally recognized that the only way to 
keep calves free from tuberculosis, when born of tubercu- 
lous cows, is to raise them in separate barns, yards, and 
pastures, and to feed and water them from separate 
utensils. In youth overstudy and over-athletic training 
are equally harmful, while late hours and the use of 170 
THE PREVENTION OF DISEASE 
alcohol, tobacco, and excesses of all kinds should be 
especially avoided in young adult life by those who have 
been exposed to consumptives. In case any of the symp- 
toms noted above develop in such individuals medical 
advice should be sought, as these are often premonitory 
of active tuberculosis and a change of life at this time is 
usually sufficient to avert the disease. 
Marriage should not be considered in the case of a 
person who has active lung tuberculosis with germs in the 
expectoration. Whether marriage is proper in the case 
of individuals with healed, inactive, or closed lesions in 
the lungs depends upon all the circumstances involved, 
and an expert should decide. A person may have active 
tuberculosis, apparently recover, and yet be a carrier of 
tuberculosis germs in his expectoration, as in the classical 
instance of the recovered consumptive who caused the 
death of four wives by tuberculosis while remaining in 
apparent health himself. 
A patient with active tuberculosis who is able to be 
about and care for himself may not be a source of any 
danger to others by conscientiously adopting the follow- 
ing precautions: His expectoration should always be 
deposited in a pasteboard box, made for the purpose, 
which is daily burned with its contents. The use of 
handkerchiefs or cloths leads to soiling of the hands, 
pockets, bed clothes, etc. When coughing in the presence 
of others a paper handkerchief should be held before the 
face to prevent spraying of the germs into the air of the 
room. Any object placed in the mouth should be burned, 
as toothpicks, cigar butts, etc. 
The tooth-brush should be used three times daily, over 
the toilet and not over a wash basin. The face should be 
kept shaven and the face and hands washed frequently. 
It has been found that the ordinary washing of eating TUBERCULOSIS 
171 
utensils is sufficient to prevent contagion from them, but 
the napkin should be kept in a separate envelope unless 
used but once. 
The bed and body clothing should be boiled for ten 
minutes before being sent to the laundry. The patient’s 
room should be cleaned without stirring up dust, using a 
moist cloth or wet broom, or, better, vacuum cleaning. 
The bed should be covered with a counterpane which is 
frequently washed, and the upper sheet should be turned 
down well over the blankets to protect them from the 
patient’s coughing and sneezing. 
With such precautions patients make safe companions, 
as shown by the fact that there is no danger from patients 
to attendants in well-regulated sanatoriums. 
New York, under the supervision of the late Dr. 
Hermann M. Biggs, is the model city of the world in the 
public control of tuberculosis. The death-rate from 
tuberculosis has been reduced 50 per cent, in the last 
twenty-five years, or from 3.98 to 1.97 per thousand. 
This is accomplished by compulsory notification of cases, 
printed instructions sent to patients, special hospitals, free 
dispensaries, and visiting nurses for charity cases; free 
examination of expectoration and early diagnosis, free dis- 
pensing of sputum cups, medicines and food, and disinfec- 
tion of all premises occupied by consumptives. By far 
the most important of all measures to prevent the spread 
of tuberculosis is the segregation of advanced cases in 
hospitals, and this has been the chief means all over the 
world of lessening the number of patients and, therefore, 
the mortality. 
As we have seen, chronically enlarged glands in the 
neck in children are very common and usually are 
tuberculous, and in course of time the germs find their 
way into the blood and may in the end lead to disease of 
the lungs. Therefore it is extremely important to cure 172 
THE PREVENTION OF DISEASE 
enlarged glands. Removal of diseased tonsils and 
adenoids in children, z-ray treatment of the glands, 
combined with a diet of milk and eggs, and living and 
sleeping outdoors, will usually cure the glandular swell- 
ings in the neck. In adults removal by the knife is 
commonly advisable. 
To prevent tuberculosis in children cows’ milk should 
be pasteurized. The cleanest milk is best, certified if 
possible. Home pasteurization js safest unless one is 
sure of the dealer. Fill the outer part of a 2-quart 
double boiler as high as possible with water and bring it to 
the boiling-point. Then take off the fire and place a 
quart of milk in the inner part of the boiler and insert 
this in outer part. Put on the cover and let the double 
boiler stand with a cloth over it in a warm place for 
forty-five minutes. Then cool the milk and keep the 
milk covered on ice. The milk should be kept at 145° F. 
for thirty minutes, and to secure this it is well to test it 
with a thermometer during the heating process. 
Cleaning and disinfecting rooms occupied by con- 
sumptives are of great importance. Mattresses and car- 
pets which cannot be sterilized by a municipal steam 
plant should be burned. 
Disinfection by formalin is most effective, followed by 
general cleaning and renovation. For this the furniture 
should be moved from the walls, rugs lifted from the 
floor, and clothing exposed. 
Then 2 cups (3dj pint) of formalin are mixed with a cup 
of water in a water pitcher, and to this is slowly added 
3 fluidounces of commercial sulphuric acid. 
One pound of quicklime is placed in a large enamel 
basin on some bricks in the center of the room and the 
solution in the pitcher is poured over the lime and the 
door quickly closed and sealed by strips of paper pasted COLD IN THE HEAD 
173 
over the cracks. This quantity of chemicals is sufficient 
for an ordinary small bedroom (10 X 10 X feet—1000 cu. 
ft.) which is reasonably tight. After the room has been 
closed for twelve hours it should be aired and everything 
possible washed with soap and water containing a 
generous tablespoonful of compound cresol solution to the 
quart. Then the walls and ceiling may be calcimined or 
prepared so as to secure the most complete renovation. 
All fabrics and bed or body clothing should be boiled for 
twenty minutes, or soaked in 1:1000 corrosive sublimate 
solution over night. 
The prevention of overcrowding in factories and work- 
shops, and medical examination at regular intervals of 
employees in stores and in buildings in which large 
numbers of persons are working, are of great value in 
limiting the ravages of tuberculosis. 
The chief measures of prevention are three: 1. Segrega- 
tion of advanced cases to avert distribution of enormous 
numbers of germs. 2. Early diagnosis. 3. Improve- 
ment of individual health. 
COLD IN THE HEAD 
Colds are due, in the first instance, to changes in the 
circulation, and, secondly, to the presence of certain 
germs in the nose and throat. 
Chilling of the whole body also chills and lowers the 
resistance of the mucous membrane of the nose and 
throat. Germs normally, or abnormally present in the 
case of chronic catarrh, are thus enabled to cause acute 
inflammation or colds. 
It is well known that exposure to cold or wet (the same 
thing) is likely to cause a “cold,” especially if one 
is overheated at the time. Other conditions likewise 
favor colds, as chronic catarrh from any cause—com- 174 
THE PREVENTION OF DISEASE 
monly nasal obstructions, diseased tonsils, and adenoid 
growths, particularly in children. Irritation of the 
mucous membranes of the nose and throat is also occa- 
sioned by hot, dry air, as from the effect of hot-air 
furnaces and by dust, and, apparently, by some forms of 
indigestion and debility. If the resistance of the 
mucous membranes to germs is not lowered by the 
foregoing means then the presence of germs which are 
ordinarily found in the air-passages may do no harm. 
Or, again, the transmission of actively infectious germs 
from a patient may lead to an attack of cold in healthy 
persons. A variety of germs are commonly found in 
the nasal discharges of those with colds, one or the other 
preponderating, according to season and place. These 
are most often various kinds of streptococci (pus germs) 
and pneumococci or pneumonia germs. The pneumo- 
cocci may cause colds without producing pneumonia. 
Then there are staphylococci (also pus germs), and the so- 
called influenza or Pfeiffer bacillus, and micrococcus 
flavus, siccus and catarrhalis. 
It may well be that the true causative organism of colds 
is yet to be discovered. 
The chief thing is to remember that all colds and 
coughs may be contagious and to burn or boil the material 
on which the secretions from nose or mouth are collected. 
Also that persons with colds should keep away from 
others. Nothing is more exasperating than to have a 
friendly (?) visitor introduce a bad cold into a home and 
leave a long trail of sickness, suffering and expense 
behind him. 
Thus, two factors are essential for the production of 
colds—lessened resistance of the mucous membranes and 
the presence of certain germs—and apparently both are 
necessary. In places free from germs, as on mountain COLD IN THE HEAD 
175 
tops and in arctic regions, exposure to cold and wet does 
not ordinarily induce colds on account of the absence of 
germs; while, on the other hand, our nasal passages 
may contain the same germs found in the discharges 
of those with severe colds, and yet we may remain 
absolutely well if we keep our mucous membranes in good 
condition. 
To avoid colds we must, then, avoid chilling, contact 
with persons having colds, chronic catarrh, overheated air 
or any causes lowering the general tone or the local tone of 
the mucous membranes. In children removal of enlarged 
tonsils and adenoids are often required, and removal of 
nasal obstructions in adults. Vaccines made of all the 
varieties of (killed) germs which are found in the nasal 
discharges of persons with colds are now used to induce 
immunity in those subject to repeated attacks and also in 
treatment of an existing cold. Their use is harmless, but 
how much value may be attributed to them it is difficult 
to state. For persons subject to repeated colds, and 
especially pneumonia, and for those with persistent colds, 
the use of vaccines has seemed to the writer to be of 
considerable worth. The injection of the vaccines is 
made under the skin in three doses about five days apart. 
These injections should be done at the time colds may be 
expected in the late fall. After a cold has lasted for 
some weeks the use of vaccines sometimes causes their 
rapid termination. 
As to the duration of protection it would seem that 
logically it would not be longer than that conferred by a 
cold. 
What shall be done on the first premonition of a cold— 
when one feels a stuffiness in the nose, sneezes frequently, 
has a roughness or dryness and discomfort in the upper 
part of the throat, and chilliness. 176 
THE PREVENTION OF DISEASE 
Both general and local measures are advisable. 
General treatment consists in increasing the normal 
secretions of the skin, bowels, and kidneys. Thus, one 
should take a laxative—one-half to one bottle of effervesc- 
ing citrate of magnesia—should drink a quart or so of 
hot lemonade, and take a hot bath before retiring, or a 
Turkish bath may be taken if one can drive directly 
home without exposure and go to bed at once. Capsules, 
each containing 1 grain of quinin, 34 grain of camphor, 
and 34 o grain of extract of belladonna, are useful in the 
very beginning of a cold. 
One should be taken each hour until four or five have 
been swallowed, unless there is much dryness of the 
mouth, when it is well to stop them. 
If the nose is much obstructed it is well to take a few of 
these tablets at any time to lessen the swelling in the nose, 
by causing contraction of the blood-vessels of the mucous 
membrane. Taking a 2-grain capsule of quinin hourly, 
until three, four, or five doses are swallowed, or until 
there is ringing in the ears, appears to have some influence 
in preventing colds, but is less effective than the above 
combination. 
Among the local remedies the dropping of half a medi- 
cine-dropperful of a freshly made 20 per cent, watery 
solution of argyrol in each nostril the writer has found 
most useful in aborting a cold if used a few times at 
three-hour intervals at the first suggestion of the trouble. 
The head should be thrown well back, and a medicine- 
dropper is filled half-full of the solution, which is 
allowed to flow slowly into the nose and so on into the 
throat. 
The solution is harmless if swallowed. It is well not to 
blow the nose afterward more than possible, and to use 
pieces of cheese-cloth or old bits of cotton, which may be COLD IN THE HEAD 
177 
thrown away as soon as used, for the solution will stain 
the handkerchief badly. These stains may be immedi- 
ately removed, however, by a 1:1000 solution of corrosive 
sublimate made with the ordinary surgical tablet. 
Argyrol is a most useful agent in preventing the growth 
of germs when locally applied, and will prevent the 
occurrence of the most dangerous inflammations of the 
eye and of the sexual organs (see page 245). When there 
is much obstruction in the nose and breathing through it 
becomes difficult one may sniff up occasionally into the 
nostrils a little Pond’s extract or witchhazel from the 
hand, which will be found very effective. But this is 
not a dissertation on the treatment of cold, and we must 
stick to our subject of prevention. The argyrol solu- 
tion may be dropped into the nostrils of infants or 
children while they are lying in bed without causing 
distress or subjecting the patient to the slightest danger 
from swallowing the medicine. As the solution does not 
keep well for longer than a week, one may use in its place 
a solution of 7x/i grains each of menthol and camphor 
in an ounce of liquid albolene (similar to liquid vaselin), 
dropped into each nostril in the same manner, and this 
solution is useful throughout a cold when dropped in the 
nose four times daily, and for children is preferable, 
in that it will not stain the clothing as does the argyrol. 
This is also absolutely harmless if swallowed. 
The best treatment of all severe colds is that secured by 
remaining in bed. While the temperature is over F. 
one is always safer in bed with a cold. The even warmth 
of the coverings tends to bring the blood to the surface of 
the body and relieve the congestion in the air-passages. 
For persons subject to colds the daily sniffing of a 
solution made from Seiler’s alkaline antiseptic tablets 178 
THE PREVENTION OF DISEASE 
(one tablet to half a cup of warm water) into the nostrils, 
and the gargling of the throat with a half pint of cold 
water twice daily, are of great benefit in cleansing 
these parts of germs. Then, as is well known, the 
hardening of the skin by daily cold baths, showers, 
or cold sponging (in delicate persons while standing 
in warm water) will be of great service. Persons with 
bald heads may bathe their heads in cold water. 
Cold baths should not be taken unless a warm reaction 
follows, and the use of a very warm bathroom greatly 
favors this result. Also light underclothing is of advan- 
tage in hardening the skin, and many persons catch cold 
by the opposite process through wearing too warm under- 
clothing in cold weather. The material is not of so much 
importance; light wool is best, but many do as well with 
cotten or linen. So children should be brought up to 
scorn drafts, unless the skin is moist from perspiration. 
It does one good to get used to sitting in drafts and thus 
harden the skin to cold, with the above exception. 
Germ-laden dust is one of the most prolific sources of 
colds and pneumonia in cities. Clean pavements will 
prevent this danger. In Seattle the streets are paved 
with brick or asphalt, and are washed daily with a hose 
in the business sections, and this city has the lowest 
death-rate in the United States. Infants should not be 
taken out in cities when the air is filled with dust unless 
the face is well protected by a veil. The general pre- 
cautions which are advised herein will apply as preventive 
measures against diseases of the air-passages and lungs 
as a whole, including bronchitis and pneumonia. 
There is one favorite preventive against cold, recom- 
mended by the justly famous Dr. Alonzo Clark, which we 
have omitted. It consisted in hanging one’s hat on the 
bedpost and drinking whisky and water until one sees INFLUENZA, LA GRIPPE 
179 
two hats. Times have changed, and neither present mor- 
als nor scientific teaching favor this, to some, agreeable 
treatment. 
INFLUENZA, LA GRIPPE 
It is impossible to define precisely what influenza is 
till we positively know its causation. There is no 
laboratory method by which influenza can be distin- 
guished from ordinary colds because the same germs 
are found in the throat and nose secretions. Since 1893 
the so-called influenza germ was accepted as the cause 
until the last great world outbreak in 1918-19. But in 
the enormous experience in the last pandemic doubt has 
been thrown on the causative relation of the influenza 
bacillus. This is because this organism was not found to 
be present in many localities in influenza patients but the 
symptoms were alike in persons of all nationalities all 
over the world. Also it was known before the recent 
outbreak that influenza germs had been found in the 
sputum of 25 to 50 per cent, of all persons with cough and 
expectoration in many diseases, as bronchitis and 
consumption, when there was no epidemic of influenza. 
Quite recently at the Rockefeller Institute investigators 
have isolated a minute bacillus-like organism (Bacterium 
pneumosintes) from the nose and throat secretions of 
influenza patients which passes through an earthernware 
filter. This germ, owing to its producing influenza in 
animals and to certain laboratory tests, is thought to be 
the true cause of influenza. An immune animal serum 
has also been secured which is being used for the protec- 
tion of persons from influenza. 
Notwithstanding the high source from which this work 
emanates it is altogether too soon to unquestionably 
accept this new organism as the certain cause of influenza 180 
THE PREVENTION OF DISEASE 
and even more impossible to evaluate the protective 
worth of the serum. 
In nose and throat secretions of influenza have hitherto 
been found the same germs as in colds: pus germs (staph- 
lococci and streptococci), germs of pneumonia (pneumo- 
cocci), the so-called influenza bacillus in a considerable 
percentage of cases, and a special germ causing cold in the 
head (Microcococcus catarrhalis). These are now looked 
upon as contributing to the severity of influenza because 
practically the sole cause of death in the recent epidemic 
of influenza was pneumonia. All the persons who died 
of influenza died of pneumonia. Pneumonia is quite 
commonly caused by streptococci and pneumococci so 
these organisms probably have an important action in 
influenza (“Secondary invaders”) and any value of the 
vaccines, composed of these killed germs and given to 
prevent influenza, rests on their prevention of pneumonia 
rather than influenza. 
After exposure 2 to 3 days usually elapse before influ- 
enza appears. It commonly has a sudden onset with 
chilliness, pain in the head, back and limbs and soreness 
of the muscles, fever, and often cold in the head, eyes, 
more or less sore throat and cough. There is also marked 
physical and mental depression. In the recent epidemic 
a dusky or bluish hue of the face, lips and hands was seen 
in severe cases. The fever is usually not much over 103° 
F. in simple influenza but when it continues at 104° F. 
for any length of time, and if there is spitting of any 
blood, pneumonia is almost surely present. The mor- 
tality differs wholly at different times. The writer had 
the advantage of a large experience in the Army having 
many thousand cases of influenza, and almost a thousand 
cases of pneumonia, under his supervision at one time. 
In the U. S. Army during the height of the influenza INFLUENZA, LA GRIPPE 
181 
epidemic one patient in every 7 had pneumonia and of 
every three with pneumonia one died. 
A few months later in the same wards filled with 
influenza patients very few had pneumonia and all 
recovered from it. 
After a worldwide outbreak of influenza—epidemics 
and isolated cases occur for years thereafter with usu- 
ally diminishing fatality. Grip or influenza is used too 
carelessly as a diagnosis by doctors as well as laymen 
when there is no epidemic prevailing. 
It is well, however, to consider colds in adults accom- 
panied by fever as influenza until a positive diagnosis can 
be made by medical observation. This is advisable 
because then isolation will be carried out and also 
because many other communicable diseases which demand 
isolation closely resemble influenza in their early stages, 
as measles, chickenpox, smallpox and typhoid fever. 
As there is no single sign, symptom or laboratory test to 
enable one to make a positive diagnosis of influenza its 
recognition must rest upon the ability of the doctor to 
exclude all other diseases which is easy during an epi- 
demic but not so at other times. 
Influenza is only communicated by contact of the well 
with the influenza patient, or with one who is convales- 
cing or is carrying the influenza germs in the secretions of 
the nose and throat. We will not know much about 
“ carriers ” until the true influenza germ is certainly 
discovered and can be generally recognized. The germs 
are conveyed from the sick to the well by sneezing and 
coughing of the patient, by the hands of the patient, 
and by the oral and nasal secretions contaminating 
eating and drinking utensils, handkerchiefs and other 
articles. The disease is not transmitted any distance 
through the air. Thus among thousands at sea none 182 
THE PREVENTION OF DISEASE 
ever contracts influenza except after leaving port or 
after mixing with crews of other vessels. 
Prevention may be secured by various means. Vaccines 
may be used consisting of the killed germs thus far found 
in influenza and they have been employed on a large 
scale. In the Army it has been found that the vaccinated 
recruits are less liable to pneumonia than the unvacci- 
nated in many thousand thus treated. The vaccinated 
are one tenth less susceptible, which is not a very great 
gain. The streptococci and pneumococci are probably of 
value in preventing the pneumonia of severe influenza. 
Three injections of the influenza vaccine must be made 
about 5 days apart and some 10 to 21 days must elapse 
after the completion of the injections before protection 
is conferred. So that the protection is not immediate. 
How long it lasts is also uncertain but probably not 
many months. If the B. pneumosintes is established as 
the true cause of influenza a vaccine made from it may 
confer lasting immunity. 
For attendants on influenza patients the wearing of 
washable gowns and gauze masks over the nose and mouth 
frequently changed, and the washing of the hands and 
face after leaving the sickroom, and especially before 
eating, are the chief means of escaping the disease. 
Persons generally in epidemics should shun crowded 
places, particularly indoors, and attend to the general 
health avoiding fatigue, exposure and dissipation. To 
prevent pneumonia the patient should go to bed at the 
very onset of influenza, remain there for three days after 
subsidence of fever, and stay indoors for a week, during 
severe epidemics. The premises do not require disin- 
fection after the sick are removed, only a thorough clean- 
ing and a day’s airing. The eating utensils and clothing 
of the sick should be boiled and the secretions from PNEUMONIA 
183 
the mouth should be received on paper or gauze and 
burned. 
One attack of influenza affords considerable immunity. 
While some persons have several attacks in a lifetime 
this is unusual. It is rare that an individual has more 
than one attack during the period of an epidemic which 
may last for many months. 
Something like three quarters of the cases of influenza 
in the last great epidemic occurred in people under 40. 
The worldwide outbreaks of influenza happen every 2 
or 3 decades and it may be that they do not take place 
oftener because of the number of immune people remain- 
ing after each epidemic has taken its toll. 
PNEUMONIA 
Pneumonia is a communicable disease. It occurs 
all over the world but is more prevalent in colder weather 
in temperate climates. While pneumonia is often 
prevalent or endemic in these regions at certain seasons, 
it may become epidemic, when persons are crowded 
together in ill ventilated buildings, and when the 
causative germ is present in virulent form. 
This happened in Army camps in the United States 
in 1917-18 when measles was rampant in 1917, and 
influenza in 1918. In both of these d'seases the strepto- 
cocci were contributing, if not causative, organisms. 
There are two forms of pneumonia—lobar, and lobular 
or bronchopneumonia. Lobar pneumonia is due in most 
instances to pneumococci, and lobular or broncho- 
pneumonia to streptococci. In the recent influenza 
epidemic (1918-19) deaths were always due to pneumo- 
nia, usually bronchopneumonia. 
In bronchopneumonia the onset is usually gradual, 
beginning with influenza, measles or other infection. 184 
THE PREVENTION OF DISEASE 
The positive diagnosis by a layman is of course impossible 
but when a patient has cough, high fever (104° F.), rapid 
and difficult breathing (30-60 per minute), bluish lips 
and finger nails, and above all, spitting of bright red blood, 
the diagnosis of pneumonia is practically certain. Bron- 
chopneumonia has been the prevailing type in this 
country for years. 
The older lobar type of pneumonia comes on suddenly 
with a chill, high fever and stabbing pain in the side, 
particularly on taking a deep breath. In this form one 
or more lobes of the lung are involved, in lobular pneu- 
monia the base of one or both lungs. In the lobar form 
the expectoration is rusty colored and like jelly, the pain 
in the side is very constant and, with recovery, the fever 
drops to normal in a few hours (crisis), while in broncho- 
pneumonia it gradually subsides after days (lysis). 
Pneumonia caused over 100,000 deaths in the United 
States in 1919 and was the third most important cause of 
mortality. Its control is of the utmost importance. 
It is chiefly communicated by droplet infection. That is 
in droplets of secretion sprayed into the air in coughing 
or sneezing from four classes of people. (1) Pneumonia 
patients, (2) healthy persons who carry the germs in 
secretions of their nose, mouth or throat; (3) and healthy 
contacts who convey the germs on their hands; or (4) 
persons with colds caused by pneumonia germs. 
Pneumonia is also communicated by eating utensils, 
fingers of the patient or attendant, handkerchiefs and 
contaminated bedding. 
How shall pneumonia be prevented? There is no 
disease in which preventive measures are more desirable. 
First, isolation of the patient in a well ventilated, sunny 
room. Sterilization of all articles soiled by the patient. 
The boiling of eating and drinking utensils from the CEREBROSPINAL MENINGITIS 
185 
sickroom, boiling of soiled towels and bed linen, burning 
of cloths or paper holding sputum. 
The nurse should wear a gown and gauze mask over the 
face in the sickroom and wash the hands before leaving it, 
or after handling the patient or his belongings. 
Men must not be overcrowded in camps. The danger 
of this was most noticeable during the War when occupa- 
tion of barracks was compared with that of tents. 
Promiscuous spitting must be stopped and the face 
should be covered when one coughs or sneezes. Persons 
with colds should stay at home and not expose others. 
In epidemics of colds, influenza or pneumonia careful 
persons will avoid crowds, especially indoors. 
The vaccine used for colds and influenza is of consider- 
able value in the prevention of pneumonia (see p. 182). 
It should be used in pneumonia or influenza epidemics 
and every winter by those who have had pneumonia. 
An attack of pneumonia makes one more susceptible to 
the disease instead of conferring immunity. 
In treatment of pneumonia there is a special serum for 
one type (type 1) of lobar pneumonia which is of benefit 
when given in the early stages. But to take this treat- 
ment the patient must be in a modern hospital with the 
best laboratory facilities because the most refined 
laboratory and bedside technique and care are required. 
Except for these limited number of patients with excep- 
tional opportunities there is no special treatment of 
pneumonia but that taught by long experience and con- 
sisting chiefly of expert nursing. 
CEREBROSPINAL MENINGITIS 
This is a disease due to a special germ (meningococcus). 
It frequently occurs in epidemics and in the country 
rather than in cities. Children are more often attacked, 186 
THE PREVENTION OF DISEASE 
although adults, particularly those living in squalor or 
crowded together as in military camps, are quite sus- 
ceptible. It is not a very contagious disease, there being 
seldom more than one or two cases in a house. However, 
it is such a dreadful malady that all possible precautions 
should be observed. Meningitis usually comes on sud- 
denly with headache, pains in the back and limbs, 
chills, and vomiting. So far it resembles “grippe,” 
but its peculiar characteristics include stiffness and rigidity 
of the muscles of the neck and back, with a drawing 
backward of the head, and the whole body may be so 
stiff that a person can be lifted like a statue. There are 
also tremblings or spasms of the muscles of the arms and 
legs. Delirium and stupor occur, the eyes are sensitive 
to light and often squint, the pupils are large, and 
a rash often appears on the body. The wonderful work 
of Simon Flexner in producing a serum by injecting into 
the blood-vessels of the horse, first a solution of dissolved, 
dead germs of cerebrospinal meningitis and, later, the 
living virulent germs has revolutionized the treatment of 
the disease. After receiving increasing doses about four 
months the horse is bled and the clear fluid (serum), 
resulting from clotting of the blood, is injected into the 
space surrounding the spinal cord of human patients at 
the earliest possible moment. 
In meningitis the normal fluid surrounding the spinal 
cord is increased greatly in amount and becomes cloudy 
from “matter” or pus. 
This fluid should be withdrawn from the spinal canal in 
the beginning of suspected meningitis, in order to abso- 
lutely verify the diagnosis, by finding the special germs 
with the microscope; and, again, the removal of this 
fluid relieves the pressure on the spinal cord and brain 
and may occasion a corresponding improvement in the CEREBROSPINAL MENINGITIS 
187 
symptoms, as headache, delirium, stupor, etc. This 
result is accomplished by inserting a strong, hollow 
needle through the muscles over the spine in the lower 
part of the back, directly into the space surrounding the 
spinal cord. After the fluid flows out through the needle 
the curative serum is allowed to flow into the needle 
from a funnel connected with the needle by a rubber 
tube. The amount of spinal fluid removed and serum 
injected are controlled by the fall of blood-pressure 
caused by both these procedures. Serum is also some- 
times injected into a vein, and the serum treatment is 
generally repeated daily for four to six doses. 
Cerebrospinal meningitis is a very fatal disease, death 
occurring in 70 to 90 per cent, of cases without the serum 
treatment. To secure the best results the serum must be 
given within the first three days of the disease, when the 
average death-rate is reduced to 34 per cent., and the 
duration of the disease shortened from many weeks to 
one or two. One authority (Sophian) has reported a 
mortality of only 15.5 per cent, in 161 cases of cere- 
brospinal meningitis by the most skilful use of serum and 
9 per cent mortality when patients were treated during 
the first 3 days. Persons may have more than one 
attack of epidemic meningitis as there is no lasting 
immunity conferred by the disease. 
Prevention.—The special germs (meningococci) are 
not found outside the human body, and they die within 
a few hours when dry or exposed to sunlight. The 
germs may be found in 90 per cent, of patients in the 
nose and throat. The disease is spread by patients, 
convalescents, and healthy persons exposed to patients 
who carry the germs about in the nose and throat 
without suffering any inconvenience, or, at most, only 
from cold in the head. It has been found that 55 per 188 
THE PREVENTION OF DISEASE 
cent, of healthy persons exposed to the disease become 
carriers, or that there are ten carriers for every case of 
meningitis. 
Carriers may communicate the germs to persons, who, 
in turn, may either become carriers or take the disease. 
Meningitis germs may live but a few days in the nose and 
throat of carriers, or they may mostly disappear and later 
reappear in large numbers, or, if the carrier becomes 
depressed in vitality, the meningitis germs may invade his 
blood and induce a real attack of the disease; or, finally, 
the meningitis germs may persist in the nose and throat of 
carriers for months or years. In the case of patients the 
germs are not only present in the secretions of the nose 
and throat, but in the urine, and in discharges from the 
eyes, ears, or skin eruptions. 
Patients should always be isolated in a well-ventilated 
and lighted room, stripped of carpet and unnecessary fur- 
nishings. The other members of the household who have 
been exposed should also be quarantined in the house, 
away from the patient, for a week, or until cultures taken 
from the nose and throat on two occasions show the 
absence of meningitis germs. The cultures are taken 
exactly as in the case of diphtheria. In order to get 
rid of the meningitis germs in the nose and throat one 
should spray these parts with a solution containing 5 
grains of common salt to 2 tablespoomfuls of water, or 
with Seiler’s or Dobell’s tablets dissolved in water accord- 
ing to directions, three times daily, and after a few days 
the desired result will usually be accomplished. Children 
should not be permitted to use any but personal hand- 
kerchiefs, pencils, eating utensils, food, etc. 
The discharges of patients should be burned and the 
urine disinfected, as advised under Typhoid Fever. All 
handkerchiefs, bed and body clothing, and eating uten- CEREBROSPINAL MENINGITIS 
189 
sils used by patients should be boiled after use. It is not 
necessary to disinfect rooms after occupation by the sick, 
as sunlight and ventilation are sufficient. During an 
epidemic the congregation of persons in public should not 
be allowed and schools may be closed. Care should be 
taken to avoid colds or to have them carefully treated, 
and close intimacy in talking, sneezing, coughing, and kiss- 
ing are inadvisable. Children should not use articles 
which have been in the mouths of others, as cups, pen- 
cils, handkerchiefs, food, gum, etc. One should avoid 
close contact with persons having colds, and handker- 
chiefs which have been used by them should be boiled. 
Plenty of fresh air and sunshine soon kill the germ in 
the house. Nurses should wear masks, gowns and caps in 
attending the sick, and cover their faces with gauze 
when exposed to the breath of patients. There are two 
special preventives which are more effective than all 
others. Vaccines, as in typhoid fever, composed of the 
dead bodies of meningitis germs in solution are injected 
under the skin at intervals of a week or ten days in three 
doses. The first dose is one-fifth (100,000,000 germs) 
that used for typhoid fever. This treatment is as yet 
in its experimental stage, but in 5000 persons thus pro- 
tected in the 1913 Texas epidemic there were no cases of 
disease and the treatment is without danger. In severe 
epidemics the injection of the serum described above 
will protect the individual for two or three weeks when 
given in small doses (about one teaspoonful) under the 
skin. Vaccination requires some weeks to secure pro- 
tection, but it is then of considerable duration—probably 
lasting several years. Serum protects at once, but tem- 
porarily, and is not so desirable if the patient has to be 
given serum later, on account of the possibility of pro- 
ducing the serum disease discussed under Diphtheria. 190 
THE PREVENTION OF DISEASE 
INFANTILE PARALYSIS (POLIOMYELITIS) 
This disease resembles cerebrospinal meningitis in 
many respects. It occurs in epidemics, more often after 
very hot weather in the latter part of summer or autumn, 
and frequently is seen in isolated cases, as is meningitis. 
Then, again, the special germ of the disease is found in 
the brain and cord and in the secretions of the nose and 
throat, as in meningitis. Another resemblance lies in 
the fact that infantile paralysis is contracted through 
contact with the sick or with carriers, i. e., healthy per- 
sons who acquire the germ through exposure to the sick 
or from other carriers, and who may remain carriers, 
or communicate the disease to others, or take the disease 
themselves. Even when the germs are injected experi- 
mentally into the brain of a monkey they soon appear 
in the secretions of the nose and throat. 
Another similarity of infantile paralysis to cerebrospinal 
meningitis consists in the circumstance that it is not par- 
ticularly contagious, and in this respect the two diseases 
may be classed with pneumonia. 
The germ of infantile paralysis is so small as to be 
invisible microscopically. It grows in the nose, throat, 
and nervous system, and is expelled in the bowel dis- 
charges. It enters the brain cavity through openings in 
the skull from the upper part of the nose. The germs 
then attack the blood-vessels of the nervous system. The 
blood-vessels are obstructed and the blood-supply to the 
nerve-cells is shut off. The spinal cord and connecting 
nerves degenerate and paralysis of muscles ensues. 
Susceptible persons, mostly infants, take the disease 
through entrance of the germs into their noses and throats. 
These germs exist in the discharges from the nose, throat, 
and bowels of patients, convalescents, attendants, or INFANTILE PARALYSIS 
191 
healthy carriers. They are conveyed to the healthy by 
means of soiled fingers, soiled household utensils, soiled 
towels and handkerchiefs, contaminated food, and flies. 
One may inhale the germs in air by standing near a person 
who is coughing or sneezing—if he has them in his throat. 
After entrance of the germs into the body the disease 
develops within three to ten days, usually six. The 
germs may be carried as long as six months in the throat 
by convalescents or healthy exposed persons. The 
latter may not take the disease at all. 
There are many different forms of the disease, and no 
attempt at diagnosis will be made here, since even the 
elect are often puzzled. 
In the more usual case the patient feels dull and disin- 
clined to play or work and fever soon appears. The 
whole body is sore and painful, and children cry on being 
moved. There may be convulsions in children, with 
squinting of the eyes, retraction of the head, and stiffness 
of the back muscles, headache, and vomiting. After one 
to three days of fever the characteristic paralysis appears. 
This may be of one leg and one arm, or both legs or arms, 
or of all the extremities. More often one leg is paralyzed 
and there is either involuntary passage of the urine and 
bowel discharges or the urine may have to be drawn with 
a catheter. The fever and other symptoms pass away, 
but the paralysis remains unchanged for two or three 
weeks, and then improves during the following months, 
but usually some groups of muscles begin to waste away 
and the limb may remain permanently much smaller 
than its fellow. When only certain muscles are involved 
they wither and deformity results. Club-foot, where 
children walk on the heel with the toes drawn up, or on 
the toes because the heel is drawn up, is a common result. 
Such deformities can now-a-days be quite successfully 192 
THE PREVENTION OF DISEASE 
remedied in many instances. Many more patients have 
abortive cases of infantile paralysis during epidemics than 
those who develop paralysis. They have fever, headache 
and vomiting, and soreness of the muscles without 
progressing to the stage of paralysis. To aid diagnosis 
in suspected cases spinal puncture should always be done. 
That is the spinal fluid is drawn off by a needle from the 
spinal canal which is not a dangerous proceeding. The 
microscopical examination of this fluid in the laboratory 
will usually determine the diagnosis. The danger to 
life from infantile paralysis is not great, varying from 4 
to 15 per cent, mortality (20 per cent, in 1916 epidemic). 
About one-fifth of the cases make complete recovery. 
Prevention.—Apparently infantile paralysis is only 
communicated by contact of the sick and carriers (or by 
objects they have soiled with their discharges) with 
healthy persons. 
The patient must be isolated for three weeks, and also 
the other members of the family, and exposed persons 
should be quarantined (except bread winners) for a period 
of two weeks, while exposed children should not return to 
school for two months. It is not possible to determine 
who are carriers by taking some of the secretion from the 
nose and throat for examination, as in diphtheria and cere- 
brospinal meningitis, because the germ is too small to be 
seen microscopically. If possible healthy children should 
be isolated away from centers of infection in the country 
during epidemics, and should be prevented from associat- 
ing with other children. The kissing of children should 
also be thwarted. 
The discharges from the nose and throat of patients 
should be collected on cloth in a paper bag and burned, 
and the bowel discharges and urine should be disin- 
fected as in typhoid fever. Bed and body linen and eat- INFANTILE PARALYSIS 
193 
ing utensils should be boiled for ten minutes or more 
after use. The hands of the nurse should be frequently 
washed in soap and water. The sick room must be 
screened from flies and regularly disinfected after 
recovery of the patient. Persons exposed to the disease 
should spray their throats three times daily with hydro- 
gen peroxid 1 part to 3 parts of water; or a snuff consist- 
ing of salol 65 grains, menthol 1 grain, and boric acid 5 
drams is recommended (Dr. Dunn) for use instead of the 
spray, a pinch to be sniffed up into each nostril thrice 
daily. 
Unfortunately there is no very successful means of 
either preventing or curing infantile paralysis at present. 
It is true that Simon Flexner introduced the use of 
human serum from patients recovering from infantile 
paralysis which is injected into the spinal canal and 
into the blood as a method of treatment for other cases. 
The source of this is limited and it is only of benefit in 
the early stages of the disease, not after paralysis has 
occurred. Rosenow has also obtained a horse serum 
immunized with a different germ that he believes is the 
cause of infantile paralysis. 
This has been largely used in the treatment of infantile 
paralysis but its value is still to be definitely established. 
The dangers of contagion are greatly magnified during 
epidemics of infantile paralysis. It is not readily com- 
municated and is said to be but one-fifteenth as con- 
tagious as scarlet fever. CHAPTER VII 
TONSILLITIS, ABSCESSED TEETH, PYORRHEA 
AND OTHER COMMON LOCAL TROUBLES AS 
SOURCES OF SERIOUS GENERAL DISEASES 
Importance of Infections of Nose, Mouth, and 
Throat.—Life is usually ended by infections or germ 
diseases. An infection does not mean simply the pres- 
ence of germs in a part, but their growth in the tissues, 
with the accompanying formation of poisons producing 
the symptoms of inflammation, which is usually synon- 
ymous with infection. Smithies, at Rochester, Minn., 
found that 80 per cent, of dyspeptics had pus germs in 
their saliva. But these may theoretically exist in the 
mouth without actually producing infection or inflam- 
mation, unless injury to the mouth by food, hot drinks, 
sharp teeth, low vitality, or some other exciting cause 
enables them to “take hold” and grow. As a matter 
of fact, it is probable that in most of these cases the germs 
were present as the result of inflammation, since but 
20 per cent, of persons have normal mouths (Mayo). 
More and more may the so-called constitutional 
diseases (supposed to result from unknown functional 
disturbances of the whole system) be attributed to the 
action of germs, as valvular disease of the heart, rheu- 
matism, inflammations of joints (arthritis), Bright’s 
disease of the kidneys, nervous prostration and anemia, 
and even diabetes. Formerly, the origin of these 
diseases being wrapped in mystery, they were accepted 
194 INFECTIONS OF NOSE, MOUTH, AND THROAT 
195 
alike by doctors and patients with a resigned fatalism. 
But progress in science is illuminating these dark spots 
in medicine and offering means of prevention and cure. 
During the past few years the remarkable researches of 
Rosenow, and the teaching of such leaders in medicine 
and surgery as Billings and Charles Mayo, have pointed 
to local infections of the nose, mouth, and throat as the 
chief sources of serious acute and chronic disease in many 
parts of the body. This knowledge cannot be too 
widely or forcibly impressed upon the intelligent layman, 
because of its tremendous significance and common 
application. 
It is generally appreciated that the nose and mouth are 
the openings in the body through which the germs of 
most infectious diseases enter. Typhoid fever, pneu- 
monia, tuberculosis, diphtheria, epidemic meningitis, 
dysentery, cholera, measles, scarlet fever are a few 
examples of diseases which gain entrance by these portals. 
It has been well known that the mouths of healthy 
persons always contain a great variety of germs (fifteen, 
besides many other accidentally present). But only 
recently has it been actually demonstrated that the 
presence of germs in acute or chronic inflammatory 
disorders of the nose, throat, and mouth are capable of 
being carried by the blood to various parts of the body, 
there giving rise to the most diverse diseases, the source 
of which has been hitherto an enigma. 
The more common local inflammations in the head, 
which are responsible for damage to the system at large, 
are chronic tonsillitis, Riggs’ disease or pyorrhea affecting 
the gums and roots of the teeth, abscesses about the roots 
of the teeth from decay, etc., and nasal catarrh extending 
to the adjoining cavities (sinuses) in the bones of the 
face and forehead. These diseased conditions are not 196 
THE PREVENTION OF DISEASE 
by any means easy to determine in all cases, and the 
services of the physician, nose and throat specialist, 
dentist, and x-ray specialist may all be required to 
secure a proper diagnosis. For instance, simply looking 
at the tonsils is not sufficient. The bands forming the 
entrance to the throat must be pushed aside to expose the 
tonsils, and these should be pressed upon to squeeze 
out any inflammatory secretion, as pus. It may usually 
be taken for granted that persons who have had repeated 
attacks of acute tonsillitis or quinsy are almost sure to 
have chronically diseased tonsils. But an enlarged 
tonsil is not necessarily infected. The infection is shown 
by the previous history of acute tonsillitis and by press- 
ing pus from the tonsil and also by the character of the 
tonsil. A small, hard, submerged tonsil is often the one 
most seriously infected. While previous attacks of 
tonsillitis and quinsy indicate chronic infection of the 
tonsil yet in more than half the cases of chronic tonsillitis 
do we find that the patients have never had acute 
tonsillitis. Enlarged tonsils and adenoid growths are 
usually diseased also and should be removed. Again, 
regarding abscesses about the roots of teeth: These may 
be caused by killing the nerve of the tooth, by infection 
from decay, irritation of improperly placed crowns or 
bridge work, by poor dentistry in allowing space for food 
to collect between the teeth, and, strange to say, in 
most cases there are not sufficient pain or tenderness in 
the diseased tooth to enable the patient or dentist to 
locate the exact site without an x-ray picture. Ulrich, 
of the University of Minnesota, finds abscess about the 
roots of teeth in 80 to 88 per cent, of adults by means of 
the x-ray. They occur at the ends of the roots in 68 
per cent, of teeth in which the nerve has been killed. 
In fact, when the nerve of a tooth is killed the tooth soon INFECTIONS OF NOSE, MOUTH, AND THROAT 
197 
becomes infected if not abscessed. A dead tooth is 
synonymous with an infected tooth. 
The same difficulty may apply to the detection of 
Riggs’ disease and disease of the sinuses in the head. 
While looseness and tenderness of the teeth and gums and 
escape of pus along the edge of the gums on pressure 
are ordinary signs of pyorrhea or Riggs’ disease, yet 
in some instances the most expert knowledge may be 
necessary to detect the condition. 
Inflammation of the sinuses usually demands examina- 
tion by the nose and throat specialist for its determina- 
tion. The symptoms of these diseases are considered 
under their titles elsewhere in this book. 
But in other parts of the body away from the head 
local infections may also lead to serious remote diseases. 
Thus, chronic inflammation of the appendix and gall- 
bladder, of the urinary and female sexual organs, may 
be included in this category. The germs from even 
slight local infections, as, for instance, from wounds of 
the fingers or of an ingrowing toe-nail; have been recorded 
as producing the most serious disorders in remote 
vital organs by transmission through the blood. How 
frequently germs inhabiting the bowels may produce 
chronic disease of remote parts, as of the joints, blood- 
vessels, heart, kidneys, and blood, is uncertain, but 
infection of the urinary tract from the absorption of 
colon bacilli from the intestinal tract is quite common. 
In this connection it may not be amiss to mention a 
common experience that persons having a chronic appen- 
dicitis are often attacked a few years later with inflam- 
mation of the gall-bladder and gall-stones. Whether 
the germs in the inflamed appendix reach the gall- 
bladder by transmission through the lymph-vessels, 
or whether both troubles originate from germs set free in 198 
THE PREVENTION OF DISEASE 
the blood, from local inflammations of the nose, mouth, 
and throat, it is impossible to say. In epidemics of ton- 
sillitis the simultaneous occurrence of appendicitis among 
patients has often been observed. 
What kind of germs are commonly found in the nose, 
mouth, throat, and elsewhere which produce serious 
disease in remote organs? 
They are the ordinary germs causing inflammation in 
wounds and abscesses, the pus germs—chiefly streptococci 
and staphylococci (practically always present in the 
adult mouth). The germs of pneumonia, or pneumo- 
cocci, are also common. It has been found that the 
characteristics of these germs may be considerably 
changed in their growth in the nose, mouth, and throat, 
so that they acquire an affinity for certain organs after 
entering the blood. In this way we explain why certain 
parts of the body are attacked by germs free in the blood 
rather than others. The germs circulating in the blood 
finally lodge in the smallest branches of the vessels in 
the tissues which they attack. 
How do we know that local infections in the nose, 
mouth and throat, and in other parts will produce 
serious disorder of remote organs? In the first place, 
the association of certain other diseases with inflamma- 
tions in the throat has been a matter of common knowl- 
edge; as, for instance, the combination of rheumatism 
and valvular disease of the heart, both secondary to tonsil- 
litis. Then the germs found in various organs secondarily 
diseased are the same as those occurring in the primary 
focus of inflammation in the head. Recently diseases 
never before attributed to or associated with throat or 
mouth infections have been found to have a causative 
relation to the latter, because the germs found in the 
various organs secondarily diseased are identical with INFECTIONS OF NOSE, MOUTH, AND THROAT 
199 
those in the original focus of inflammation in the throat. 
This applies to Bright’s disease of the kidneys, ulcer of 
the stomach, inflammation of the gall-bladder, appendici- 
tis, etc. Moreover, when germs from infected human 
tonsils are injected into the blood of animals the same 
organs are attacked as those secondarily diseased in man 
with tonsillitis; that is, the heart, joints, stomach (ulcer), 
gall-bladder, and appendix. 
And, finally, surgical removal of the local infectious 
foci in the nose, throat and mouth, or elsewhere is often 
followed by improvement or recovery from remote 
diseases which have been found experimentally and in 
practice associated with such nose, throat, and mouth 
infections. Thus, the cutting out of diseased tonsils 
may be the means of curing or alleviating rheumatism 
and valvular disease of the heart. 
It is probable that chronic disease of the heart, joints 
(rheumatism), and kidneys is usually not due to a single 
infection, but to repeated infections extending over years. 
That is, every now and then germs from the infected 
teeth or tonsils escape into the blood and thence are 
carried to the heart, joints or kidneys according to their 
affinity for one or other of these organs. By eradicating 
the source of supply, in removal of teeth or tonsils no 
further damage is done the heart, joints or kidneys and 
disease of these organs will not progress, or may even 
be wholly cured. In this connection it may be advisable 
to state that medical enthusiasts often recommend 
removal of the teeth or tonsils in far advanced cases of 
joint, heart or kidney disease. In such patients the 
structural changes are so great that nothing will cure 
them, besides adding to their miserable existence another 
source of suffering and possible death by the infliction 
of wholly useless surgery. 200 
THE PREVENTION OF DISEASE 
In some cases of high or low blood pressure the removal 
of local infections may prove curative. 
It would be absurd to affirm that all sufferers from 
local infections in the head are doomed to acquire 
serious remote disease, for most persons have more or 
less chronic infections about the nasal passages, mouth, 
and throat. But the possibilities of such troubles 
should be recognized by the laity in order that proper 
attention be given to treatment. If left to persist, 
any depressing circumstances, as colds, dissipation, 
financial or social disasters, overwork, poor food and sur- 
roundings, may so weaken the resistance of the body 
that the escaping germs in the blood may attack some 
vital organ. 
For instance, there is a most painful and serious inflam- 
mation of the bones frequently mistaken for rheumatism 
(osteomyelitis). It begins with the severity and sudden- 
ness of appendicitis, and in twenty-four hours may de- 
stroy the bone of the leg or thigh, so that amputation or 
death may result. This condition doctors have described 
as ‘'idiopathic,” a cloak for ignorance as to its origin. 
Now we know that it is due to infections about the nose 
and throat, colds, sore throat, or tonsillitis, and occurs 
perhaps a week or two after recovery. But this point 
I wish to emphasize, that the bone trouble is precipi- 
tated by a slight fall or injury to the limb in many 
cases. An injured point always weakens resistance to 
infections from within or without. In other words, the 
germs from the inflammation in the throat have en- 
tered the blood, and a slight local injury may be the 
means of their selecting the bones for the site of their 
growth. First, the cold, next the injury, and then a 
disease fatal to life and limb, unless treated at once and 
understandingly. INFECTIONS OF NOSE, MOUTH, AND THROAT 
201 
A categoric list is never interesting, but it will be of 
advantage to impress the layman more specifically with 
the results of the apparently unimportant local infections 
under consideration. By direct extension—that is, the 
direct transmission of the germs from the infection in the 
nose, mouth, and throat through the natural drainage 
spaces and canals in the tissues (lymphatics)—the 
glands of the neck (the normal catch-basins in this system, 
become enlarged and tender. Swollen glands or lumps 
under the ear or jaw are the most common complication 
of mouth or throat infection. But we are chiefly con- 
cerned with the more remote dispersion of the germs 
after they enter the blood and are carried to other parts 
of the body. One of the most frequent results is a con- 
dition in which acute inflammation of the joints, or 
acute rheumatism, is associated with valvular disease 
of the heart. Indeed, it has been shown that certain 
strains of streptococci from tooth abscess and tonsil 
inflammation, after their escape into the blood, have a 
special predilection for these tissues—the joints and 
heart valves. In fact, all joint inflammations (except 
those due to gout or direct injury) are probably of 
germ or infectious origin, although usually masquerading 
under the meaningless name of rheumatism. Many 
cases may be ultimately cured by first removing the 
cause in the mouth or throat. In childhood there may 
be also an added complication—chorea or St. Vitus’ 
dance—to the rheumatism (?) and heart disease. More 
often one of these diseases occurs separately with ton- 
sillar infection. The writer has had recently under 
his care a boy suffering from mild chorea and valvular 
disease of the heart, associated with chronic tonsillitis, 
from which he has wholly recovered since removal of 
his tonsils. Germs in the blood from diseased tonsils 202 
THE PREVENTION OF DISEASE 
attack the valves of the heart and set up inflammation 
and distortion of the valves, which then fail to close 
and become leaky, as would an ill-fitting valve of a 
pump. 
The lodgment of the same germs in the finest blood- 
vessels of the joints and nervous system from the infected 
mouth or throat gives rise to the rheumatism (?) and 
St. Vitus’ dance. 
It has only lately been discovered that many nervous 
disorders originate apparently in the same way from 
germs in the blood derived from the infected nose, 
mouth, or throat, such as neuritis, neurasthenia, dizzi- 
ness, disturbances of vision, chorea, and disturbances 
of sensation in the limbs (feeling of pricking by needles 
and pins). No troubles are more surely cured by any 
remedial measures than are nerve and muscle pains 
(called neuritis and myositis) about the neck, shoulders 
and arms by the removal of infected teeth and tonsils. 
In one patient the teeth may be at fault, in another the 
tonsils or sinuses. I have repeatedly seen patients go 
the medical rounds for constant, unbearable pain in the 
arm who were relieved at once by removal of diseased 
teeth or tonsils. 
In the young pyorrhea or abscessed teeth are rare 
and in them tonsillar infection is common. In those 
of middle or advanced age pyorrhea and abscessed teeth 
are most frequent, especially when many teeth have been 
crowned. No tooth can abscess while the nerve is 
alive, but in crowned teeth the nerve has often been killed. 
The writer has seen many middle-aged men, naturally 
robust and active, lose strength, energy and “pep,” 
become nervous and neurasthenic and fancy they were 
“breaking down.” This condition has been completely 
remedied by removal of teeth owing to infection about INFECTIONS OF NOSE, MOUTH, AND THROAT 
203 
their roots or gums. In cases of advanced pyorrhea 
extraction of the teeth is the only cure. 
Exophthalmic goiter associated with moderate swell- 
ing of the gland that lies under the “Adam’s apple” 
in the neck, is another disease of doubtful origin. In 
some cases at least this trouble appears to arise from 
infection with germs in the blood derived from diseased 
tonsils. The same remark may apply to a fatal disorder 
with swelling of glands in various parts of the body 
(Hodgkin’s disease). 
The cause of gall-bladder inflammation, gall-stones, 
appendicitis,' and chronic ulcer of the stomach and first 
part of the intestines has been the subject of much specu- 
lation, experiment, and controversy, but these disorders 
may be reproduced in animals by injection into their 
blood of streptococci from diseased human tonsils, and, 
moreover, these same germs are found in the diseased 
human gall-bladder and ulcerated stomach and intestines. 
Thus, apparently we have a positive demonstration of 
at least one of the causes of these diesases. 
Some of the inflammations in the nose, throat, and 
mouth are due to the germs of pneumonia, and while 
these may be constantly present and may not produce 
pneumonia, yet it is to the escape of germs into the 
blood from these sources that we must attribute pneu- 
monia in some instances. 
A certain percentage of the tonsils (15 per cent.) 
removed are found to be infected with tuberculosis 
germs. Tuberculosis of vital organs, as the lungs and 
kidneys, may arise from entrance of the tuberculosis germs 
into the blood from tuberculous tonsils. The strepto- 
cocci, so often the cause of inflammations in the mouth, 
nose, and throat, are also the source of erysipelas and 
rashes which resemble scarlet fever. 204 
THE PREVENTION OF DISEASE 
The so-called idiopathic (cause unknown) cases of 
erysipelas may, in fact, be due to primary inflammations 
in the nose, throat, or mouth. 
When diphtheria antitoxin (horse blood-serum) is in- 
jected at long intervals into a human being he may 
rarely develop sudden and alarming symptoms, with 
difficulty of breathing and evidence of lack of air or 
oxygen. This follows because the system has become so 
sensitized to this foreign substance that a later dose may 
produce the most alarming condition. It is now thought 
that the system likewise becomes sensitized to the poisons 
constantly produced by the growth of germs in chronic 
inflammations in the nose and throat, and the result is 
difficulty in breathing and asthma, or skin eruptions 
(nettle-rash), such as are seen in poisoning by antitoxin. 
Asthma is frequently cured by removal of diseases in the 
nose and throat. 
Particular emphasis must be laid on the fact that not 
only the head infections, but any local focus of infection 
anywhere in the body constitutes a constant menace to 
the host. The nose, mouth, and throat infections have 
been especially dwelt upon because they are so common 
and familiar. There are fashions in medicine, as in 
clothing, and the profession continually suffers from 
kangaroo-like mental jumps in its action over new 
discoveries. 
Perhaps, as the result of recent researches in head infec- 
tions, too many comparatively healthy tonsils may be 
removed without reason. 
When they are unquestionably infected they should be 
cut out, and all means should be exhausted in extirpating 
all apparently unimportant infections anywhere in the 
body to avoid remote serious disease of vital organs. 
There is an ancient proverb—“Study sickness when you TONSILS AND ADENOIDS 
205 
are well.” This is even truer in the case of the near- 
well. 
More and more do we come to find most diseases of 
bacterial or germ origin. Rheumatism, long thought to 
be a constitutional disease—whatever that means—is 
now known to be due to the direct action of germs carried 
in the blood to joints and muscles. So it is with most 
chronic diseases—they are due to the effect of germs 
acting perhaps over a score of years. There is no method 
of prolonging life more effective than preventing the 
entrance of disease germs into the circulation. 
And there is no method of preventing germs from enter- 
ing the circulation more effective than eradication of 
local or focal infections. In fact the discovery of these 
focal infections is now the chief work of the modern 
diagnostician for there are hardly any chronic diseases 
which are not benefited by their removal and many which 
are cured thereby. The appreciation of the role of focal 
infections is.the greatest advance in medicine during the 
present generation. 
Tonsils and Adenoids.—While the cause of enlarged 
and diseased tonsils and adenoid growths is not absolutely 
determined, it is probable that breathing a bacteria-laden 
air may produce these conditions in schools or whenever 
individuals are crowded together in ill-ventilated rooms. 
However, enlarged tonsils and adenoids are the first 
signs we have, and these are commonly called to our 
attention owing to frequent attacks of cold or tonsillitis 
or by mouth-breathing. Any layman can tell by looking 
into the back of the throat whether tonsils are enlarged 
(Fig. 2, A), because in health they are not visible at all 
(as projections on either side of the entrance to the throat). 
Adenoid growths cannot be seen, but fill the region at the 
back of the nasal chambers where these join the top of the 206 
THE PREVENTION OF DISEASE 
throat (Fig. 3, A). When the tonsils are enlarged in 
children it is safe to infer that adenoid growths also occur. 
The only efficient treatment is by surgical removal, in 
children under ether, and in adults under cocain or ether. 
Only within a few years has it been customary to do more 
than slice off the outer part of the tonsils, but it has been 
Fig. 2.—A, Enlarged and diseased tonsils. The normal tonsils are 
in-risible. (Redrawn after Matthews.) 
found that the tonsils enlarge again after this operation, 
and that the scar covering the remaining stump of the 
tonsil seals it over and retains germs and poisons in the 
tonsil which are then all the more likely to be absorbed 
and to poison the system. The only proper procedure 
is complete removal of the tonsil, which is a much more 
difficult operation and requires the services of an expert 
throat specialist in most instances. As adenoid growths 
interfere with breathing, and therefore the general 
health, produce deafness by stopping the tubes which lead 
from the upper part of the throat to the inner region of TONSILS AND ADENOIDS 
207 
the ears, and favor abscess of the inner ear with its 
frequent extension to the bone of the skull back of the 
ear (mastoid process), and then to the brain, it will be 
seen that there are more than sufficient reasons for the 
removal of diseased tonsils and adenoids—when such is 
without danger and without any bad consequences. 
Fig. 3.—E shows about the level of the eustachian tube connecting 
the throat with the ear. The adenoid growth (A) blocks up, or causes 
mucus and swelling to block, the eustachian tube and induces deafness 
among other troubles (Zuckerkandl). 
Nor is the train of consequences caused by the presence 
of adenoids by any means exhausted. The obstruction 
to breathing leads to many other troubles. Thus the face 
becomes dull and stupid and the mouth is held open, im- 
parting a vacant expression to the face. The upper jaw 
is narrowed, the roof of the mouth becomes high, the lips 
are thick, and the entrance to the nostrils is slit-like and 
has a “pinched-in” appearance (Fig. 4). The breath- 
ing is apt to be noisy and snorting at night and screaming 
and shortness of breath during sleep are common. Altera- 
tions in the shape of the chest follow, as the narrow, pointed 208 
THE PREVENTION OF DISEASE 
chest, or what is called chicken- or pigeon-breast; or, if 
there is asthma, the chest becomes rounded; and occasio- 
nally a depression forms at the lower end of the breast 
bone. The nasal voice is an ordinary accompaniment. 
Headache, frequent colds, loss of energy and backward- 
ness, dulness and stupidity at school are characteristic. 
The habit of making facial grimaces may be cured by 
removal of adenoids and tonsils. 
Fig. 4.—Expression in adenoids (Friihwald) 
Foul breath is often due to accumulated secretions 
retained in diseased tonsils and also to pyorrhea. To 
locate the source of the bad breath one may press the 
fingertip firmly back upon one’s tonsil and also draw a 
thread under the edge of the gums in various places and 
between the teeth. 
Whichever is most disagreeable to the smell is apt to 
indicate the location of the trouble. If the tonsils are at infections 
209 
fault operation is indicated, but if the thread is most 
offensive, pyorrhea is the source of the bad breath and 
may be treated as below. 
It should be recognized that some pyorrhea is the rule in 
persons of middle age or over, and they should make 
frequent visits to the dentist. 
Brushing the teeth after each meal with Lavoris will 
also tend to overcome the bad breath. It is unnecessary 
to refer again to the dangers resulting from decayed teeth, 
or infections about the teeth or Riggs’ disease, as these 
should be remedied by constant cleanliness, and may be 
prevented by visits to the dentist at monthly intervals 
for thorough removal of tartar and polishing of the teeth 
so that no foreign substances will adhere to them. 
Decayed teeth and Riggs’ disease require special treat- 
ment. As noted above, an rr-ray examination of the 
jaws is the only certain method of determining the 
presence of diseased teeth in doubtful cases. The pres- 
ence of crowns on roots in which there is any infection 
may favor general disease by permitting absorption of 
germs or their poisons into the blood. 
Chronic inflammation of the gall-bladder and appendix 
also call for surgery, as no other treatment is of value. 
But while the disturbance of digestion and local complica- 
tions (see Cancer, p. 226) are chiefly feared, the danger of 
permanent damage to the heart, kidneys, and other 
internal organs (owing to germs from these organs set 
free in the blood) is frequently neglected. Inflamma- 
tion of the female organs and of the urinary apparatus 
in both sexes must receive appropriate treatment to avoid 
complication of the systemic diseases we have noticed. 
Occasionally some unusual local infection, as in the case 
recorded by Billings, where the formation of pus about an 
ingrowing toe-nail led to an attack of rheumatic fever, 210 
THE PREVENTION OE DISEASE 
may be responsible for serious general disease and must 
not be overlooked. 
The gist of the whole matter is that some apparently 
trivial local diseases about the mouth and throat may 
have the most far-reaching and important consequences, 
and that local infections in any part of the body have the 
same significance and should never be permitted to persist 
untreated. Whoever is a sufferer from such chronic ail- 
ments as chronic heart, joint, or kidney disease should be 
thoroughly examined from head to foot—literally—for 
some source of local infection, and all the modern tests, 
such as the x-ray, microscope, test-meals followed by 
emptying the stomach, etc., may be necessary to discover 
the cause. 
But still more to the point is it that persons having 
one of the local diseases about the throat or elsewhere 
should seek its removal before serious organic disease 
in other parts of the body is secondarily caused thereby. 
Because one has had enlarged and diseased tonsils for 
years, and has escaped any of the direful consequences 
herein described, is no proof of their harmlessness. 
Parents are apt to point to themselves as examples when 
urged to have similar faults remedied in their children. 
Experience (of the profession) teaches “one swallow 
maketh not summer.” 
Riggs’ Disease.—We have in another place (see page 
40) discussed abscess formation about the roots of teeth, 
or between the roots and the gums, in pyorrhea or Riggs’ 
disease. The abscesses at the very tip of the roots, which 
occur so commonly in teeth in which the nerve has been 
killed, can only be certainly discovered by x-ray pictures. 
Dentists have been teaching their patients that all teeth 
should be saved when possible. But these teeth abscessed 
at the end of the roots may give no pain and yet be the rigg’s disease 
211 
means of causing serious disease from absorption of pus 
into the blood. 
Dentists must change their methods, and not wait until 
a physician finds some secondary disease in joints, heart, 
etc., due to a slow absorption of pus germs from abscessed 
teeth which has been going on probably for years. They 
must take x-ray plates of teeth in adults as a routine prac- 
tice so as to avoid waiting until irreparable damage has 
been done. They must also alter their principles about 
saving teeth, because in many cases only extraction will 
cure. In treating dead teeth with abscess at their roots 
by boring down through the tooth, as has been the 
custom, it has been found by the x-ray, and by pus later 
breaking out through the gums, that such treatment has 
often not been successful. 
Finally, it may be reasonably objected that we make 
much ado about nothing when a large proportion of 
human kind have infections about their teeth and remain 
healthy. It can only be said that unless all of us had 
possessed great natural resistance against infections 
we would not now be alive. 
The large percentage of sufferers from the remote effects 
of mouth infections is only just beginning to be appre- 
ciated by the profession, while about ten years more 
will be required to educate the public in this matter. CHAPTER VIII 
THE PREVENTION OF CANCER 
INTRODUCTORY NOTE 
Cancer of the lip, tongue, and inside of the mouth is largely pre- 
ventable. It occurs in smokers and in those with rough teeth who 
do not take proper care of their mouths. Syphilis is present in a 
small percentage of cases. The precancerous conditions usually 
consist in the appearance of one or more white spots or patches or 
ulcers in the mouth; or, on the lip, of a small black area (burn), or 
a thickening or warty growth. These commonly produce some 
pain or discomfort. 
If smoking is immediately stopped, the teeth put in order, and 
if saleratus is used frequently as a mouth-wash the trouble may 
heal at once. If it does not heal within two or three weeks the 
diseased area should be cut out by a competent surgeon who will 
know whether or not to remove the neighboring glands. 
Cancer about the mouth may thus be avoided in most cases by 
following these simple rules. 
Cancer of the skin originates in pre-existing tumors, moles, birth- 
marks, warts, and scaly, thickened patches (keratosis). These, as 
a rule, should be removed with a knife or cautery, including a 
good margin of healthy skin, and the removed tissue should be 
then examined microscopically. Any local skin defect—as an 
ulcer, wart, tumor, scaly, thickened patch, or discharging aperture 
on the skin—must be regarded as precancerous. It matters little 
whether the cause be injury, tuberculosis, or syphilis of the skin, 
or keratosis due to exposure to the sun or lead or arsenic, the possi- 
bility of cancer is about the same. If such areas are healed or cut 
out cancer may be avoided. Cancer of the skin, therefore, is a pre- 
ventable disease. 
Cancer of the Breast.—Not knowing its cause, we have no means 
of preventing or treating it until a lump appears in the breast. 
When such lumps are at once removed on their discovery half will 
212 THE PREVENTION OF CANCER 
213 
be found benign (not cancerous). Only 1 per cent, of lumps in the 
breast are malignant under twenty-five years of age. Every lump 
in the breast of a female over twenty years should be explored. 
When benign, its removal will absolutely prevent cancer. 
The chances of permanent recovery in true breast cancer—if 
removed on its discovery—depend upon its kind. If adenocarci- 
noma, recovery should occur in 96 per cent, of cases; if a cancer cyst, 
or in the scirrhous or medullary form, 86 per cent, have been per- 
manently cured—providing the growth is removed by the complete 
operation as soon as discovered. The chances of recovery grow 
less and less as the delay is more and more protracted until the 
cancer is incurable from the extent of the local or general involve- 
ment (metastasis). 
When all the women have this knowledge and seek the physician 
at once, and when he acts promptly, and the proper surgery is 
immediately done, the number of deaths from cancer of the breast 
will be tremendously decreased. 
Cancer of the Thyroid.—If, in individuals over twenty, every 
irregular lump of the thyroid gland (situated directly below the 
“Adam’s apple” in the throat) was removed as soon as found 
cancer in this region would be practically unknown. Cancer here 
begins as a benign growth, and if removed before the surrounding 
parts are involved, general or local recurrence will not occur. 
Sarcoma of Soft Parts.—Lumps under the skin in all parts of the 
body should be removed, as it is impossible to tell the benign from 
the malignant. No harm is done by removing benign growths and 
there will never be a better time to remove sarcomata. Surgery 
must be thorough and the growth must be removed surrounded by 
a wide margin of healthy tissue—not merely shelled out. 
Sarcoma of Bone.—Early intervention offers the only hope of 
cure. Pain at one point in a bone or joint, especially after injury 
(continuous or at a later date), demands x-ray, blood, and urine 
examination. In my experience the first thing to be done is that 
done last and too late for the cure of malignant disease of bone or 
joint. 
Cancer of the womb is largely preventable. The majority of cases 
begin at the outlet (cervix) in women who have borne children. 
Every woman should keep a careful watch and record of the char- 
acter and periods of menstruation, and on observing anything un- 
usual, should submit to a careful examination. The reappearance 
of bleeding after the change of life is a message requiring immediate 214 
THE PREVENTION OF DISEASE 
attention. Doctors may also prevent cancer of the womb by 
better obstetrics, by careful examination of women after child- 
birth, by early repair of lacerations, by correcting displacements 
and endometritis—thus avoiding precancerous conditions. 
Cancer of the Stomach.—If it is true that a large percentage of 
cancers of the stomach develop on pre-existing ulcer, then it is a 
preventable disease. Ulcer of the stomach is regarded by patients 
as “indigestion” and does not receive early expert attention, and 
many doctors begin with treatment instead of thorough examina- 
tion. I believe the best treatment in simple gastric ulcer consists 
in prolonged rest and a semistarvation diet. 
Cancer of the Colon (Large Intestine).—This may not be a pre- 
ventable disease, but if recognized and removed early it is one of 
the most curable forms of cancer. In the left colon acute obstruc- 
tion leads to early intervention, but in the right colon the fluid 
contents do not favor obstruction and discovery of cancer is late. 
However, patients do have symptoms for months and years before 
obstruction, and wide-spread growth occurs, and proper examina- 
tion in this period will bring out indications for operation. 
Cancer of the Rectum and Lower Bowel (Sigmoid).—The early dis- 
covery of this condition rests largely with the doctor in making an 
examination by finger or instrument (proctoscope) because, as a 
rule, the patient seeks advice early. 
IVIany types of cancer are preventable and most malignant 
growths may be recognized early. In this period surgery offers a 
large probability of permanent cure. The difficult problem is how 
to convey the information to millions instead of hundreds, and how 
to get them to act on this information. A book of this character 
will have a large influence for good—especially among the reading 
public and profession. My own intensive study of the educa- 
tional propaganda has forced me to conclude that the individual 
doctor is, on the whole, the best medium for spreading this knowl- 
edge. He should feel that it is part of his professional duty to 
educate all individuals who seek his advice about personal hygiene, 
and should give them that information which will allow them to 
recognize possible diseases early. 
Joseph Colt Bloodgood. 
This matter I regard as by far the most important and 
vital subject treated in this book, since it has been the THE PREVENTION OF CANCER 
215 
predominant thought and endeavor of medical men 
throughout the world for many years. 
Recently articles have appeared on this subject by 
some of the leading surgeons of America—Drs. Mayo, 
Bloodgood, etc. 
While the essential cause of cancer is unknown, 
many facts of vital value have come to light. 
Maurice Richardson’s maxim that every cancer is 
curable at some stage of its existence is now generally 
accepted. Then, again, it is known that, whether cancer 
is due to germs or not (apparently not), local irritation is 
the essential first stage of cancer, or what has been called 
the precancerous stage. The precancerous stage may 
merely mean a state of local chronic irritation anywhere in 
the body, although, strictly speaking, it should describe 
the earliest microscopic changes in the tissues recognized 
as cancer. We shall use the term in its wider rather than 
in this stricter interpretation. The precancerous con- 
ditions are becoming very well known, and the surgery of 
such conditions is safe and their removal by this means 
accomplishes a certain cure of cancer in practically all 
cases. This is the present hope which the medical 
profession has to offer, and in so far as it is accepted and 
acted upon by the profession, in so far will cancer dis- 
appear, for it is a preventive rather than a curative 
measure. Cancers may be divided into four classes: 
(1) The class in which a certain diagnosis cannot be 
made before operation. (2) The class in which diagnosis 
is reasonably probable before operation. (3) The class in 
which the disease is so far advanced that there is extension 
to some of the neighboring glands, but, nevertheless, 
the case would be considered best treated by operation. 
(4) The inoperable class, in which the disease has become 
general and in which local removal has become impossible. 216 
THE PREVENTION OF DISEASE 
If all cases of cancer could be treated in the precan- 
cerous stage (of the first class) the cures would be certain 
and recurrence would be unknown. These conditions 
are recognized at the time of operation by the microscopic 
section, and occasionally by the appearance and feel of 
the tissues removed. Thus, it is not uncommon to dis- 
cover cancer beginning in an inflamed appendix, gall- 
bladder, ulcer of the stomach, or in a lump in the breast 
by microscopic examination after removal which could 
not by any means be determined prior to operation. 
Such cases are always cured if they are in strictly the 
precancerous stage, but as the patients are ignorant of 
their condition, often not being told after the operative 
discovery, it is impossible for them to realize that they 
have been cured of cancer, and the public cannot be 
impressed by such cures. 
In the second class of cases the chances of recovery are 
immensely greater than the third class. For example, 
in cancers where the disease has extended to the neighbor- 
ing glands the chances of recovery are diminished by 75 
per cent. Thus, in cancer of the breast the returns at the 
Mayo and Johns Hopkins clinics show that before any 
glandular lumps have formed in the armpits about 80 per 
cent, of cases are well five years after operation. But 
when the operations are done after these lumps in the 
armpits have occurred, the percentage of five-year cures 
is reduced to 25 per cent. We, as a profession, are as 
much to blame as the laity for the fearful frequency of 
cancer. There are some 80,000 deaths from cancer 
annually in the United States, and probably half of 
them might be prevented with the knowledge we have 
today—by attacking the precancerous conditions to 
be described. In England, where the statistics have 
been kept more accurately for a longer period than in THE PREVENTION OF CANCER 
217 
the United States, it has been found that 1 in every 
7.4 women and 1 in every 9.7 men over thirty-five die 
of cancer (Hoffman). 
The same statistics apply in this country, according to 
the leading surgeons. That cancer kills 1 in 7 women 
and 1 in 11 men over thirty-five years of age is common 
knowledge (Bainbridge). In the United States in 1912 
of deaths over thirty, 1 in 11.5 and of deaths over forty, 
1 in every 10.5 persons was from cancer (Taylor). The 
proportion is larger in women on account of their liability 
to cancer of the womb and breast. One-third of all the 
cases of cancer are in the stomach. 
The researches of the Pennsylvania Cancer Com- 
mission shed a strong light on the reasons for the 
unfortunate cancer condition. 
They gathered together valuable statistics concerning 
400 cases of cancer, and found that 68 per cent, of oper- 
able cancers were on the surface or in cavities, as in the 
outlet of the womb and in the mouth, where they could 
be readily seen, and the remainder of the operable cancers 
were deeply seated, but in both groups over a year on the 
average had elapsed after the patients had consulted 
their family physicians before they were referred to the 
surgeon. As it has been discovered that about this time, 
or less, is required for extension into the neighboring 
glands, so that they may be felt as lumps by the ex- 
amining doctor, and as this is the chief reason why 
physicians delay in such cases—to make a certain diagno- 
sis—the cause of the awful result is easily seen. 
By this watchful course, which is only made possible by 
the patient’s ignorance and inherent dread of operation, 
the doctor has caused the patient to have but one chance 
of cure in four, instead of having three chances of cure in 
four, as he would have had before the diagnosis became 218 
THE PREVENTION OF DISEASE 
absolutely certain and plain to the veriest medical tyro. 
Therefore when a doctor waits in suspected or possible 
cancer for all symptoms to develop so that the diagnosis 
becomes absolute, he is almost criminal. The early pre- 
cancerous conditions must be doubtful to be permanently 
and successfully removed. 
Nothing is lost by operating in this stage except the 
comfort of the patient, and what is this beside a possible 
life of pain and death from cancer? Surgeons are daily 
confronted with the results of watchful waiting in cancer, 
and these cases constitute the dread of his career. 
In 13 per cent, of cases of cancer of the breast the 
family physician advised watchful and suicidal waiting, 
and in 20 per cent, of the cases of cancer of the stomach 
and womb similar bad advice was given, and no local 
examination in either disease was made in 10 per cent, 
of the pat ients. 
At Johns Hopkins it has been found that 84 per cent, 
of the cases of cancer of the breast do not come to opera- 
tion until the glands in the armpits are enlarged so that 
lumps may be felt there. At present, operation leads to 
from 10 to 50 per cent, of cures in cases of operable cancer 
of all kinds, while 25 per cent, of cases of cancer of the 
bowel and stomach are curable, and 50 per cent, of 
cancers of the breast—the cures being based on the 
patients remaining well five years after the operation 
(Rodman). 
But some cancers are more readily cured by operation 
than others. Thus, at the Mayo clinic 93 per cent, of the 
cases of cancer of the lip are reported as cured by their very 
thorough operation. If surgeons should refuse to operate 
in advanced cases of cancer, operations for all cancers 
would be much more readily and profitably accepted 
by the public. Deaths in advanced cancer do not THE PREVENTION OF CANCER 
219 
occur from the effects of the operation in most cases, but 
from the disease. But such deaths deter early cases from 
operation because patients recall the death of friends from 
cancer after operation and wrongly attribute the result 
to the operation. If surgeons only operated on pre- 
cancerous and early cancerous conditions, the results 
would be so remarkable that the benefit to the world 
would be inestimable—as object lessons. But humanity 
demands a fighting chance, and alleviation of suffering is 
often the only object sought nowin truly inoperable cases. 
It is, indeed, a fearful state of affairs which is reported 
by leading surgeons, as by Childe, that 90 per cent, of the 
cases of cancer of the womb are so far gone as not to be 
operable when they first come to him, and that the same 
percentage of patients with cancer of the stomach are 
inoperable when they first present themselves to Munro 
and Bottomley. Dr. William J. Mayo finds that one- 
third of the cases of cancer of the stomach coming to 
him are curable by operation, but in his clinic many 
cases are discovered by elaborate means of diagnosis in 
patients seeking relief for various diseases. His statis- 
tics are the most encouraging in this disease—38 per 
cent, of the patients operated on for cancer of the stomach 
are well at the end of three years, and 25 per cent, are 
alive and well at the end of five years. 
The results of the treatment of all kinds of cancer 
would be infinitely better today if patients would apply 
for relief at an early stage of the trouble, and it is the 
object of this article to point out the precancerous con- 
ditions which should warn the patient to seek immediate 
surgical advice. 
Of course, in the precancerous conditions of the skin and 
surface of the body recognition is the rule in the earliest 
stages, and these should be cured by the slightest opera- 220 
THE PREVENTION OF DISEASE 
tions and with the best chance for certain permanent 
cures. 
Local irritation as a cause for cancer has recently been 
forcibly presented in an address before the American Sur- 
gical Association by Dr. W. J. Mayo. In it he brought 
forward many known forms of local irritation productive 
of cancer, and mentioned the betel-nut chewers of India. 
Cancer of the mouth is so common from the irritation of 
this substance that in 976 cases of cancer from all the 
causes in the Madras General Hospital nearly 50 per cent, 
were located in the mouth. And, again, the influence of 
heat irritation was adduced, as exemplified by the fre- 
quency of cancer on the shins of locomotive drivers, 
and in the natives of Kashmir, who wear hot Kangri 
fire baskets next the skin of the lower abdomen in winter. 
Among some 2020 tumors in the Kashmir Mission Hos- 
pital there were 363 cancers caused by the burns of these 
baskets on the abdomen. Constant exposure to the 
z-rays has been a notable source of cancer among medical 
men. Local irritation, or some form of skin trouble, 
preceded every one of the 820 cases of cancer of the skin 
and mucous membrane reported by Professor Bloodgood. 
Malignant tumors frequently arise from blows. Dr. 
Murphy states that a single blow on the breast is not 
uncommonly followed by the appearance of cancer in 
women. Warts and dark moles on the skin, especially 
when subjected to irritation through rubbing of the 
clothing, scratching, or pressure, are well recognized 
precancerous conditions; this fact was emphasized in a 
(now classical) paper by Professor Keen delivered in 
1904. He showed that the cancerous change frequently 
occurred some thirty, forty, or even fifty years after the 
existence of the wart or mole, and that, as there was no 
special reason why the growth should be removed today THE PREVENTION OF CANCER 
221 
rather than tomorrow, or this year rather than next, 
it was allowed to remain until some local irritation, such 
as combing a wart on the head, or through the pressure of 
a hat or rubbing of a collar on a mole of the neck, the 
wart or mole suddenly took on a growth which in most 
cases was malignant. The moral is to remove such at 
the first opportunity, but if there are many warts or 
dark moles on the body the subject may wait until there 
is the slightest sign of irritation or growth in any wart 
or dark mole, when it should be immediately removed by 
a surgeon. The habit of partially removing such growths 
by scraping them off the skin and leaving the base is 
illustrated by a case coming to the attention of the author, 
where a mole became irritated and was partially removed, 
and a general malignant disease of all the internal organs 
followed within a month or two. 
Warts or moles should be removed properly with their 
skin bases by a surgeon after the injection of cocain. 
Cancer of the lip is rarely seen except in smokers, and is 
thought to be due to the heat or pressure of the pipe stem. 
In the mouth white patches form on the tongue and inside 
of the lips and cheeks—more usually on the tongue in 
smokers—and this condition quite often becomes can- 
cerous unless smoking is stopped and the white patches 
are cauterized. The constant taking of hot food or 
drink may produce dangerous irritation in the mouth. 
Parts subjected to blows should be carefully watched 
and operation should be done on the slightest sign of 
malignant disease. Coley has found a history of previous 
injury in about one-third of 328 cases of cancer. 
Cancer of the breast, so common in women, has a very 
bright outlook when the tumor is removed early—before 
spread of the disease into the surrounding tissue and the 
glands in the armpits—as we have seen. Any lump in the 222 
THE PREVENTION OF DISEASE 
breast demands the immediate attention of a surgeon. 
There are no means by which the innocent lump may be 
distinguished from the malignant tumor in many cases. 
The inflammatory lump or the innocent tumor frequently 
become malignant in time. 
It is common practice for a physician to find a movable 
lump in the breast of a young woman (cancer of the 
breast is very rare in women under twenty-five (1 per 
cent.) and tell her to come back in six months or some 
other time, adding there is nothing he can see to worry 
about. There is nothing that anybody can see to worry 
about, but there may be something very serious that no 
one can see or feel to cause worry. If such a lump is 
removed and found innocent the operation is neither 
dangerous nor disfiguring, and the patient has the satisfy- 
ing knowledge that there is no danger from that source in 
the future. If it is allowed to remain, danger threatens, 
and the lump ought to be a continuous cause of anxiety. 
A tjrpic cancer occurs in a woman of middle age or over, 
is situated in the upper and outer part of the breast, 
and is not painful or tender at first, but later may 
become painful. After a time the tumor becomes fixed 
in the skin and may cause dimpling of the skin or a 
drawing in of the nipple, and then the tumor is not freely 
movable. The tumor is best felt not by pinching up a 
fold of the breast, but by pressing the surface of the breast 
with the open palm against the chest while the subject is 
lying flat on her back. 
But there are all kinds of exceptions to this description. 
A sore on the skin or irritation of the skin about the 
nipple, or a discharge from the nipple, should lead a 
woman to consult a surgeon at once. 
Patients in their twenties may have cancer of the 
breast, it may occur in any part of the breast, pain may THE PREVENTION OF CANCER 
223 
be the first symptom, it may be freely movable and not 
possess the slightest suggestion of cancer, or it may appear 
inflammatory. At the risk of repetition, for it cannot be 
too strongly emphasized, a woman with a lump in her 
breast should go at once to a competent surgeon for 
advice. The modesty which causes the patient to hide 
her trouble until it begins suddenly to grow apace is 
terribly false and mistaken. A tumor of the breast 
which has caused no trouble for months or years, and 
then begins to rather rapidly enlarge is almost invariably 
cancer, and the chances are that the surrounding tissue 
will be so invaded that the likelihood of cure will be much 
reduced. Almost one-third of the patients with cancer 
of the breast now come to surgeons when the growth 
has already advanced to a stage when operation really 
offers no hope of cure. 
Cancer of the Stomach.—As we have seen, the stomach 
is the most common situation of cancer in the whole 
body; one-third of all the cancers originate in this organ. 
Dr. Mayo has pointed out that cancer of the stomach is 
uncommon in animals and savages, that there is some- 
thing in the habits or preparation of food which favors 
the occurrence of cancer in civilized man. 
Cancer of the stomach can be less readily diagnosed 
in its earlier stages than any other common form, so that 
at present but about one-third of the cases—at the best— 
come to the surgeon in time for successful removal of the 
growth. But, as we have noted, ulcer of the stomach is 
the most frequent precancerous condition, and a previous 
history of ulcer of the stomach is found in more than half 
the cases by some authorities. 
So that ulcer of the stomach must be treated to avoid 
cancer. While this book is not intended as a text-book 
in medicine, a few words as to ulcer of the stomach may 224 
THE PREVENTION OF DISEASE 
not be amiss. Many cases of ulcer were formerly called 
nervous dyspepsia. The chief distinguishing feature is the 
occurrence of pain at a regular time after eating—one-half 
hour to five hours—which is relieved by food, vomiting, 
or saleratus, and is accompanied with much gas, heart- 
burn, and acidity. Attacks occur during periods for 
years and there are long intervals of good health inter- 
vening. Medical and surgical cure of chronic ulcer is 
possible, and such symptoms should not be regarded 
lightly, if only because cancer may be the ultimate end. 
Therefore cancer appears in persons who are having 
symptoms of ulcer of the stomach, in those who have 
been well for many years after a former history of ulcer, 
and in about half of the cases the symptoms of cancer 
come out of a clear sky in persons of middle age who have 
previously enjoyed good health. This fact is one of the 
most suspicious possible—i. e., the occurrence of symp- 
toms of continuous severe indigestion in one of middle age 
or past who has previously been free from stomach trouble. 
Thus, the aggravation of previous symptoms of 
stomach trouble, or the sudden appearance of them in a 
person past young adult life, are equally suggestive. The 
general condition is as characteristic as are stomach 
symptoms. The patient begins to lose weight, strength, 
appetite and energy, suffers from mental depression and 
weariness, and has a sense of “impending evil.” There 
is pallor about the nose, eyes and mouth, and the face 
has a pinched expression (Graham). Pain in the stomach 
may be absent, but usually there is a continuous inde- 
scribable feeling of distress, worse after eating, with the 
presence of much gas and heartburn. 
Vomiting of undigested food many hours or days after 
it has been taken is particularly suggestive, especially if 
some dark blood is present. THE PREVENTION OF CANCER 
225 
The patient may feel a movable lump in the region of 
the stomach, and this tumor may be evidence of a rather 
favorable case for operation. 
The new use for the z-ray in the examination of the 
stomach within the last few years has been of much aid in 
the diagnosis of ulcer and cancer, but should never be 
employed apart from physical examination by an expert 
in stomach troubles, as the findings of the rr-ray must be 
construed in the light of bedside experience. 
Since cancer of the womb is common, and the majority 
of cases (90 per cent.) come to the surgeon too late for 
satisfactory cure, the importance of the knowledge of 
suggestive signs cannot be too strongly emphasized 
nor too quickly acted upon. The occurrence of local 
irritation here is an important precancerous condition; 
that is, the existence of lacerations, which are the rule 
following childbirth. The repair of these is then always 
essential, if only for the prevention of cancer, although 
they are a source of many other troubles. Cancer should 
always be thought of in women of middle age (thirty-five 
to forty), or in later life, when there is irregular flowing 
following severe exertion or at other times. The same 
condition is common during the change of life, and this 
causes women to slight the symptom and neglect the 
trouble when it is in the most curable stage. Women 
should always consult a doctor and insist on a local 
examination in any case of irregular flow, even if it be 
slight. 
If such occur after the change of life is apparently past 
the demand for local examination is even more urgent. 
A colorless or brownish watery discharge, with or without 
unpleasant odor, is another suggestive sign. Pain in the 
lower part of the body or thighs may or may not be 
present, as well as pain and irritability of the bladder. 226 
THE PREVENTION OF DISEASE 
The repair of lacerations following childbirth may, 
therefore, prevent future precancerous conditions, while 
seeking advice on the first appearance of the slightest 
irregularities, as suggested above, may be the means of 
saving the patient’s life in early middle age or at any 
time thereafter. 
In the abdomen a chronic inflammation of the appen- 
dix and gall-bladder may lead to cancer in these organs; 
particularly is this so in the case of the gall-bladder. 
Operations to remove these organs will, therefore, not 
only cure the appendicitis and gall-bladder trouble, 
with their accompanying digestive disturbances, but 
will prevent the possibility of future cancer in these 
parts. 
Cancer of the skin, we have seen, has its precancerous 
stage in irritation of some already existing skin troubles, 
as warts, pimples, and moles, or scaling or scurfy patches 
in old persons. This remark applies especially to the 
thickened, scaly patches—perhaps as large as a pea or 
bean—that are common on the face, ears, or hands in 
middle age and beyond. The scales are white or brown- 
ish and come off—only to retun again. Then there are 
hard, brown warty patches on the face that crumble when 
picked off—only to reappear. These conditions may be 
readily removed freezing with carbonic acid snow 
before they become cancerous. Irritation about the 
nose, lips, tongue, and angles of eyes should receive 
particular attention because these are favorite sites of 
cancer. All sores and ulcers must be treated to prevent 
them from becoming chronic, and then a possible source 
of cancer. Cancer of the skin occurs more often on the 
face and head, in elderly men on the site of skin defects. 
Cancer of the lip is most frequent, and begins in men over 
forty on the under lip as a thickening or warty growth at THE PREVENTION OF CANCER 
227 
the margin of skin and mucous membrane. This usu- 
ally is produced by a straight, short-stemmed pipe, 
as more likely to be hot. The little pea-sized wart or 
thickening of the lip becomes raw and then scabs over, 
but does not heal permanently. After three or more 
months lumps or enlarged glands form under the jaw, 
but when this happens the proper time for operation is 
past. The radical operation, in which all the glands in 
the upper part of the neck are removed before they are 
invaded, is rewarded by permanent cure in almost all 
cases, as noted above. But still better is the very early 
operation—when it is only necessary to remove a V- 
shaped portion including the pimple or sore on the lip—a 
simple and slight surgical procedure and practically 
always followed by cure. 
A small thickening or abrasion on the lower lip, persist- 
ing for some months in a man over forty, is almost sure to 
be cancer. 
Cancer of the nose, face, eyelids, forehead, ear, back of 
the hand, etc., beginning in a wart, mole, scurfy patch, 
or red, yellow, or pearly pimple, it enlarges, crusts, and 
then gradually disappears, melting away into a raw 
ulcerated spot, which may gradually involve the surround- 
ing skin. The lacerated or excavated raw patch has 
raised, pearly borders. Its growth is slow and several 
years may be required for it to become of much depth or 
size and extend all over the face. In some cases the 
original wart, mole, pimple, or scurfy patch may grow 
into a tumor, which later breaks down and ulcerates, and 
in other cases it presents a number of raw projections 
like a cauliflower. Cancer of the tongue is quite common, 
and starts from the irritation of hot and cold food, an 
irregular and sharp tooth, or the white patch caused by 
excessive smoking. There is at first a crack in the tongue 228 
THE PREVENTION OF DISEASE 
and soon a raw spot or ulcer with a thickened base. Al- 
most all of the skin cancers are quite susceptible of per- 
manent cure in the beginning by removal with the knife 
before the disease has permeated into the neighboring 
glands. Various means are used to remove cancers of 
the skin, as caustics, x-ray, radium, freezing, etc., but 
growths can be removed at once by the knife, and only 
by this measure can just the proper amount of tissue 
be destroyed by the directing hand of the able and ex- 
perienced surgeon. But superior to this and all other 
curative means is the removal of the precancerous stage 
of cancer of the skin and the avoidance altogether of the 
occurrence of the naturally dreaded malignant disease. 
x-Ray and radium may cure skin cancers, but they should 
not be used to treat deep-seated or early growths 
where which are curable by the knife (Mayo). Cancer 
cells are more readily destroyed by heat than healthy 
tissue cells, so that heat, by a sort of slow cooking, is 
now used in the treatment of cancer not curable by the 
knife. By this means the cancer growth may be arrested 
even if a permanent cure is not obtained. An 
electrically heated instrument is used, with the patient 
under ether. There is now a great deal said and written 
about x-ray and radium in cancer. The knife is still 
by far the most certain means both of removing cancer 
and of preventing its return. 
Great advances have been made in treating cancer by 
x-ray in deeper portions of the body (deep x-ray therapy), 
but the rule still holds that the knife is preferable in all 
cases where it can be used. In inaccessible and super- 
ficial regions the x-ray or radium may be the proper 
agencies for treating cancer, but the experienced and able 
surgeon is always the best judge of the kind of treatment 
indicated, and not the radiologist. THE PREVENTION OF CANCER 
229 
So-called special cancer cures, as pastes, vaccines, 
vegetarian diet, etc., are all very undesirable, if not 
intrinsically harmful, in delaying surgery. Early surgery 
is the hope of cancer. 
Immunity to Cancer.—Gaylord found that there is 
immunity to cancer. That mice sometimes spontaneous- 
ly recover from inoculated cancer; that these cannot 
again be given cancer; and that their blood confers slight 
curative and immune effects when it is injected into 
animals suffering from cancer. 
There have been some recoveries from malignant 
tumors in man caused by the injection of cancer cells 
from other human patients or animals in the same way 
that we cure infections by the use of vaccines composed 
of the dead germs causing infections. One object of 
operating in the early stage of cancer is that then the 
patient’s immunity is strongest. In the late stages of 
cancer operation may lead to rapid recurrence and death, 
as it seems to aggravate the disease in the absence of 
immunity. In cases where the cancer is of slow growth 
there is much natural immunity. 
Some persons and families appear to naturally possess 
some immunity to the growth of cancer, and the opposite 
tendency may explain an hereditary susceptibility to 
cancer (much questioned). Miss Slye has recently been 
able to breed families of mice in which cancer occurred in 
most of the adult individuals. This is either due to in- 
herited lessened immunity to cancer or to increased sus- 
ceptibility to the effects of irritation or injuries to the 
tissues. There is no reason why these facts cannot be 
applied to the human being, and why we are not justified 
in saying that cancer may be inherited, as in the case of 
nervous diseases, viz: that the tendency is inherited. 
Editorially, the Journal of the American Medical Asso- 230 
THE PREVENTION OF DISEASE 
ciation (April 17, 1915) regards Miss Slye’s work as “one 
of the great contributions to our knowledge of cancer.” 
Miss Slye draws two practical deductions: (1) The elimi- 
nation of sources of irritation of the tissues in persons of 
high cancer ancestry; and (2) that the control of marriage, 
so that cancer may not be potential on both sides, ought 
to decrease the frequency of human cancer to a consider- 
able degree. That is when cancer has occurred in one or 
both of the parents of either the man or the woman con- 
templating marriage. It has been found that after great 
improvement from one or two treatments of cancer with 
x-ray or radium, the growth may suddenly become much 
worse and may spread to various parts of the body. It is 
known that the power of immunity against the growth of 
germs and cancer in the body resides in the tymphatic 
system (and in the bone-marrow and spleen), and that 
this system is weakened by overuse of either radium or 
x-ray, hence the need of the greatest care and experience 
in their use. 
Cancer Heredity.—The hereditary tendency to cancer 
is doubted by leading medical authorities. Dr. William 
Mayo affirms that he knows “no evidence that would lead 
to this belief”—i. e., that cancer is hereditary. He says 
the tenet that some families have tissues which on chronic 
irritation are more apt to develop cancer is purely prob- 
lematic, and also notes the fact that the occurrence of 
cancer in several members of a family is not strange 
considering its frequency. He quotes the enormous 
statistics of Hoffman, statistician of the Prudential 
Insurance Co. of America, who finds not the slightest 
evidence “to warrant the belief that cancer is in any sense 
hereditary.” 
Taylor summarizes the influence of heredity in cancer 
as follows: (1) That in most instances heredity exerts no THE PREVENTION OF CANCER 
231 
influence in cancer. (2) That there may possibly be an 
exception in some families. (3) That some precancerous 
conditions, as warts and birthmarks, may be hereditary. 
The most striking example of a “cancer family” is that of 
Napoleon. He himself, his father, two sisters, and one 
brother died of cancer. 
Miss Slye’s work on mouse cancer has been carried on 
for nearly fifteen years now (1923) and has been carefully 
followed and studied by the noted pathologist, Dr. H. 
Gideon Wells of Chicago, who believes that the results 
may be applied to man. These seem to show that if one 
parent has cancer there will be no special liability to can- 
cer in the children but that it may appear in later 
generations. 
When, however, both parents have cancer the occur- 
rence of cancer in the children is extremely probable— 
providing they survive till cancer age. The inheritance 
of mouse cancer strictly follows Mendel’s law originally 
applied to the crossing of varieties of plants. 
Cancer heredity is still doubtful but the results of Miss 
Slye’s investigations and her conclusions are worthy of 
most serious consideration. 
Cancer is not contagious. Among the thousands of 
cancers operated upon daily throughout the world not an 
instance has occurred of cancer following from the many 
accidental cuts and pricks sustained by surgeons in their 
work. Other infections are frequently transmitted in 
this way. Contact of husband and wife, even when the 
sexual organs are involved by cancer, does not produce 
cancer in the healthy party. 
When cancer does occur in husband and wife, as is not 
uncommon, it is only coincidence, such as would be 
expected from the frequency of the disease. 
To indicate the enormous extent of malignant disease 
in this country the statistics show that there are 80,000 232 
THE PREVENTION OF DISEASE 
deaths from cancer in the United States annually, includ- 
ing 25,000 deaths from cancer of the stomach and 18,000 
deaths from cancer of the breast. Also that the rate of 
mortality from cancer is increasing 2.5 per cent, per 
annum (Hoffman). 
But statistics is the mother of deception. The 
explanation of the apparent increasing frequency of can- 
cer is encouraging rather than alarming. To begin with 
cancer is a disease of the aged. It rarely occurs before 
forty. In early times when life was ended in the thirties 
by contagious diseases, now under control, or by the club, 
spear or sword, cancer was almost unknown. 
Every agency that prolongs life increases the liability 
to cancer. This has notably occurred within the past few 
decades so that life in some regions has been lengthened 
by ten or fifteen years. 
Therefore, as we must all die of some disease the longer 
we live the more apt are we to have cancer. Again, 
owing to the use of the x-ray and other modern diagnostic 
means, we are able to discover cancer of the internal 
organs that formerly escaped notice. So, by the pro- 
longation of life enabling many more persons to reach 
cancer age, and by our ability to discover cancer which 
cause deaths formerly attributed to other diseases, we 
can account for the apparent alarming increase of cancer. 
This analysis should rob statistics of much of its dread. 
But if one heeds the preliminary stage of cancer, which 
we have endeavored to impress upon the reader in this 
chapter, the predisposing causes of irritation may be 
removed in most cases before cancer results. 
Even when the patient goes to the surgeon for the first 
time in the early period of genuine cancer the curative 
results of operation are wonderfully better than those 
ordinarily obtained in cancer in the various stages in THE PREVENTION OF CANCER 
233 
which it is treated today. Thus, Dr. Bloodgood, the 
distinguished surgeon of Johns Hopkins, and the leading 
authority on cancer in this country, offers the following 
encouraging statement: “ From what we know of the early 
signs of cancer and the local growth in the early stages of 
cancer, or what precedes cancer, we should draw the 
greatest encouragement as to the probability of the 
percentage of cures possible in these early stages by good 
surgery. In the breast it should be at its worst 86 per 
cent., in local cancers of the skin over 98 per cent., in 
the lip and tongue over 90 per cent., in the bone over 75 
per cent. With the accumulating experience of each 
succeeding year with such early cases, the percentage of 
cures increases.” CHAPTER IX 
THE PREVENTION OF SEXUAL DISEASES AND 
SEXUAL HYGIENE 
INTRODUCTORY NOTE 
In the realm of preventive medicine no more vital subject can 
be considered than that which stands at the head of this chapter. 
It is vital partly because of its fundamental relation to human 
society and race betterment, and partly because until recently the 
whole discussion of reproduction and the sex life has been distorted 
by misconceptions, befogged by ignorance, and veiled by mysticism. 
Themedical profession will welcome the author’s scientific and 
conservative presentation of this subject as representing a message 
from their profession to the public. 
The laity will welcome the chapter as presenting much desired 
and highly prized information expressed in clear and concise lan- 
guage, authoritative and reliable. 
The author is especially to be commended for the stress which 
he lays on the care and instruction of children by their parents, 
with a view of controlling physical conditions and of implanting 
at an early age wholesome ideas and high ideals. 
Winfield Scott Hall. 
This is a tremendous subject, but the discussion herein 
will be chiefly confined to protection of the individual 
rather than the public. There are but two important 
sexual diseases—gonorrhea and syphilis. The preva- 
lence of these diseases is much greater than most persons 
realize. Authorities have estimated that 8 out of every 
10 men in New York have had gonorrhea, and that 3 
out of every 5 married women have acquired the disease 
in some degree in consequence. It is also calculated 
234 SEXUAL DISEASES AND SEXUAL HYGIENE 
235 
that 75 per cent, of all operations on the sexual organs of 
women, and 60 per cent, of the work done by specialists in 
women’s diseases, and 80 per cent, of the deaths of women 
from inflammation of the sexual organs, result from 
gonorrhea. A large part of sterility in both men and 
women (estimated at 50 per cent.) is caused by gonorrhea. 
Ten per cent, of all blindness and 70 to 80 per cent, of 
blindness in the newborn are attributable to gonorrhea. 
Gonorrhea is almost always contracted by sexual inter- 
course with a victim of the disease, and five to six days 
must intervene (more rarely three to seven days) before 
the first symptoms arise. These usually consist in 
frequent and painful urination, accompanied by a 
whitish discharge from the urinary passage which causes 
a cloudiness of the urine first passed. 
The disease may run a few weeks with complete recovery 
or may become chronic and last for months, or, rarely, for 
years, during which time the patient may be capable of 
communicating it by sexual intercourse. The inflamma- 
tion frequently invades various parts of the sexual and 
urinary tracts of the male and female, but is not by any 
means confined to these organs. 
Gonorrhea may produce general blood-poisoning 
through the presence of the special germs in the blood, 
and these may also attack the heart or joints, with the 
most serious results. So-called gonorrheal rheumatism 
is a very frequent complication, and there are many other 
sequels of the disease. Husbands who have had attacks 
of gonorrhea may infect their wives, and if the lat- 
ter become mothers, they may transmit the disease to 
the eyes of their newborn infants during the process of 
birth. This is due to direct contact of the baby’s eyes 
with germs of gonorrhea in the birth-passages of the 
mother, and if this does not happen, there is no other 236 
THE PREVENTION OF DISEASE 
acquired or inherited taint in the offspring from the 
disease in the parents. Gonorrhea in either sex may lead 
to death years after its apparent cure. Thus, a male 
patient of the author’s has recently died from the effects 
of a total obstruction of the urinary passage (a stricture) 
caused by gonorrhea acquired some forty years previous. 
The consequent retention of urine led to a general 
poisoning (uremia) of the whole system. 
Syphilis, while usually contracted by sexual inter- 
course, is sometimes acquired in other ways, as by means 
of drinking cups, towels, eating utensils, brushes, combs, 
barbers’ and surgeons’ instruments, kissing, etc. Syphilis 
germs live only five or six hours outside the body. The 
disease is most often acquired between the ages of eigh- 
teen and twenty-six. Moist lesions in the mouth and 
sexual organs are the only means of transmission of 
syphilis. The disease begins on an average in from 
twenty to thirty days after exposure, more rarely from 
two weeks to three months. A sore then appears on the 
site of inoculation, as on the private parts, lips, etc., 
with enlargement of glands in the neighborhood, as in the 
groins when the sexual organs are involved. After six 
weeks the so-called secondary stage appears, with fever, 
sore throat, a general rash, headache, and pains in various 
parts of the body. Falling of the hair and white patches 
in the throat and mouth are often observed. This stage 
may last indefinitely or may appear intermittently for 
years. 
The secondary stage may never be noticed by the 
patient, or complete apparent recovery may ensue, or 
the secondary stage may glide imperceptibly into the 
third or tertiary stage. There is no regular time for its 
incidence. In this there may be destructive changes in 
any organ in the body or upon any part of the skin SEXUAL DISEASES AND SEXUAL HYGIENE 
237 
surface. Finally, there is a fourth stage which frequently 
occurs one or two decades after apparent complete 
recovery from syphilis (not less than eight years), and 
its commonest manifestation takes the form of either 
locomotor ataxia (syphilis of the spinal cord) or general 
paresis (syphilis of the brain). Medically well-treated 
men leading a temperate life are less susceptible to paresis 
and locomotor ataxia, which occurred in about 1 per cent, 
of 1016 syphilitics (White). Church reports (1916) that 
among 4000 Austrian officers, examined twenty-two 
years after they had acquired syphilis, some 1.5 per cent, 
had developed locomotor ataxia and 4.6 per cent, had 
developed paresis. He believes that in syphilitics who 
develop paresis or locomotor ataxia the syphilitic germ 
has become so modified in the body that it acquires a 
special affinity for the nervous system—as we have seen 
is the case in respect to germs (streptococci) which enter 
the blood from diseased tonsils. After a person has 
had syphilis three or four years he can usually not 
communicate it to another individual. This follows 
because the germs of syphilis usually bury themselves in 
the tissues, dig in, as it were, and often so remain during 
the life of the patient. This is not an invariable rule, 
however. Syphilis is transmitted from mother to 
offspring. In fact, it is the only disease known to be so 
transmitted in full virulence. Syphilis is occasionally 
inherited in the third generation. Syphilis is said to be 
the cause of 40 per cent, of miscarriages and of many 
still-births, while 60 per cent, of the living children 
die at an early age. When they live they are usually 
stunted and defective. The mortality, as a whole, in 
hereditary syphilis is about 75 per cent. It appears more 
often three to four weeks after birth, and very rarely 
later than six months, but cases as late as the twentieth 238 
THE PREVENTION OF DISEASE 
year are recorded. Children are often born apparently 
healthy of syphilitic parents. Such children should be 
subjected to the Wassermann test. Syphilis is, with rare 
exceptions, acquired from the syphilitic mother and 
not directly from a syphilitic father. This follows 
because there are more than 200 million spermatozoa 
capable of fertilization and only one of these is utilized 
in the conception of a child. 
Even in the syphilitic it is unlikely that many of the 
200,000,000 spermatozoa contain the germs of syphilis. 
After five years has elapsed since the mother has acquired 
syphilis there is little danger of its being communicated 
to her offspring, but during relapses this may occur for 
eight or ten years. In such a case she may have healthy 
alternating with syphilitic children. If a pregnant 
woman has active syphilis and is treated vigorously 
early in the disease, especially if the infection occurs 
after the seventh month of pregnancy, the chances of the 
child being healthy are much greater. The mothers of 
syphilitic children frequently appear perfectly healthy 
because syphilis is often mild in women, and antibodies 
are formed in the infected child in the mother’s womb 
which protect the mother. Syphilis has been a disease 
often impossible of diagnosis because it remains latent 
for years in persons of apparent robust health, only to 
break out anew without sign or warning. The modern 
tests for syphilis (Wassermann and Noguchi) are very 
accurate, but until recently its incidence has been mere 
guesswork. Its prevalence is, indeed, fearful to con- 
template. Recent results, obtained by examination of 
the blood by means of the Wassermann test, are as 
follows: In 111 children in a Boston hospital (Lucas) 
and in 102 children in a Chicago hospital (Churchill) 
one-third were found to be syphilitic. Among 100 SEXUAL DISEASES AND SEXUAL HYGIENE 
239 
obstetric patients in an Australian hospital (Piper) 
1 in 6 patients was found to be infected with syphilis, 
both by the test and in most cases by other evidences of 
the disease. Browning has recently found that every 
one of 104 prostitutes and all of 109 tramps were suffering 
from syphilis.. 
In picked men (at the age when the disease is, however, 
most likely to be taken) the prevalence of syphilis is much 
lower. In the United States Army the rate has varied in 
different commands from 2 to 10 per cent., but in the entire 
army Nichols affirms that syphilis exists to the extent of 
over 5 per cent., or one case in every 20 men. Vedder,1 
however, found that syphilis was prevalent to the extent 
of about 17 per cent, in picked recruits for the army, 
after 83 per cent, of the number applying had been 
rejected for various reasons, including a recent history of 
syphilis. Syphilis shortens life about four to five years 
on the average; in 25,000 insurance risks life was short- 
ened five and one-half years. Syphilis is five times more 
common in men than women. It is prevalent to the 
extent of about 10 per cent, in men in foreign cities 
and in from 5 to 10 per cent, in American cities. There 
are 1,200,000 adult syphilitics in the United States 
(Pusey). The “golden period” for the treatment of 
syphilis is during the few days after the appearance of 
the sore on the sexual organs and before the beginning 
of the secondary symptoms, and before the germs have 
become buried in the tissues all over the body. With 
modern treatment the disease may be wholly and 
permanently cured by killing every syphilitic germ in 
the body within a few weeks at this period in place of 
requiring several years by the older methods. Unfor- 
1 Prevalence of Syphilis in the Army, Surg.-Gen. Bull. No. 8, 
June, 1915. 240 
THE PREVENTION OF DISEASE 
tunately this immediate total annihilation of the syphili- 
tic germs is rarely realized in practice and, while the 
patient may appear well, there are still germs living unseen 
and unfelt in some part of the body. When patients are 
apparently cured they must remain under observation 
and be subjected to the Wassermann test at regular 
yearly or other intervals. 
In the tertiary period syphilis can never be cured, in 
the sense of killing all the syphilitic germs in the body. 
The symptoms may often be wholly relieved, but the 
germs are too deeply embedded in the tissues to be 
reached by drugs circulating in the blood. 
Proper treatment in the early secondary stage will 
result in 99 per cent, of permanent cures. By the older 
methods about 90 per cent, of cases of syphilis were cured 
in dispensary practice and 97 per cent, in the best private 
practice, the rest going on into the tertiary stage. 
Prevention of Sexual Diseases.—The vast amount of 
controversy concerning the pros and cons of the segrega- 
tion, legalization, and medical sypervision of prostitutes 
has resulted in a consensus of opinion of authorities 
opposed to this as a means of preventing immorality, 
sexual disease, and crime. 
Our task is to consider the means of preventing sexual 
disease in the individual. I believe that the problem is 
largely a matter of proper training, education, right 
living, and thinking; that the means employed to prevent 
sexual disease are identical with those most beneficial in 
promoting the general health of body and mind in the 
individual. It is folly to ignore the fact that the sexual 
desires are the most powerful of any in the world. Self- 
control is necessary to combat them, and for this purpose 
both body and mind must be at their highest point of 
health. On the other hand, it is right to pray, “Lead us 241 
SEXUAL DISEASES AND SEXUAL HYGIENE 
not into temptation but deliver us from evil.” This 
means the avoidance of all agencies which both improperly 
stimulate the sexual desires and weaken the will. It 
also means the acquisition of habits which strengthen 
the body and will and divert the interests and activities 
to other and healthier pursuits. The reasons for 
refraining from immoral practices are too self-evident to 
need more than a brief reference to them. Morals are 
synonymous with customs, and customs are usages found 
most beneficial for the individual and race. Immorality 
then leads to shame and deception consequent upon 
consorting with immoral women. It involves the chance 
of causing illegitimate pregnancy in the woman and 
the danger of acquiring one or both of the dreaded sexual 
diseases. It is the means of degrading a woman who 
might be a wife. It is likely to lead to postponement of 
lawful marriage and to be a source of lasting regret after 
marriage to a chaste partner. It lowers the whole moral 
tone through association with depravity and the attendant 
vices of vulgarity, profanity, and the use of alcohol, 
cocain, morphin, etc. 
While escaping temptation is not so glorious or helpful 
as overcoming it, yet there is sure to be enough in store. 
A healthy existence with plenty of outdoor sport and 
exercise with companions of the same sex conduces to 
normal sexual life. Co-education of youth in high schools 
of both sexes is to be condemned as favoring sexual evils, 
and teachers as well as doctors will almost universally 
endorse this opinion. The fashion of allowing great free- 
dom of intercourse between the youth of both sexes is, in 
the mind of the author, wholly bad. One sees boys and 
girls sprawling about together in hammocks and in partial 
undress on beaches without let or hindrance from parents 
of the highest social standing. Sexual desire is one of the 242 
THE PREVENTION OF DISEASE 
strongest, if not the strongest, emotion which actuates the 
human being, and is beyond the control of society, how- 
ever much people may prate. Close intimacy between the 
opposite sexes should not be tolerated before the begin- 
ning of adult life. It is well known by the informed that 
the sexual act, from a physiologic standpoint, strictly 
begins with the first thought, word, look, or touch relat- 
ing to a desired one. And while the persons concerned 
may be wholly innocent or, rather, ignorant, “yet very 
easily may stimulation pass from one state to the next, 
the next, and the next, until the great sexual act is 
complete, and a babe lies nestled at its mother’s breast.” 
In this, as in many other matters, it is well to regard the 
poet’s warning, “Oh, small beginnings ye are great,” and 
avoid them. This, again, means the avoidance of 
prurient books and plays and, above all else, bad com- 
panions. Hard work and play are essential to the 
healthy body. Idleness here, as always, is the devil’s 
most effective tool. 
Constant association with the opposite sex, especially 
among engaged persons to whom custom allows unusual 
intimacy and caresses, often results in great physical 
injury when continued for a long time. This follows 
because continual stimulation of the sexual organs, with- 
out nature’s mode of relief in sexual intercourse permitted 
by marriage, causes local congestion and inflammation 
of the sexual organs in both sexes. Distressing symptoms 
arise, and the normal functions are enfeebled so that the 
sufferer may become unfitted for marriage when the 
time comes for it to occur. Moreover, the frequent 
sexual excitement engendered bjr such unnatural inti- 
macy without proper physiologic relief produces a state 
of nervous exhaustion or prostration with its host of 
accompanying evils, and the afflicted person is wholly SEXUAL DISEASES AND SEXUAL HYGIENE 
243 
unfitted for the joys or duties of life and becomes an 
abomination to himself (or herself) and friends alike. 
Short engagements and early marriages are desirable 
(the latter especially as preventing sexual disease) when 
they may take place without privation. Long engage- 
ments should be shunned unless the parties to the 
contract are separated by distance. The present social 
state of the world does not favor early marriages because 
the position demanded by society may not be attained 
without a long course of training or years spent in trade. 
A recent writer has marshalled statistics to prove that 
the partners of early marriages in the middle classes have 
a much higher death-rate than their friends who marry 
later, owing to the excessive struggle required to retain 
their place among social equals. 
The use of alcohol among young men is especially con- 
ducive to sexual immorality, since it not only excites the 
sexual desire, but has an equally paralyzing influence over 
the will power. This is universally recognized—the 
shedding of modesty, reserve, and self-control under the 
action of alcohol—as evidenced by the old saying, “ in vino 
veritas.” 
Among all other influences alcohol and persuasively 
bad companions head the list in favoring sexual immora- 
lity. The sexual organs are stimulated by highly spiced 
or peppered food, by an overabundance of meat or eggs, 
and sleeping on soft beds with an overwarm covering. 
Conversely, the daily morning cold bath and the use 
of a moderately hard bed with light coverings are to be 
recommended. The first and chief aid to the young man 
should be the thought that he will marry, and that the 
sort of woman he wants will demand that he be as chaste 
as herself. Keeping this always before him—living the 
proper life, full of work and play, and knowing the danger 244 
THE PREVENTION OF DISEASE 
to morals and health from being unchaste—he will 
serenely pursue his way, exerting self-control to the 
utmost when temptation arises. 
Supposing a young man has already fallen from grace 
owing to infection with one of the sexual diseases, is it 
safe for him to marry without endangering the health of 
wife and possible offspring? In such a case no man 
should marry without a careful medical examination by 
a specialist in genito-urinary diseases, and only recently 
(1913) a similar test was requested by statute in Wiscon- 
sin and has been upheld by the Supreme Court of the 
state (1914). After proper treatment, and the lapse of 
two years from the appearance of the last manifestation 
of syphilis, a man may safely marry, according to Osier. 
This advice should also include several negative Wasser- 
mann tests taken at intervals during the first three 
years. Hoffman’s rule is often followed concerning 
marriage of syphilitic men; that is, if men have been 
thoroughly treated, and have had no symptoms for two 
years, they may marry from three to five years after 
the onset of syphilis. The Wassermann test is unim- 
portant in this connection after five years, for of a large 
number of men having healthy children five years after 
the beginning of syphilis 50 per cent, showed a positive 
Wassermann test. Within the first three years a positive 
Wassermann test should mean postponement of marriage. 
So that five years after the beginning of syphilis, in a 
man who has been well treated medically and free from 
symptoms for two years, marriage may be sactioned 
despite the existence of a positive Wassermann test 
(Pusey). 
In the case of a person who has had gonorrhea a careful 
microscopic examination of any discharge which exists 
(or may be made to appear by massage of the deeper SEXUAL DISEASES AND SEXUAL HYGIENE 
245 
parts of the urinary tract, and the drinking of a consider- 
able amount of beer) may be necessary to determine the 
presence of the special germ and the danger of contagion. 
Then the new test (complement-fixation) is of great 
value in discovering chronic and apparently cured cases 
of gonorrhea. By proper treatment the male patient 
can usually be permanently cured within a few weeks or 
months. 
To avoid direct exposure to possible infection with 
syphilis one should refrain from use of a common towel, 
hair-brush, comb, soap, drinking cup, and barber’s 
implements (more particularly the razor). During the 
past few years preventive measures have been used in 
the treatment of males who have been exposed to the 
perils of sexual intercourse in order to avert infection 
with either gonorrhea or syphilis. Objection may be 
raised to this on the ground that rendering illegitimate 
intercourse free from nature’s punishment will only 
encourage its greater prevalence. While such reasoning 
may to some extent be borne out by the facts, yet the 
risk to innocent wives and babes unborn and to other 
sufferers from accidental infection is paramount and 
will justify all such measures which will reduce the prev- 
alence of the sexual diseases. In the case of newborn 
infants it is the rule that a few drops of a 2 per cent, 
solution of silver nitrate or a 20 per cent, solution of 
argyrol should always be instilled into their eyes a few 
moments after birth, to prevent the possibility of gonor- 
rheal infection and consequent loss of sight. 
The same drugs will in most cases prevent the disease 
in men if dropped into the urinary passage within a 
few hours after sexual intercourse. 
Metchnikoff, in experiments on monkeys, found that 
protection against infection with syphilis could be secured 246 
THE PREVENTION OF DISEASE 
in most cases by the application of ointment containing 
30 per cent, of calomel. A young medical student, Paul 
Maisonneuve, allowed himself to be inoculated from two 
virulently infected patients, and then calomel ointment 
was applied one hour later, with no development of 
syphilis, while a monkey succumbed from the same infec- 
tion without treatment. Treatment must be applied 
within eighteen hours, and the sooner the better. In the 
United States Army and Navy these methods have been 
enforced during the past few years with moderately suc- 
cessful results. The principle is laid down that no man 
has a right to deprive the government of his services and 
to become a burden besides through sickness. Therefore 
every exposed soldier or sailor returning to garrison or 
ship is required to report for preventive treatment. 
This consists, first, in thorough washing of the sexual 
organs with soap and water, dropping into the urinary 
passage a medicine-dropperful of a freshly prepared 
20 per cent, solution of argyrol, and squeezing the end of 
the passage to keep the solution in for five minutes; and, 
finally, rubbing a salve, composed of benzoinated lard 
containing 30 per cent, of calomel, thoroughly over the 
whole surface of the sexual organs. Neither of these 
drugs produce any discomfort. As argyrol solution 
does not keep, it may be freshly made by dissolving 
12 grains of argyrol (which keeps indefinitely in powder 
in a stoppered bottle) in a teaspoonful of cold water. 
In the United States Army and Navy the man who 
develops sexual disease without reporting his exposure 
and receiving preventive treatment is punished. The 
results of this treatment are as follows: Major Howard 
reports but 1 case of syphilis in 3800 exposures, and that 
the yearly ratio of sexual diseases had been cut from 
227 to 18 per 1000. That the preventive measures SEXUAL DISEASES AND SEXUAL HYGIENE 
247 
are not generally so successful on the average in the whole 
army (in 1913) is shown by the report that the rate of 
sexual diseases per 1000 men has fallen from 115 to 
85 (Nixon). This moderate reduction is probably due 
in great part to carelessness in the use of the preventive 
measures. But it must be borne in mind that no pre- 
ventive measures will certainly preclude the possibility 
of an attack of one or both of the sexual diseases after 
exposure through sexual intercourse. This method of 
prevention of sexual disease, or venereal prophylaxis as 
it is called, was widely used in the Army and Navy during 
the Great War. For that reason it is now popularly 
known and too much confidence is placed in it as a 
safeguard by individuals wishing to escape the penalty 
of immorality. The very moderate reduction in the 
rate of sexual diseases in the Army, quoted above, 
shows that these preventive measures do not afford 
great protection, when all is said, and this is the experi- 
ence of the specialists in venereal diseases in private 
practice. And, as has been pointed out, there are numer- 
ous other reasons, besides the danger of infection with 
venereal diseases, why a self-respecting person should 
avoid the moral and social risks of illegitimate sexual 
intercourse. Moreover, without personal instruction 
from a physician in the use of the drugs described for 
the prevention of sexual diseases the result is likely to 
be a failure. Avoidance of exposure to these diseases 
is the chief essential in prevention of the diseases them- 
selves. A bachelor may refrain from sexual intercourse 
indefinitely without harm, providing he does not subject 
himself to agencies which frequently excite the sexual 
desires. If the sexual organs are constantly stimulated 
under such conditions the result may be as disastrous as 
not infrequently occurs in engaged persons noted above. 248 
THE PREVENTION OF DISEASE 
But the real preventive measures against sexual disease 
should be begun by the parents at birth, and if the boy 
is properly taught during his first ten years, when the 
brain is most impressionable, his future will be in most 
cases secure. If the mother or father begin during the 
first few years to talk naturally about the sexual organs, 
as one would instruct a child about the care of his teeth 
or other part of the body, the child will have no hesitancy 
in reporting any happenings of his own bearing on this 
matter, for there will be older and vicious boys, 
girls, or adults who will try to lead him or her astray. 
Self-abuse.—The chief endeavor in young children 
should be to prevent masturbation or self-abuse, whereby 
the sexual organ is so stimulated by rubbing or irritation 
that the child experiences the same sensations and excite- 
ment (orgasm) which occur during sexual intercourse. 
Any local irritation about the penis in the male will cause 
the child to handle the part, and so he will be more likely 
to acquire the bad habit. For this reason circumcision is 
advisable in the male in preventing the retention of secre- 
tion and urine and avoiding consequent irritation. This 
operation may be best done after the infant is two or 
three weeks old and before the monthly nurse departs. 
The writer believes in circumcision as a routine practice 
for every male child. As the foreskin is somewhat 
adherent in infants, many trained nurses are taught to 
force it back by daily attempts at withdrawal. The 
author does not believe in this practice, as it may have 
the effect of arousing desire for stimulation of the organ 
even at this early age. Self-abuse is not confined to 
children, but is often practiced by monkeys and other 
male animals. It is not nearly so common in girls, as 
in boys but is, on the other hand, not rare. The more 
exposed organs of the male probably favors irritation. SEXUAL DISEASES AND SEXUAL HYGIENE 
249 
Babies may bring the sexual crisis or orgasm about by 
rubbing the thighs together. They should be carefully 
watched to prevent irritation of their sexual organs by 
any method, and should be punished if found addicted 
to the habit. As soon as children are old enough they 
should be told that handling, rubbing, or irritating 
their sexual organs is bad for them. They should also 
be warned not to permit any other child or person to 
touch their sexual organs and to report any occurrence 
of the kind. When they are eight or ten years old 
boys should be instructed as to the harm done by mastur- 
bation. As a matter of fact, in the past almost all boys 
have masturbated for a longer or shorter time, and have 
given up the practice from some inherent sense of decency 
and because companions have told them it would make 
them crazy. With the prevailing custom of education 
in these matters the habit should become infrequent. 
The harm done is that wrought by frequent stimulation 
of the immature nervous system, so this is the most 
important part of the body to suffer. Then there is no 
limit to the frequency of the practice, which does not 
obtain in sexual intercourse. When boys masturbate 
after reaching the age of puberty (beginning at some 
period between twelve and seventeen and lasting two 
years or so) there is a loss of the fluid (semen) secreted 
from this time on by the testicles, and containing the 
millions of microscopic sperm cells, any one of which may 
produce a new individual when it comes in contact with 
the female germ cell, egg, or ovum. 
We may summarize the evil effects of self-abuse as 
follows: (1) The shock to the nervous system, noted 
above. (2) The loss of sperm cells representing such 
tremendous energy and incredible potentiality. (3) 
Lessened formation and absorption into the blood of the 250 
THE PREVENTION OF DISEASE 
internal secretion of the testicle which determines and 
controls the development in the youth of the sexual 
attributes of the virile adult male (Marshall). 
These consist in tremendous growth of the long bones, 
particularly in the thighs, which give height to the frame; 
in the growth of the sexual organs, and also in the appear- 
ance of hair on these parts and on the face; in the change 
of voice, which is said to be due to lengthening of the 
vocal cords. All these evidences of increased nutrition 
are due in great part to the activity of certain glands which 
pour their secretions into the blood. They each have 
their function to perform, and if one produces a greater 
or less amount of secretion than normal the most serious 
results ensue. Thus, disturbances of the secretion of 
the small gland at the base of the brain (pituitary) may 
either be the cause of such growth that a giant is produced 
or, on the other hand, the subject may become very 
fat and the sexual organs may become undeveloped. 
Total removal of the thyroid gland (in the region of the 
Adam’s apple in the neck) will cause an individual to 
become unrecognizable by coarsening of the features, 
and many other serious changes occur. Removal of 
the testicles and ovaries produce marked alterations in 
the body and character. So it is wise to impress upon 
the growing youth (Prof. Hall) that the secretion of 
the testicles must not be wasted, as it is necessary to 
make the body strong and athletic and to preserve the 
balance essential to the proper functioning of the various 
ductless glands. 
While excessive masturbation may so break down the 
general health as to lead to the production of impotency, 
sterility, and even idiocy and insanity, these are very rare 
occurrences, and it is really the case that idiocy and insan- 
ity are more frequently responsible for the lack of self- SEXUAL DISEASES AND SEXUAL HYGIENE 
251 
control which results in such an unnatural habit. When 
children have acquired the habit they are apt to be thin, 
nervous, and peevish, and at a later period, after ten or 
twelve, the subject is prone to lose interest in play and 
become depressed and sit by himself and mope. He is 
sallow and loses his appetite. Parents should be on the 
watch for such signs and have a confidential talk with the 
lad. If he confesses to the habit, the boy should be 
encouraged and told that if he exerts his self-control he 
will soon overcome it and no evil effects will ensue. 
The treatment consists in not allowing children to sleep 
together and in requiring them to sleep on rather hard 
beds with light covering. A boy who has contracted the 
habit should not be permitted to lie in bed after waking 
nor read in bed after retiring. He should take a cold 
bath in the morning and, if tempted to indulge, should 
bathe the sexual organs in cold water. Plain diet, with- 
out an excess of meat or eggs, and an outdoor life are 
desirable. Horseback exercises often lead to stimulation of 
the sexual organs, however, owing to friction of the saddle. 
Improper books, shows, and companions must be 
avoided. Circumcision is adVisable. But the instruc- 
tion of the child from the earliest year should prevent the 
occurrence of self-abuse, and if such has not been begun 
early, then it is much more difficult to talk to boys about 
the later dangers. At the age of puberty (twelve to 
seventeen) the boy should be warned by his father, or by 
a doctor, of the occurrence of spontaneous discharge of 
semen from the penis during sleep. These so-called 
“ pollutions ” are normal if they do not happen more than 
once or twice a week; when occurring three times or 
more a doctor should be consulted. 
The use of a hard bed, light covering, cold water 
applied to the sexual organs, abstinence from alcohol, 252 
THE PREVENTION OP DISEASE 
tobacco, and avoidance of such books and plays, or 
intimacy with the opposite sex, as might excite sexual 
desires, are all part of the treatment. Sleeping on the 
back favors loss of seminal fluid at night, and may be 
avoided by tying a towel about the waist with a knot in 
the back. At this period, also, boys should be warned 
against the perils of sexual intercourse which have been 
discussed in the earlier part of this section. 
Both man and maid enter into wedlock with the 
greatest ignorance of the physiology of the sexual organs 
in most cases. Custom has made ignorance, masquer- 
ading as modesty, seem the only decent course in this 
matter, but it is a fatal mistake, as the experience of 
doctors soon teaches them. Just as during a long 
marriage engagement stimulation of the sexual organs 
without physiologic relief in sexual intercourse leads to 
nervous breakdown and local inflammations of the 
sexual organs, so do unnatural practices in sexual inter- 
course during married life produce equally unfortunate 
results. 
Both the man and the woman should secure medical 
advice before marriage concerning the marital sexual 
relations, or, when this is not feasible, a book of this kind 
may serve in a measure as a poor substitute. 
It will, at any rate, suggest the importance of many 
matters which may lead to the seeking of professional ad- 
vice in difficulties. The woman should know that she 
will be subjected to sexual intercourse immediately after 
marriage, and she should not be imbued with the idea 
that her husband is unusually sensual or brutal in 
expecting this of her. On the other hand, the man should 
understand that as the first impressions of fear and pain 
SEXUAL HYGIENE IN MARRIAGE SEXUAL HYGIENE IN MARRIAGE 
253 
may render sexual intercourse unpleasant to his wife for 
months or years, he should be especially considerate in 
this respect in the beginning of their sexual relations. 
Indeed, in some cases it may be wise for him to refrain 
from such for a day or so until mutual love and desire 
break down all barriers. In some women the hymen, or 
membranous fold which partially closes the front pass- 
age, offers so much resistance that it may be badly torn 
and give rise to considerable bleeding from the results 
of sexual intercourse. Gradual dilation is sometimes 
done by physicians before marriage, but is rarely 
necessary. 
Still this is one reason why a professional consultation 
may not be amiss in the case of the woman about to 
marry. 
The wear and tear of preparation for marriage, the 
achieving of the trousseau, together with that of the 
ceremony itself and travel afterward, is but a poor begin- 
ning for married life. If to offset the exhaustion conse- 
quent to these doings indulgence in wine is added in 
celebrating the event, we have the most unfavorable 
state for the conception of a child. The honeymoon 
should be passed in a quiet country place, at the moun- 
tains, seaside, or on the water, among the most healthy 
surroundings. Travel, hotel life, and sight-seeing are 
only fit for the uncommonly robust at such a time. 
The frequency of sexual intercourse is a matter of 
importance. Persons differ in their sexual power as 
much as in muscular strength or in any other physical 
quality, and it is not any more possible to lay down exact 
rules than it would be to state precisely the amount of 
food required by any individual. During the first few 
weeks of married life it is too much to expect any very 
rigid adherence to rules, but later the axiom laid down by 254 
THE PREVENTION OF DISEASE 
Luther is as good as any we know. He said, “twice a 
week we need not fear.” Repetition of the act during 
the night or day is inadvisable. The use of alcohol at 
such times leads to subsequent exhaustion, and endangers 
the health of a child conceived under these conditions, 
whether father or mother be the transgressor. 
Sexual relations are forbidden by custom during men- 
struation, and in some religions severe penalties, even 
death, are attached to disobedience of this command. In 
animals sexual intercourse is only practised during such 
periods (rut, heat), and the sexual desire is often strongest 
during the latter part of menstruation in women. While 
abstinence is the rule from a sense of delicacy and esthetic 
considerations, there is no evidence that physical harm 
to man or woman results from sexual intercourse during 
the “unwell” period. Sexual intercourse is permissible 
during pregnancy (unless there has been a tendency to 
miscarriages) except in the last month or two, and except 
during six weeks after childbirth or after a miscarriage. 
Since the nervous system of the woman is disturbed 
during menstruation and the pregnant state the husband 
should make allowance for depression, peevishness, 
unreason, and irritability at these times, and treat his 
wife with unusual gentleness and consideration in conse- 
quence. Excess in the matter of sexual intercourse is 
at once shown by the effect upon the general health. 
Headache, pressure or pain in the back of the neck, 
exhaustion, lack of interest and energy, with mental 
depression, may be the immediate result. The appetite 
and digestion are impaired, and there may be pain in the 
loins and increased susceptibility to “catching cold.” 
In women there may be a white discharge from the front 
passage or vagina. The cause of such symptoms should 
readily be recognized and corrected at the earliest moment. SEXUAL HYGIENE IN MARRIAGE 
255 
Women should not feel abashed at discovering themselves 
subjects of sexual passion, when happily married, although 
their upbringing has often led them to believe such feel- 
ings immodest and unladylike. This is, of course, all 
bosh, and a happy marriage means a happy union of the 
soul, mind, and body. 
Overwork, anxiety, pre-occupation, poor health, and 
unvaried monotony of life will abolish, to a considerable 
extent, the natural sexual desires. Change of scene and 
relaxation will often restore the normal sexual functions. 
Absolute personal cleanliness is essential in both partners, 
and offense to the senses has an immediate influence in 
destroying sexual desire. 
We hear much now-a-days about race suicide. This 
is not, of course, due to any loss of vitality in the race, 
but is caused by artificial methods for the prevention of 
pregnancy. 
While this is often wholly inexcusable, the condition of 
the woman may be such as to endanger her life were she 
to become pregnant, and too frequent pregnancies are 
exhausting and inadvisable. Financial circumstances 
and the health and happiness of the family may require 
limitation of offspring, however. The reasons for and the 
desirability and justification of pursuing such a course are 
strikingly set forth in a book.1 Almost all the artificial 
means of preventing pregnancy are more or less unreliable 
or injurious to the health. The common practice on the 
part of the husband of withdrawing before final com- 
pletion of the sexual act, so as to avoid conception, is 
quite likely to cause a breakdown in his wife’s nervous 
system. The author has in mind the case of a fine, 
1 Fewer and Better Babies or Limitation of Offspring by Pre- 
vention of Conception,” W. J. Robinson, M. D., Critic and Guide 
Co., New York, 1915. 256 
THE PREVENTION OF DISEASE 
healthy, attractive young woman who became a nervous 
wreck from this means, because she dreaded a second 
child after a hard and painful delivery of the first baby. 
The setting free of the ovum or egg from the woman’s 
ovary does not always coincide with the time of menstrua- 
tion. This is shown by the fact that women become 
pregnant when they have not been unwell for months 
previously, as while nursing a baby or, very rarely, after 
the change of life. Then the spermatozoa, or germ cells 
of the man, may remain alive in the tubes of the woman 
for three weeks after sexual intercourse. 
So that it will be seen that menstruation is not the time 
during which a woman is most likely to become pregnant . 
The flow of blood will tend to wash out the male germ 
cells. There is, in fact no time when sexual relations 
are free from the possibility of pregnancy, either before, 
or after, or between or during the unwell periods. It has, 
however, been found by experience that conception is 
most apt to occur within the first eight days after the 
end of menstruation, and is least likely to take place 
between the fourteenth and twenty-first day after 
menstruation. To show nature’s prodigality in the way 
of propagation possibilities it has been calculated that a 
man is capable of producing some 300,000,000,000 
spermatozoa during his sexual life, while a young woman 
starts out with 30,000 potential eggs in her ovaries. 
When the health of the wife demands the avoidance of 
pregnancy a doctor should be consulted and he will then 
feel justified in recommending quite certain methods for 
its prevention. 
While a woman nurses her child menstruation usually 
ceases and conception does not often occur. On the 
other hand, menstruation may begin almost any time 
during the milk-giving period, and then conception is as 
likely to occur as at any other time. Extraordinarily, SEXUAL HYGIENE IN MARRIAGE 
257 
conception may happen, even in the absence of menstrua- 
tion, while the mother is nursing, as noted above. 
Married life exerts a strong influence on disease and 
longevity. There are Swedish statistics which show that 
there are twice as many single men who die at the age of 
forty as married men at the same age. These figures, 
which deal with deaths in Sweden between 1881 and 1890, 
give 14.67 deaths of single men at forty as against 7.42 
deaths among married men at forty per 1000; while at 
forty-five there were 19.07 deaths among single men, as 
compared with 9.22 deaths among married men per 1000. 
Among women the saving in life is not so great, on account 
of the dangers, cares, work, and vicissitudes of married 
life, but there is a considerable advantage in favor of the 
married. Using the same statistics as above, at the 
childbearing age of thirty the deaths per 1000 among 
married women are 6.37 and among single women 6.43; 
while at the age of fifty the number of deaths in married 
women per 1000 are but 8.99, as against 12.18 among 
single women. The regularity of the habits of the 
married, the greater freedom from dissipation among 
married men, and the fact that, as a class, the stronger 
and healthier are those who marry account for the 
greater longevity of wedded persons. 
At the age of fifty it has been computed that the 
married man has an expectation of five years longer life 
than the single male, while the married woman at the 
same age has an expectation of one year longer life than 
the spinster of the same age. Many of the accidents 
incidental to the childbearing period can be prevented 
by modern methods and will increase the longevity of 
the married woman accordingly. It is said, on good 
authority, that the pregnant wife is less subject to fatality 
than the non-pregnant on account of the extra care given 
her at this time. CHAPTER X 
THE PREVENTION OF ACUTE AND CHRONIC 
RHEUMATISM, NEURITIS AND ACUTE 
TONSILLITIS 
We have already considered in another place the far- 
reaching and damaging effects of tonsillitis and other 
localized infections in the production not only of rheuma- 
tism, but of many other serious disorders (see page 
194). 
In the prevention of rheumatic fever and various forms 
of so-called rheumatism we find the tonsils to be the chief 
source of these troubles. Acute rheumatism is a disease 
which begins suddenly with fever, sore throat, and pains 
in the larger joints, which, in turn, become swollen, hot, 
and exceedingly tender. In four-fifths of the cases of 
rheumatic fever tonsillitis precedes or accompanies the 
rheumatism. It is the duty of the tonsils to stop the 
entrance of germs into the blood from the throat. In 
their attempt to do this they themselves frequently become 
acutely or chronically diseased, and are, notwithstanding, 
often unable to check the invasion of bacteria into the 
system at large. In acute rheumatism the germs find 
their way into the blood from diseased tonsils, and not 
only attack the joints, but have an affinity for the valves 
of the heart and lungs, so that valvular disease of the 
heart is the most common complication of acute rheuma- 
tism, while pneumonia and pleurisy are not infrequent 
accompaniments. The whole train of diseases which 
may end in permanent disability of the heart for life, or 
258 RHEUMATISM, NEURITIS, AND TONSILLITIS 
259 
rapid fatality from the acute attack, begins in the 
apparently harmless and commonplace tonsillitis. While 
acute rheumatism is a well-defined and recognized special 
disease, the causative germ is not so well established. 
Recently however, it seems pretty well ascertained that 
it is due to a common germ, the cause of many of the 
most severe wound inflammations and of the most 
serious inflammations in many parts of the body. The 
injection of these germs (streptococci) from diseased 
tonsils into animals has experimentally produced all the 
symptoms of rheumatic fever, with even the heart com- 
plication; while, on the other hand, the removal of 
diseased tonsils in man has been followed by complete 
recovery of acute and chronic forms of rheumatism. 
Extensive outbreaks of acute tonsillitis have of late 
years been traced to the action of germs (streptococci) 
in milk derived from cows having inflammation of the 
udder, or originating in the throat of men who convey the 
germs to milk through handling or tasting it. Thus, in 
Boston, in May, 1911, an epidemic began in which there 
were 1048 cases of what was called septic sore throat, a 
severe tonsillitis, in which the glands, joints, lungs (pneu- 
monia), heart, kidneys, and other organs were also 
attacked by the entrance of germs from the tonsils into 
the general circulation. There were forty-eight deaths 
from these complications. In this instance the disease 
was traced by Professor C.-E. A. Winslow to an appar- 
ently healthy employee who was a “carrier” of streptococci 
in his throat. It is practically impossible to avoid such 
occasional accidents from drinking raw milk, and the only 
safe-guard, therefore, is the taking of cooked milk (see 
p. 347). Indeed, the dairy responsible for this unfor- 
tunate outbreak had been celebrated for a generation as 
the show dairy of New England, and employed both a 260 
THE PREVENTION OF DISEASE 
sanitarian and veterinarian of the highest standing to 
supervise and direct the handling of the output. 
The author at the present moment of writing has a 
patient (the keeper of a small corner grocery) under his 
care with tonsillitis, and on the fourth day of the disease 
(today) he suddenly develops acute rheumatism in his 
knees, ankles, and hands. Fancy the number of similar 
cases he might create by handling the milk he sells—if it 
were not in sealed bottles—and by handling other food 
eaten raw, as he lives in the back of his store. 
Even in the midst of rheumatic fever it may be best 
to remove diseased tonsils if they are not acutely inflamed. 
While diseased tonsils are the chief cause of acute rheu- 
matism, in some cases other disorders of the nose, mouth, 
and throat in which the same germs are present (strepto- 
cocci) may be also causative factors. These include 
abscessed teeth, inflamed gums or Riggs’ disease, catarrhal 
inflammation in the nose or in the cavities in the face and 
forehead (sinuses) connected with the nasal passages, 
and inflammation in the back of the nose favored by 
the presence of adenoid growths. 
So that these conditions must be remedied. But even 
when the germs in these parts do not enter the blood, to 
produce inflammations in other parts, it is thought that 
their toxins or poisons are absorbed and are sufficient to 
account for the so-called growing pains in the limbs of 
children. Moreover, these poisons generated by the 
germs in diseased tonsils and adenoids lower the whole 
vitality and stunt the development in children and render 
them more liable to germ diseases general^. 
Enlarged Tonsils and Adenoids.—In regard to tonsils 
and adenoid growths, it may be said that the presence of 
either so that they can be plainly seen and felt is evidence 
that they are abnormal. Enlarged tonsils may be seen by RHEUMATISM, NEURITIS, AND TONSILLITIS 
261 
looking into the open mouth. There are two membran- 
ous folds on each side of the mouth which separate it 
from the throat, and the tonsils (one on each side) are 
situated in the space between the folds. In the normal 
throat we only see these folds (pillars), but if the tonsils 
are enlarged and diseased they appear as rounded pro- 
jections jutting out into the throat, sometimes being 
so large as to almost block the entrance to the throat 
(see Fig. 2, page 206). The amount of infection or 
germ growth in them can only be determined by an 
expert. The adenoid growths are situated at the upper 
part of the throat and back of the nose and are out of 
sight. Their presence may be discovered by the doctor 
when he inserts a forefinger into the mouth, and then 
hooks it up behind the roof of the mouth till he touches 
the top of the throat, which may also be regarded as the 
back of the nose. For, if one should pass an instrument 
(held horizontally) into the nostril, and so onward until 
it touched the back of the throat, it would reach the 
location of the glandular growth known as adenoids 
(see Fig. 3, page 207). These produce frequent colds in 
children and deafness and abscess in the ear by blocking 
up the openings of the passages which connect the deeper 
part of the ears with the throat. 
Enlarged tonsils and adenoids are exceedingly common 
in children and it is not necessary to make the uncom- 
fortable examination to determine the presence of ade- 
noids if enlarged tonsils are seen, because the appearance 
of enlarged tonsils is sufficient evidence of the occurrence 
of adenoids, since they are practically always co-existent. 
The recent custom of systematic medical inspection of 
school children has done more than anything else to call 
parent’s attention both to the presence and danger of dis- 
eased tonsils and adenoid growths. But it is not possible 262 
THE PREVENTION OF DISEASE 
for the inspectors to discuss the specific dangers of the 
condition which we attempt to do here and also in more 
detail in another section (see p. 194). 
In respect to the prevention of rheumatic fever, it 
should be added that besides the removal of diseased 
tonsils and adenoids and the proper dental treatment of 
abscessed teeth and inflamed gums (Riggs’ disease), to- 
gether with the cure of any existing disease of the nasal 
passages or cavities connected with them, there are 
certain general measures of importance. Thus, the 
avoidance of chilling and occupations where one is 
continually wet, the wearing of clothing sufficiently 
warm but not so excessive as to produce sweating, and 
the improvement of the general health are essential. 
A tendency to the disease appears to be quite commonly 
hereditary. Indeed, in 7 out of every 10 cases there is 
found to be a history of the occurrence of rheumatic 
fever in the family of the patient. Chorea, or St. 
Vitus’ dance, is apparently often due to the same germs 
infecting the nervous system as are found in the joints in 
acute rheumatism. In other words, it is rheumatic and 
frequently occurs with or follows rheumatic fever. 
St. Vitus’ dance is shown by the presence of uncontroll- 
able jerking of the limbs, or grimacing, and the same 
measures useful in preventing acute rheumatism should 
be employed for the purpose of averting chorea. 
Chronic rheumatism is probably always due to the 
absorption of germs or their poisons into the blood and 
thence into the joints. Chronic rheumatism is thus an 
infection and not due to some imaginary constitutional 
cause. In this disease, which is given various names, 
such as rheumatic gout and various forms of arthritis 
(inflammation of joints), there is chronic swelling, pain, 
and disability in various joints, as in the fingers, knee, and RHEUMATISM, NEURITIS, AND TONSILLITIS 
263 
spine, jaw, etc. The disease may begin acutely in several 
joints with fever, or come on gradually with increasing 
tenderness, swelling, and pain in one joint, to be followed 
by a similar condition in other joints at a later period. 
The more common form is seen in young or middle- 
aged women, where the knuckle-joints of the fingers 
become red, swollen, tender, painful, and stiff. Chronic 
rheumatism or rheumatic gout has no connection what- 
ever with gout. In all cases of chronic rheumatism 
the same causes are operative as in acute rheumatism, 
and the disease may be cured by removal of them. 
New, at the Mayo Clinic, found that the removal of 
abscessed teeth and the cure of pyorrhea (and local 
points of infection elsewhere in the body) had a wonder- 
fully curative effect in patients with acute joint inflam- 
mation, in rheumatic fever, and in acute pain in the 
joints and muscles. On the other hand, but few patients 
with chronic joint disease or chronic rheumatism were 
benefited by this treatment. So that it is as a preventive 
measure, and in early cases of rheumatism, that the 
removal of abscessed teeth, and of gum, tonsillar and 
other local infections, has its greatest value. New 
concludes by saying—“It would seem that in the future 
the conscientious dentist, knowing the terrible suffering 
and mortality of the results of the past era of dentistry 
(general disease arising from improper care of the teeth 
and gums), would warn patients of the possibility of 
the presence of dead teeth in the mouth, and discuss 
with them the dangers of crowns and bridges. Unless 
the dentists of today can perfect their technique so as to 
give all their patients clean mouths, free from abscesses 
and gum inflammation, the old time dentist who ex- 
tracted teeth and put in plates was really a more useful 
member of the profession, for with his methods the mouth 264 
THE PREVENTION OF DISEASE 
was at lest kept free from foci of infection.” In addition 
to the infections of the mouth and throat, it is possible 
for infections in other parts of the body to produce 
rheumatism, as in the case of inflammations of the sexual 
organs in men or women. Then there is a possibility 
that chronic constipation or, as the fashion dictates, 
auto-intoxication may lead to chronic joint troubles by 
absorption of germs or their poisons from the stagnant 
intestinal contents. 
The moral is, in all cases of acute or chronic joint 
inflammations to prosecute a most thorough search 
throughout the body for some focus of local infection. 
These are more commonly in the mouth and throat, as 
we have seen. Prevention consists, then, in seeing to it 
individually that one has a normal mouth (teeth and 
gums), throat, and nose, that one may not only escape 
rheumatic troubles, but the host of serious diseases in 
remote parts of the body which may in time result from 
apparently insignificant local causes of discomfort 
(see page 194). 
There are other chronic joint inflammations which 
come on in the course of special germ diseases and are 
due to the joints becoming attacked by the specific 
organism. Thus there may be such complications in 
influenza, gonorrhea, syphilis, tuberculosis, etc., and the 
name of the disease is applied to the disordered joint, 
as gonorrheal, syphilitic, tuberculous arthritis, etc. All 
joint inflammations are infections except those due to 
injury or gout. Some are due to unknown infection, 
and receive names according to the changes in the joints 
but popularly are classed under the name of rheumatism; 
others are so unquestionably but a part of a general 
germ disease that they receive the name of the special 
causative organism. RHEUMATISM, NEURITIS, AND TONSILLITIS 
265 
Muscular Rheumatism and Neuritis.—This is a con- 
dition about which we know very little; that is, we are 
ignorant of its pathology or the morbid changes which 
occur in the muscle, leading to sudden pain, stiffness, 
and perhaps tenderness on pressure. Almost every 
one is personally familiar with the discomforts of stiff 
neck and lumbago. Young persons are more subject to 
the former and the middle aged to the latter. A person 
may awake and be suddenly seized with the most agoniz- 
ing pain on moving the neck, or it may come on at any 
time after exposure to cold, as after getting out of a 
cold bath. So, on lifting a heavy body the middle-aged 
man finds he can hardly straighten up, or after indulging 
in some sport which he pursued when younger he has to 
take to his bed from pain in the muscles most concerned. 
To prevent the disorder one should keep in training by 
regular daily exercise, as one attack seems to favor a 
recurrence of the trouble. Muscular rheumatism is 
common in the gouty, who should restrict the amount of 
food, eat meat sparingly and never more than once 
daily, and drink plenty of water (see page 63). The 
avoidance of exposure to cold and damp and of sitting in 
drafts when warm are most essential. 
The same causes are responsible for muscular rheuma- 
tism and neuritis (pain and tenderness along the course 
of nerves) as for other forms of rheumatism, that is, 
infected teeth, gums, tonsils, gall-bladder, etc. Infected 
teeth or tonsils are the most common causes, the former 
in the aged, or middle aged, the latter in younger persons. 
Neuritis pains and muscular rheumatism about the neck, 
chest, shoulder and arms are almost surely relieved by 
removal of teeth or tonsil infections, more so than any 
other disorder. To alleviate severe forms of muscular 
rheumatism one should at once resort to rest and heat 266 
THE PREVENTION OF DISEASE 
on the first warning pain in the muscle. Lying down 
with the hot-water bag in stiff neck and lumbago, and 
strapping of the small of the back with surgeon’s adhesive 
plaster, by limiting the action of the muscles, secure the 
most rest and comfort. Moving the bowels with two 
or three compound cathartic pills and taking a few 
10-grain capsules of aspirin, followed by a whole glass 
of water, at two-hour intervals, may cut short an acute 
attack of muscular rheumatism, whether it be in the 
neck, back, or chest. Strapping the chest with plaster 
gives the most rest and relief in muscular rheumatism 
in this region when breathing and movements are painful. 
Muscular Cramps.—Cramps in the calves of the legs 
are common at night after retiring. These are caused 
by some form of poisoning. Either by the poisons 
generated in the muscles from overfatigue, or those due 
to various diseases, as diabetes, gout, and chronic 
Bright’s disease. Such poisons as lead, arsenic, and 
alcohol will also cause muscular cramps. Bandaging 
the legs before going to bed will often prevent attacks 
when they are due to over-exertion, but when this cause 
may be ruled out, the patient should seek professional 
advice lest he be a sufferer from one of the constitutional 
conditions noted. 
ACUTE TONSILLITIS 
This is a contagious disease due to streptococci and 
should be treated as such, although it has hitherto not 
been included among the diseases reportable to the health 
authorities. It attacks young persons most frequently 
and all patients should be isolated. Contagion is pro- 
bably only acquired by direct contact with the patient, 
as by kissing; or from the secretions of the nose and 
throat, as by use of a common drinking or eating utensil, ACUTE TONSILLITIS 
267 
towel, etc. Therefore the handkerchiefs should be 
boiled or, better, the secretion from the mouth or nose 
should be collected on paper and immediately burned. 
The eating and drinking utensils should be boiled. 
Tonsillitis is a dangerous disease on account of its 
frequent complications, as enlarged glands, pneumonia, 
valvular disease of the heart, acute Bright’s disease of 
Fig. 5.—Acute follicular tonsillitis (Gleason) 
the kidneys, inflamed joints, etc. (see page 294). For 
this reason one cannot teach the public too often or 
emphatically that it is to be avoided by all means. 
Because patients apparently more often escape the 
dangers is no reason for making light of them, especially 
as many of the complications occur so long after the 
attacks of tonsillitis that they are not attributed to their 
true cause (see page 194). There is the most peculiar 
danger in tonsillitis and sore throat in dairy employees, 
as the causative germ grows and multiplies most favor- 
ably in milk, so that such patients have not infrequently 
been the cause of outbreaks of hundreds of cases of septic 
sore throat by infecting the milk they handled (see page 
259). 268 
THE PREVENTION OF DISEASE 
The dairy employee with sore throat should be im- 
mediately removed from work and the local health au- 
thority notified, to protect both the employer (from 
damages) and the public. 
The most useful measure to avoid acute tonsillitis 
consists in painting the tonsils two or three times with a 
strong (10 to 20 per cent.) solution of silver nitrate 
during the first day at the first suggestion of sore throat. 
In the very first stages this may abort an attack, but 
later it may do harm by shutting in the infection through 
the coating caused by the silver. This treatment should 
be applied by a physician; but persons subject to acute 
tonsillitis are also the victims of chronic tonsillitis, and 
the consequences of this condition are both dangerous 
and far reaching (see page 194). To avert these, and 
recurrences of acute attacks, the total removal of the 
tonsils is commonly the only proper remedy. 
We cannot repeat too often that the removal of the 
tonsils should be surgically complete. The tonsil 
clumsily removed in part is often more dangerous to 
the owner than the tonsil uncared for. CHAPTER XI 
THE PREVENTION OF DISEASES OF CHILDREN 
While the surest way to achieve longevity is to possess 
long-lived progenitors, yet much may be done to secure a 
useful, healthy, and long life by the care given the child. 
What has already been accomplished, as affecting, the 
average duration of life among civilized nations and in 
diminishing the death-rate in the case of certain diseases 
within a comparatively short space of time, is most 
remarkable. The infant mortality has had most to do 
with statistics concerning the general death-rates. If a 
considerable part of the population die within the first 
year of life, the statistical average duration of life will 
be tremendously and misleadingly altered. In com- 
puting averages it is notorious that extremes have most 
effect. The reduction in infant mortality is chiefly due 
to improvement in the milk supply of artificially fed 
infants, so that the diarrheal diseases, or so-called 
summer complaint and cholera morbus, are in great part 
extinguished. 
Thus, in Rochester, N. Y., to give a single instance, 
largely through the efforts of the efficient Health Officer, 
Dr. G. W. Goler, the infant mortality has been reduced as 
follows through the supplying of clean milk for infant 
food: In the decade including the years 1887 to 1896, 
before the milk work was done, the average mortality in 
infants under one year in the month of July was 1010; in 
1897 to 1906, after the milk work was under way, the 
average death-rate in babies was only 413 in July under 
the same general conditions. 
269 270 
THE PREVENTION OF DISEASE 
The fight against tuberculosis has been so successful 
that, while it has been authoritatively estimated that the 
death-rate from this disease amounted to one-fourth of 
the whole population in Europe during the last century, 
at the present time it causes but one-tenth of all deaths in 
the most enlightened communities. The annual mortality 
from all causes in London in the 17th century was 50 per 
1000, as against 15 at present; in Boston, in 1700, the 
death-rate was 34 and now is 19; and within a century 
London, Berlin, and Munich have cut their death-rates 
in half. Sweden with its school gymnastics and govern- 
ment-installed hygiene, has the longevity record of the 
world; the average life duration of men in Sweden is 
fifty and of women fifty-three; in the United States it is 
forty-four for men and forty-six for women; while in 
India the average length of life for men is twenty-three 
and for women twenty-four years (Price Collier). 
Seattle has the lowest death-rate in the United States 
(8.37 per 1000), owing to the climate, young population, 
pure water and pure air (clean streets, frequent rain), 
and pure milk supply. The absence of slums and excel- 
lence of the health department in controlling the milk 
supply and infectious diseases also contribute to the 
causes which give Seattle its unique position. 
The earlier we can begin with the work of preventive 
medicine, the more satisfactory will be our results. I 
believe that there are certain particular preventive meas- 
ures which apply to the generality of children and which 
all parents should know. These I propose to consider 
here, but not necessarily in any great detail. To begin 
with the first weeks of the child’s life: 
The operation of circumcision for all males is desirable. 
I quote here from one of our leading specialists in children’s 
diseases, Dr. Kerley: “Should circumcision be practised THE PREVENTION OF DISEASES OF CHILDREN 
271 
as a routine measure? There is not the slightest doubt 
that it would be for the best interest of every male in- 
fant if he were circumcised. The operation during the 
second week is a trivial matter. In 1 out of every 5 male 
infants circumcision is a necessity, both for comfort and 
health. In marked degrees of phimosis (narrow or pin- 
hole opening in the sheath) it is the only means of relief.” 
How many parents there are who begin by shirking this 
simple method of prevention of disease. This matter we 
have already discussed under another head (see page 248) 
and it is unnecessary to amplify it in this place. 
Proper Food for the Infant.—The business of a proper 
food supply is the subject of most consequence in the case 
of the newborn infant. Of course, if the mother can fur- 
nish this the child is infinitely better off. In some of the 
older foundling asylums the mortality of newborn infants 
was 90 per cent., owing to our former ignorance in arti- 
ficial feeding and to the generally inferior physique of 
foundlings. 
In this place it may not be uninteresting to present 
some statistics concerning infant mortality and its causes. 
In the United States census of 1900 the death-rate for 
every 1000 infants born was highest in Charleston, S. C., 
being 419.5; while in Washingon it was 274.5; in Balti- 
more, 235.1; in New York, 189.4. According to the 1910 
census for every 1000 babies born, there were deaths 
under one year of age as follows: Seattle led all the 
country with but 79; Rochester, N. Y., came next, with 
86 deaths; while in the larger cities the deaths rose to 
217 in Boston, and a still greater number in the largest 
cities. 
Again, figuring the deaths in infants under one year of 
age to every 1000 of population according to the 1910 
census, we have the following results: Seattle shows its 272 
THE PREVENTION OF DISEASE 
leadership once more with 1.66 deaths, and these increase 
in number until we reach the larger cities, as Boston with 
3.34 deaths; New York with 3.67, and Baltimore with 
3.84 deaths. 
Russia has the highest infant mortality, and fully half 
the infants die during the first year of life in many dis- 
tricts. In Germany about one-fifth of the infants die 
during their first year. About one-half of the deaths in 
infants under one year of age are due to diarrheal dis- 
eases, and these are chiefly caused by germ-laden cows’ 
milk. Among babies who die, about 90 per cent, are 
fed with cows’ milk and 10 per cent, are fed from their 
mothers’ breasts, according to Charles Harrington’s Ger- 
man statistics. 
It has been abundantly proved that the importance 
of having cows’ milk comparatively free from germs 
greatly transcends the matter of its chemical identity 
with mothers’ milk. 
When the author first began his milk work in Seattle, 
some nineteen years ago, the mortality of babies under one 
year of age per 1000 births was very nearly 120, as com- 
pared to 66 in 1913. Owing to the production of certified 
milk by several farms, and to the popular interest in 
clean milk aroused by our writings and labors, and later 
to most excellent work of the former Health Officer 
(Dr. Crichton), and of the Health Commissioner 
(Dr. McBride), the general quality of the milk supply has 
so improved that Seattle leads the country in this respect, 
and has taken several first prizes for certified and market 
milk at the National Dairy Shows. One advantage we 
have consists in the cool weather in summer, and this is 
not only directly more favorable to infant health, but 
prevents the' growth of germs in milk which is not 
properly cooled and kept cool. Still, the reduction of the THE PREVENTION OF DISEASES OF CHILDREN 
273 
infant mortality by one-half in a decade may be attrib- 
uted chiefly to the improvement in the milk-supply alone, 
as the climate has naturally remained the same, and no 
other new factors of importance have obtained. 
The remarkable showing of Rochester, N. Y., in her 
pioneer work is all the more creditable, since that city 
has to contend with much hotter weather than Seattle 
ever has. 
The means by which one can secure a pure milk supply 
have been described in another section (see page 344). 
The method of artificial feeding of babies with cows’ 
milk by “modified” milk has been most popular in the 
United States. This aims at so altering the chemical 
composition of cows’ milk that it will, chemically, closely 
resemble human milk. 
In a general way this result is accomplished by diluting 
the upper part of milk (top-milk or cream), after standing 
in bottles, with water or barley-water. Since cows’ 
milk contains less sugar, about the same amount of fat, 
and much more casein or curd than human milk, by dilut- 
ing a rich cow’s milk with water we may obtain the right 
percentage of fat and at the same time reduce the normal 
quantity of casein, so that it will coincide wtih that natural 
to human milk. In this process the sugar is diluted, and 
this loss is made good by the addition of milk-sugar to the 
mixture. The various methods of feeding babies will 
not concern us in this book, but, besides all professional 
advice which can be obtained, it is well for all mothers 
to possess a good book devoted to the care of babies, 
among which Holt’s is the accepted classical work. 
The United States Public Health Service is endeavor- 
ing to promulgate through its publications a much 
simpler method of feeding babies than with modified 
milk. Skimmed milk should be fed only during the first 274 
THE PREVENTION OF DISEASE 
week of life. At the beginning of the second week one 
part whole milk and two parts skimmed milk are given. 
After the end of the second week one will use half whole 
milk and half skimmed milk, while during the fourth 
week a mixture of three parts whole milk and one part 
skimmed milk is given. Beginning with the second 
month, whole milk is fed, but this should not contain 
over 3 per cent, of fat. Cities require that milk shall 
contain more than this amount of fat, although some 
Holstein cows give milk containing less. One must find 
out from one’s milkman or city authorities what is the 
fat content of the milk to be used, and then take some of 
it off to leave a milk containing only 3 per cent, of fat. 
Thus, from a quart of milk, after standing four hours, 
which contains 4 per cent, of fat, remove the upper 1% 
ounces (4 tablespoonfuls); from a quart of milk contain- 
ing 4.5 per cent, of fat, remove the upper 5 tablespoonfuls; 
and from milk containing 5 per cent, of fat, remove the 
upper seven tablespoonfuls, to get a 3 per cent. milk. 
The amount of milk wdiich is fed daily should be equal to 
one-seventh of the weight of the baby up to three months 
of age; one-eighth of the weight, from three to six months, 
and after that from one-ninth to one-tenth of the infant’s 
weight. Thus, for a month old baby who weighs 9 
pounds, or 144 ounces, one would use one-seventh of this, 
or 20 ounces divided into eight feedings, given in the 
twenty-four hours. Plach feeding consists of 21-£ ounces 
supplied at intervals of two and one-half hours, although 
more milk may be given at a feeding if the baby demands 
it. This arrangement permits of a nap of at least four 
hours in the night, and it may be extended to seven 
hours—from 10 p. m. to 5 A. M.—by training, in which case 
the amount in each bottle may be increased so as to give 
20 ounces in the twenty-four hours. THE PREVENTION dF DISEASES OF CHILDREN 
275 
During the first three months the milk should be boiled 
by filling the milk bottles for twenty-four hours’ use, 
stoppering them with absorbent cotton, standing them in 
boiling water to their necks, and boiling them for three- 
quarters of an hour. Then the bottles are to be taken 
out, cooled in cold water, and kept on ice. After the 
third month the milk should be pasteurized as described 
on page 347. Boiling the milk makes it more digestible 
by preventing the formation of tough curds in the child’s 
stomach.1 
This method of feeding babies from birth with boiled 
skimmed milk and then with gradually increasing 
amounts of whole milk, until at the beginning of the 
second month of life whole milk containing 3 per cent, of 
fat is given exclusively, has been extensively used abroad 
and has been found by the writer suitable in most healthy 
babies. It has the merit of great simplicity compared 
with the modifications more commonly employed, such 
as the additions of varying amounts of cream, milk- 
sugar or malt sugar, barley-water, water, and lime-water, 
the proportions of the different ingredients requiring 
constant changing from time to time. Recent researches 
have shown that it is not the large amount of curd or 
casein in cows’ milk which is difficult of digestion for 
babies, as formerly held, but, on the contrary, it is the 
fat of cows’ milk which usually disagrees and gives rise 
to apparent curds (in reality, soap) in the bowel dis- 
charges. This discovery removes the original scientific 
basis of modified milk, although many of the modern 
modifications produce a, result very similar to the 
whole milk containing 3 per cent, of fat. But it must be 
1 After the first month two teaspoonfuls of freshly prepared 
orange juice should be given the baby twice a day about an hour 
before the milk feeding (see pages 276, 277, 367). 276 
THE PREVENTION OF DISEASE 
distinctly understood that no one dilution or modification 
of cows’ milk will agree with all infants, and in many cases 
the most careful study of the expert is required to arrive 
at the particular combination of the chief ingredients 
of milk which will best suit a baby with delicate 
digestion 
The great desideratum, however, is that the milk be 
clean—as free from germs as possible. Even if one uses a 
milk which does not agree with the baby, so that it is 
fretful, does not gain, vomits, or is constipated and has 
abnormal bowel discharges with curds, etc., there is little 
danger, providing one can secure professional advice as 
to altering the food. It is merely a case of malassimila- 
tion or indigestion. 
Whereas, if the milk contains many germs, especially 
those found in manure in dirty milk from the bowels of 
the cow, the baby may be poisoned beyond all help or, at 
any rate, is likely to be in a fight for its life lasting for 
weeks. Such were the cases of summer diarrhea and 
cholera infantum wThich carried off the babies to the 
extent, of fully one-half their number during the first year 
in former days—simply cases of milk poisoning—and 
now a thing of the past owing to production of clean milk 
and pasteurization. The older teaching of the profession 
that pasteurized milk causes scurvy, rickets, anemia, and 
malnutrition in children is not true when orange-juice is 
used. Dr. North has probably tried the largest single 
experiment in the world in feeding 10,000 babies on pas- 
teurized milk. The change from raw to pasteurized milk 
was made in a day, and no digestive disturbances, mal- 
nutrition, scurvy, or rickets occurred from the change, 
although the infants were never put back on raw milk. 
With the use of fresh orange-juice daily during the first 
year, and the addition of cereals and other food after the The prevention of diseases of children 
277 
sixth to ninth month, there appears to be no harm possible 
from using pasteurized milk, and no other is given to the 
millions of babies brought up on the continent of Europe. 
The modern pasteurization, at the low temperature of 
145° F. for thirty minutes, while destroying all disease 
germs, has been held by leading authorities not to in any 
way alter the chemical or vital qualities of milk. Very 
recently (1915), however, Dr. A. F. Hess has indubitably 
shown that a mild form of scurvy occurs in many infants 
fed exclusively on pasteurized milk (heated to 145° F. for 
thirty minutes) without orange-juice. This is more apt 
to occur when boiled or condensed milk is fed. Orange- 
juice will always prevent scurvy from heated milk. 
On the other hand, the dangers from raw cows’ milk, even 
the product of the most sanitary stables of millionaires 
and of dairies run like well-conducted operating-rooms, 
cannot be certainly avoided, either those originating in the 
cow or in the human employee (see page 346). 
The food should be adapted to each individual child by 
an expert and his advice should be sought whenever 
possible. 
The method of feeding infants best adapted for uni- 
versal use by the average baby is that devised by Drs. 
Holt and Shaw and supported by the authority of the 
American Medical Association.1 Whole cows’ milk is 
diluted with water because its fat and curd (or proteins) 
are not so readily digested by babies as the same ingre- 
dients of human milk. Also because cows’ milk contains 
more than double the percentage of proteins found in 
1 “Save the Babies,” prepared for use in Baby Health Confer- 
ences for the Committee on Public Health Education Among 
Women, by Drs. L. Emmett Holt and Henry L. K. Shaw. Coun- 
cil on Health and Public Instruction, American Medical Associa- 
tion. 278 
THE PREVENTION OF DISEASE 
human milk. Sugar is added because it is a normal ingre- 
dient of milk. Cows’ milk contains less than human milk 
and when cows’ milk is diluted there is all the more need 
for adding sugar. 
Milk-sugar or malt sugar should be used for most 
babies. Ordinary sugar agrees with some infants, but 
accustoms them to an oversweet food. Lime-water is 
used because it prevents the formation of too hard a curd 
in the infant’s stomach or, in other words, makes the 
cows’ milk more digestible. 
Beginning on the third day, the average baby should be 
given 3 ounces of milk daily, diluted with 7 ounces of 
water. To this should be added 1 tablespoonful of lime- 
water and 2 level teaspoonfuls of sugar. This should be 
given in seven feedings. 
At one week the average child requires 5 ounces of milk 
daily, which should be diluted with 10 ounces of water. 
To this should be added even tablespoonfuls of sugar 
and 1 ounce of lime-water. This should be given in 
seven feedings. The milk should be increased by 
ounce about every four days. The water should be 
increased by ounce every eight days. 
At three months the average child requires 16 ounces 
of milk daily, which should be diluted with 16 ounces of 
water. To this should be added 3 tablespoonfuls of sugar 
and 2 ounces of lime-water. This should be given in six 
feedings. The milk should be increased by ounce 
every six days. The water should be reduced by lx2 
ounce about every two weeks. 
At six months the average child requires 24 ounces of 
milk daily, which should be diluted with 12 ounces of 
water. To this should be added 2 ounces of lime-water 
and 3 even tablespoonfuls of sugar. This should be 
given in five feedings. The amount of milk should be THE PREVENTION OF DISEASES OF CHILDREN 
279 
increased by Y ounce every week. The milk should be 
increased only if the child is hungry and digesting his 
food well. It should not be increased unless he is hungry, 
nor if he is suffering from indigestion, even though he 
seems hungry. 
At nine months the average child requires 30 ounces 
of milk daily, which should be diluted with 10 ounces of 
water. To this should be added 2 even tablespoonfuls of 
sugar and 2 ounces of lime-water. This should be given 
in five feedings. The sugar added may be milk-sugar or 
if this cannot be obtained cane (granulated) sugar or 
maltose (malt sugar). At first plain water should be 
used to dilute the milk. 
After three months, sometimes earlier, a weak barley- 
water may be used in the place of plain water; it is made 
of level tablespoonful of barley flour to 16 ounces of 
water and cooked for twenty minutes. 
At six months the barley flour may be increased 
to 1}4 even tablespoonfuls cooked in 12 ounces of 
water. 
At nine months the barley flour may be increased to 3 
level tablespoonfuls cooked in 8 ounces of water. The 
milk mixture should be pasteurized from the start and 
1 to 2 tablespoonfuls of orange-juice be given daily 
(see page 366). The author has found that the addition 
of Peptogenic Milk Powder (made by Fairchild and 
Foster) to the milk mixtures advised above is of the 
greatest advantage for children who have weak diges- 
tion—those who have colic and cry frequently and do 
not thrive and gain as they should but have no special 
digestive disorder. 
System in the bringing up of children is of as great 
importance as in any other business of life. There is a 
proper time for everything—a time for nursing or feeding, 280 
THE PREVENTION OF DISEASE 
a time for sleeping (at midday and at night), a time for 
bathing, a time for movement of the bowels, and a time 
for playing. If regularity is observed in enforcing the 
business of these times it will be of great service in 
the development, growth, and health of the child, and the 
mother will have much more time for her other affairs. 
The necessity for the isolation of children, especially 
from other young persons, at times of sickness has been 
noted elsewhere. This is particularly desirable when the 
sick child has fever (as shown by a thermometer) and 
symptoms of a cold or stomach trouble, as many of the 
contagious diseases begin in this way. 
Only recently some 90 cases of measles were reported 
by a state health officer as having originated from one 
man who went about with, as he called it, a bad cold, 
apparently visiting every one he knew and complaining 
of his misfortune, instead of staying at home in bed with 
measles. The diet in infants should always be reduced in 
the case of any acute disease. In breast-fed babies this 
is accomplished by giving the child 4 to 6 tablespoonfuls 
of barley-water in a bottle before each nursing. In 
bottle-fed babies it is a good rule to add an equal quantity 
of water to the ordinary milk mixture given at the time. 
There are no fevers in children which are not benefited 
by sponging of the whole body with tepid water when 
the temperature is high or over 102.5° F. The use of a 
well-lighted, ventilated, and simply furnished room is 
desirable for children with fevers. 
If a child does not develop satisfactorily, is pale, under 
weight, and delicate, especially if he keeps his mouth open 
during play and sleep, one should immediately suspect 
the presence of enlarged tonsils and adenoids. We have 
described their appearance and method of detection in 
another place (see page 207). THE PREVENTION OF DISEASES OF CHILDREN 
281 
At the risk of repetition, it may not be amiss to again 
emphasize the great importance of their removal because 
of the probability of the irreparable damage which they 
may do the body. There is no local trouble which is at 
the same time so common and has the possibility of lead- 
ing to such wide-spread disaster. Enlarged glands in 
the neck practically always are induced by diseased 
tonsils and adenoids, and the glands are found to be 
tuberculous in most cases if they persist for many 
months. They, in turn, are often the forerunners of 
general tuberculosis or consumption. 
Goiter is often brought on by infection through a 
diseased tonsil. 
Colds in the head are favored by adenoid growths, and 
if these are severe, deafness commonly follows and often 
abscess of the ear, which may result in abscess in the bone 
of the skull behind the ear (mastoid abscess), with pos- 
sible complications of brain abscess, permanent disease 
of the ear, facial paralysis, and all sorts of fearful 
possibilities. 
Children who take influenza, diphtheria, measles, and 
scarlet fever will be much more likely to have mild 
attacks and will be freer from complications if they are 
without adenoids or diseases of the tonsils. 
The presence of adenoids and diseased tonsils in a child 
is the most frequent cause of permanent valvular disease 
of the heart, of rheumatic fever, chorea, or St. Vitus’ 
dance, night terrors, and other nervous disorders. Dis- 
orders of the kidneys and lungs, as Bright’s disease and 
pleurisy, are directly caused by diseased tonsils, so that 
it is the unquestionable duty of parents to have enlarged 
and diseased tonsils and adenoid growths removed in 
early childhood, and removed in their entirety, and not, 
as has been the custom until recently, by cutting off the 282 
THE PREVENTION OF DISEASE 
tops of the tonsils and leaving the stumps covered by a 
scar, so imprisoning the germs that they are a greater 
menace to the body than before. It is, therefore, neces- 
sary that an expert do this simple operation, the results 
of which may be of such extraordinary value to the 
patient. School inspection is now the chief means of 
emphasizing the necessity of this operation upon parents, 
since diseased tonsils and adenoids produce dulness and 
backwardness in pupils, besides giving them a stupid 
expression through alteration in the shape of the jaws, 
face, and chest (see page 207). Another duty of the 
parents is the care of the teeth, since here again it has 
recently been discovered that the presence of germs in 
decayed teeth may produce as wide-spread disease as 
occurs in the case of diseased tonsils. The same germs 
may be present, and being absorbed into the blood will 
produce the same effects in distant organs. 
The straightening of the teeth will often greatly 
improve the appearance of the face by widening the jaw, 
and at the same time increase the assimilation of food by 
giving a better grinding surface, in making the teeth 
of the two jaws meet. Then, in widening the upper jaw 
by correcting irregularities in the growth of the second 
teeth, one prevents the occurrence of a high, narrow palate 
which leads to obstructed nasal breathing or, in other 
words, favors mouth-breathing (see pages 38, 207). 
Vaccination.—The baby should be vaccinated against 
small-pox in the early months of life. The younger the 
child, the less severe is the vaccination, providing the sub- 
ject is over one month old. We have discussed the 
matter more fully in another place (see page 94). Then 
the question of sexual hygiene begins with the birth of the 
child, and constant attention should be paid to this 
matter until the completion of adolescence (see page 248). THE PREVENTION OF DISEASES OF CHILDREN 
283 
Children should early receive the Schick test and, if not 
immune to diphtheria, should lie vaccinated with the 
toxin-antitoxin mixture against diphtheria. 
Vaccination for typhoid fever is also essential for 
children who live in a section in which the disease occurs 
or who travel about. 
In many parts of the United States most of the inhabit- 
ants have typhoid fever, but there is no longer any excuse 
for taking this long and dangerous disease (see page 103). 
Again, children living in malarial regions should be given 
quinin regularly as a preventive during the open season, 
so to speak. Quinin is harmless and will avert this 
weakening and serious malady (see page 152). Hook- 
worm disease, so common in many parts of the United 
States, may be prevented by forbidding children to go 
barefoot. Delicate children should be brought up as 
recommended for the children of nervous parents, and the 
same sort of care will be indicated for the offspring of 
tuberculous progenitors (see page 307). 
Children who have long, narrow chests and abdomens, 
who are thin and poorly developed, are inclined to stoop, 
and who have shoulder-blades jutting out behind like 
wings, with bellies large in proportion to the rest of the 
body and most prominent in the lower part—these are 
likely to develop indigestion and nervous troubles and 
should receive special care (see page 340). 
Children should be taught from infancy the necessity 
of individual handkerchiefs, soap, towels, wash-basins, 
clothing, pencils, and eating and drinking utensils. 
Some of the most serious eye troubles, as trachoma or 
granular lids, are usually acquired at school from these 
articles used in common. Even at home, eruptive 
diseases, colds, tonsillitis, diphtheria, tuberculosis, etc., 
may be communicated by the common use of these 284 
THE PREVENTION OF DISEASE 
articles. It is of the utmost importance to instil the habit 
of only using one’s own articles during infancy, so that 
the child will come to only want his own things, and a 
habit will be formed which will endure and become 
second nature. CHAPTER XII 
THE PREVENTION OF DISEASES OF MIDDLE AGE 
Arteriosclerosis, High Blood Pressure, Heart Disease, Bright’s 
Disease of the Kidneys 
In this section I shall chiefly consider diseases of the 
blood-vessels, heart, and kidneys, since these are the 
troubles most to be feared with advancing years. By dis- 
ease of the blood-vessels I refer to thickening of the 
arteries or, as it is called technically, arteriosclerosis. 
ARTERIOSCLEROSIS 
The blood-vessels are not only thickened, their caliber 
thus being lessened, but they degenerate (hardening) and 
break more readily. This process takes place naturally 
in old age, and is, therefore, physiologic. When arterio- 
sclerosis occurs in youth or middle age it is abnormal and 
leads to many other disorders. Thus, thickening of the 
arteries is almost always associated with disease of the 
heart and kidneys, being either the cause or result of 
these maladies. The importance and gravity of thicken- 
ing of the arteries is reflected in that trite medical 
maxim, “a man is as old as his blood-vessels.” 
The most frequent cause of thickening and hardening 
of the arteries is their overuse. As is the case with any 
other organ in the body, overuse leads to overgrowth. 
Thus, strain of the heart nature tries to overcome by 
means of its enlargement. Strain of the arteries nature 
attempts to remedy by increasing their thickness. By 
285 286 
THE PREVENTION OF DISEASE 
strain of the arteries is meant attempts at their overfilling, 
thus augmenting the pressure from within on their walls. 
Overuse of the blood-vessels is commonly seen in three 
classes of persons: In those who customarily undergo 
severe physical exertion; in those frequently exposed to 
nervous excitement, and in those who habitually overeat. 
The site of the overuse of arteries is apt to be that in 
which the thickening of the arteries occurs. Therefore 
in overuse of the muscles the blood-vessels of the limbs 
are most thickened; in those subject to nervous excite- 
ment the vessels of the brain and heart are chiefly 
affected; while in those who overeat, the vessels all over 
the body may be thickened as well as those supplying 
the digestive organs. 
Thickening of the vessels in one part of the body 
may not be nearly so serious a matter as the same 
trouble occuring in another part. In persons who have 
undergone severe manual labor it is common to see hard 
and thickened arteries in the limbs. The arteries may 
contain so much lime that they are almost bony tubes and 
show beautifully in x-ray plates. But a rupture of one 
of these vessels, or its partial obstruction, does not 
threaten life so nearly as the break of an artery of the 
brain (apoplexy), or the obstruction of the artery which 
supplies the heart with blood, when death is immediate. 
Both apoplexy and heart failure are the common results 
of arteriosclerosis in persons of middle or advanced age. 
Overeating is one of the most frequent causes of arterio- 
sclerosis in well-to-do individuals over forty. Overeating 
works harm in various ways. Thus, it leads to overfilling 
of the arteries supplying the abdominal organs, and if 
these become thickened and narrowed there is apt to be 
increased blood-pressure all over the body. This follows 
because the abdominal blood-vessels form a great natural ARTERIOSCLEROSIS 
287 
reservoir, and in their normal condition can hold all the 
blood in the body if they are dilated. Overeating of meat 
is especially injurious, since meat contains substances 
which tend to raise blood-pressure, and the kidneys are 
the organs which chiefly eliminate the end-products of 
meat. 
The kidneys are thus overworked, and disease of the 
kidney is one of the most frequent causes of hardening of 
the arteries. Furthermore, overeating actually increases 
the amount of circulating blood and, therefore, the 
pressure or strain on the arteries. In this explanation 
one may see the common effect of a vicious circle. One 
factor begins to work harm, and in so doing sets another 
agency into action which aggravates the effect of the first. 
The nervous causes of arteriosclerosis are of great 
importance. Every one is familiar with the results of 
mental emotion in causing changes in the blood-vessels, 
as shown by sudden pallor or blushing of the face. In 
one case the heart may be temporarily arrested and 
the blood-vessels of the brain underfilled (fainting); in the 
other example the heart may be beating violently and the 
arteries of the head may be overfull. In either instance 
there is over- or underaction of the blood-vessels and 
heart due to their subordination to the control of the 
nervous system. The frequent and continued stimula- 
tion of the nervous system, with the consequent overuse 
of the heart and blood-vessels, is a prolific cause of 
thickening of the arteries and of heart disease through 
the obstruction to the flow of blood in the thickened 
artery of the heart itself. This explains the reason for 
the common occurrence of such calamities as apoplexy 
and sudden heart failure in persons who are under con- 
stant mental excitement, expectation, hope deferred, 
anxiety and uncertainty dependent upon certain phases 288 
THE PREVENTION OF DISEASE 
of modern life, as the endeavor to keep one’s place in the 
world, or following a speculative business, or arduous 
profession, or indulging in too frequent sexual excitement 
(see page 252) or in other dissipations. 
Nervous strain, then, means heart and vessel strain. 
Heart and vessel strain signify overuse of the heart and 
blood-vessels. This results in overactivity of the heart 
and overfilling of the arteries, with consequent thicken- 
ing of the blood-vessels and enlargement of the heart. 
Then eventuate all kinds of troubles due to insufficient 
and impeded blood-supply to the various organs of the 
body, known to physicians by the word “arteriosclerosis, ” 
and to the public chiefly by the more startling and calam- 
itous results, as seen when a brittle, thickened blood- 
vessel bursts in the brain with unconsciousness and 
paralysis (apoplexy or a stroke of paralysis), or when the 
heart gives out slowly or at once through failure of its 
degenerated muscle or obstruction in its own arteries. 
Obesity puts an extra strain on the heart, as the 
requirements are greater in moving about and supplying 
with blood a heavy body. 
This strain is felt particularly in the artery which sup- 
plies the heart with blood. Its consequent thickening 
and the impairment of the circulation leads to weakness 
and irregularity of the heart and the fearful heart-pains 
(angina pectoris) occurring in middle and advanced age. 
The same results may be occasioned by arteriosclerosis 
of the vessels of the heart from other cause. Certain 
chemical substances favor the production of arterio- 
sclerosis. The abuse of alcohol (the cause of 25 per cent, 
of cases of arteriosclerosis—Edwards), tobacco, tea, and 
coffee may be included under this head, while the poisons 
generated by the germs of typhoid fever, syphilis, and 
tuberculosis are recognized as fertile causes of arterio- ARTERIOSCLEROSIS 
289 
sclerosis in persons who have suffered from these diseases. 
Workers in lead and the subjects of gout and diabetes 
are also more liable to disease of the arteries. Chronic 
constipation may induce hardening of the arteries through 
poisons resulting from the stagnation of the intestinal 
contents and their putrefaction. The presence of colon 
bacilli (normally inhabiting the intestines) in unusual 
numbers may be the cause of intestinal putrefaction, as 
shown by flatulence, distention, and foul-smelling bowel 
discharges. The treatment consists in total avoidance 
of meat, fish, and fowl and the substitution of a vegetable 
and fruit diet, reinforced by a liberal use of butter, cream, 
eggs, and milk. 
In addition, several glasses of buttermilk should be 
taken daily, and any existing constipation must be over- 
come. Enemata once in five days are useful. If any 
form of local inflammation is present, as chronic appen- 
dicitis or gall-bladder trouble, it must be cured, as it 
affords a local nest for the breeding of the colon bacilli. 
Chronic intestinal putrefaction is of great importance, 
since the absorption of the poisons generated by the colon 
germs may lead not only to high blood-pressure, harden- 
ing of the arteries, but even to chronic Bright’s disease of 
the kidneys. Heredity is a most important factor in the 
production of early degeneration of the blood-vessels. 
If one inherits poor material in the structure of the 
arteries, they will not stand the wear and tear attendant 
on the vicissitudes of a long life in this vale of tears. 
The more correct and cheerful view of the matter is that 
so characteristically put by Sir William Osier when, after 
stating that whole families show the tendency to early 
arteriosclerosis through bad material in their vessels, he 
adds, "more commonly the arteriosclerosis results from 
the bad use of good vessels. ” 290 
THE PREVENTION OF DISEASE 
Diseases of the kidneys, as we have already noted, is a 
prolific cause of thickening of the arteries and the 
highest blood-pressures are found in such conditions. 
This brings us to the relations of thickening of the arteries 
and kidney disease. In general arterial thickening the 
kidney vessels and the kidney may be involved, while in 
chronic kidney trouble (Bright's disease) there is always 
secondary thickening of the arteries. Bright’s disease 
is, therefore, either the cause or effect of arteriosclerosis. 
Bright’s disease is the cause because much of the kidney 
tissue is obliterated and the blood-pressure must be higher 
than usual in order that more blood may be forced 
through the small amount of remaining kidney tissue, 
and by this means the kidneys may remove a sufficient 
amount of waste matter from the blood. It is nature’s 
method of compensation, but precisely how nature 
accomplishes it is still a debated subject. But we do 
know that the arteries are thickened and weakened, and 
that the heart becomes enlarged in most all cases of 
chronic Bright’s disease of the kidneys. 
It may appear strange to the layman that thickening 
of the arteries means weakening of them. Thickened 
arteries are also degenerated arteries, poor in quality, 
smaller in caliber, and do not supply the proper amount 
of blood, and are moreover, likely to break. So the 
enlarged heart after a time becomes a weakened, dilated 
heart, or fails through lack of a proper blood-supply 
owing to the thickened arteries in the heart itself. 
Blood-pressure is the pressure of the blood upon the 
arteries. The circulation may be likened to an apparatus 
consisting of a pump (the heart) forcing a fluid (the 
blood) through a system of elastic tubing (the arteries). 
The blood must be under a certain amount of pressure to 
be forced through the finer vessels (capillaries) which are ARTERIOSCLEROSIS 
291 
of chief importance in bathing all the tissues with blood 
for their upbuilding and removal of waste. A constant, 
high blood-pressure is one of the most common causes of 
thickening of the arteries, as we explained in the beginning. 
We have also seen, as a further result, that disease of the 
heart and kidneys follows, the artery of the heart being 
Fig. 6.—Technic of sphygmomanometry with thq Stanton instru- 
ment. Blood-pressure apparatus attached to arm. On squeezing the 
smaller bulb the cuff about the arm is inflated and air-pressure in 
chamber above mercury is increased, forcing the mercury up the 
graduated tube. At the moment the pressure about the arm is so 
great as to stop pulse at the wrist the point at the upper level of the 
mercury is read off the tube. This indicates the amount of pressure 
required to shut off the pulse, which is the same above the mercury as 
about the arm. 
itself diseased, narrowed, or the heart being strained by 
pumping blood through the thickened vessels. But 
thickening of the vessels is not always accompanied by 
high blood-pressure, unless disease of the abdominal ves- 292 
THE PREVENTION OF DISEASE 
sels is present (see above) or the kidney or heart becomes 
involved. Combined, the three morbid conditions of 
enlarged and degenerated heart, of disordered and 
degenerated kidneys, and hardened blood-vessels consti- 
tute one of the most common diseases of late middle age 
which shorten life. It is called cardio-vascular-renal 
disease, in other words, heart-vessel-kidney disease. 
Fig. 7.—Rogers’ sphygmomanometer. Another form of blood- 
pressure apparatus in which the air-pressure is indicated by a hand 
on a dial as in an aneroid barometer. More convenient but less accur- 
ate (Morrow). 
In high blood-pressure we look, therefore, for arterial, 
heart, or kidney disease, alone or in combination. There 
are many cases, however, in which no disease of the heart 
or kidney can be detected in patients with high blood- 
pressure (Essential hypertension) and these may be most 
benefited by proper treatment. It should be added that 
the highest blood-pressures are seen in head injuries and 
disease where there is pressure on the brain. 
The estimation of blood-pressure has become an impor- 
tant aid to diagnosis in recent years, as by its means we 
have an accurate method of determining the tension of the 
artery, while the older method of guessing by feeling the 
pulse has been shown most ridiculously unreliable. In HEART DISEASE 
293 
the popular mind the real import of blood-pressure per se 
is probably unduly exaggerated. A recent English writer 
on America thinks we are given to fads about our physical 
ailments, and states that some years ago, during a visit, 
everybody was talking about his or her appendix, but 
now it is their blood-pressure, and many persons with 
whom she came in contact had their own instruments and 
took their own blood-pressures several times a day. 
Blood-pressure is actually obtained in practice by blow- 
ing up a wide, hollow, rubber cuff, which wholly encircles 
the arm above the elbow, until it compresses the arteries 
so that the pulse is obliterated in the wrist. The interior 
of the hollow cuff is connected either with a column of mer- 
cury or with an aneroid barometer, so that in either case 
the observer (with his fingers on the pulse in the wrist of 
the patient) notes the height of the column of mercury, 
or the position of the hand on the dial, at the moment 
that the pulse in the wrist is arrested by the pressure of 
the cuff on the arm. The normal blood-pressure varies 
between the figures 120 and 140. These are merely 
figures representing the height to which the column of 
mercury ascends (measured in millimeters), as found by 
practice in the use of the instrument in vast numbers of 
healthy individuals. 
HEART DISEASE 
There are four common causes of heart disease. Two of 
there we have just considered; that is, disease of the 
blood-vessels and kidneys. We have found disease of 
these organs commonly associated. 
The most frequent cause of valvular and other diseases 
of the heart in young persons, and more often in young 
women, is acute rheumatism. 294 
THE PREVENTION OF DISEASE 
This form of heart disease follows attacks of tonsillitis 
and frequently rheumatic fever, and may be associated 
with St. Vitus’ dance. All three troubles are due to infec- 
tion by a special germ originating in inflammation of the 
tonsils, and all may be prevented by removal of the ton- 
sils (see page 258). The fourth cause of heart disease 
is syphilis, the heart trouble occurring more usually, 
in middle-aged men and seldom susceptible of cure. 
The heart is weakened, dilated, and diseased (usually 
temporarily) in any of the acute germ disorders, espe- 
cially so by diphtheria, grip, and pneumonia. 
This result follows the action of the germs, or poisons 
formed by the germs of these maladies. A cure is usually 
possible by means of absolute rest, the patient remaining 
flat on his back in bed until the doctor finds that it is 
safe for the patient to sit up. This is particularly true of 
old persons, and sudden deaths following grip in the aged 
occur simply because the patients get on their feet too 
soon. 
Any disease causing obstruction to free circulation of 
blood in the lungs may produce disease of the heart from 
its overstrain. All the blood in the body is first pumped 
from the heart through the lungs, where it is supplied 
with oxygen, before it returns to the heart for distri- 
bution to the rest of the body. Disease, as tuberculosis, 
which obstructs the blood-vessels in the lungs will, 
of course, greatly increase the resistance in the lungs 
to blood forced through them by the heart. 
BRIGHT’S DISEASE 
Chronic inflammation of the kidneys, commonly 
called Bright’s disease, is, as we have seen, often part 
and parcel of disease of the blood-vessels. In younger PREVENTION OF ARTERIOSCLEROSIS 
295 
persons it is caused by the poisons of acute germ diseases, 
particularly scarlet fever, and that produced in some 
cases (toxemia) of pregnancy. 
The same germs responsible for tonsillitis, rheumatism, 
and heart disease may induce disease of the kidney as 
well. The remedy is simple (see page 258). Some of 
the same chemical poisons mentioned as favoring arterio- 
sclerosis may lead to inflammation of the kidneys. 
Alcohol, ether, chloroform, and other drugs are included 
in this group. 
It is possible that poisons generated in the course of 
chronic constipation may be a factor in the production of 
Bright’s disease, as in arteriosclerosis. Exposure to cold 
is an exciting cause of kidney trouble because the blood 
leaves the surface and tends to produce congestion in the 
kidneys. 
With the exception of special individual causes, noted 
in relation to disease of the heart and kidneys, the con- 
sideration of prevention of disease of the vessels, heart, 
and kidneys will be treated under one head, as many of 
the causes are common to all three diseases. 
PREVENTION 
It is probable that no book advice looking toward the 
prevention of the diseases of middle age would be so valu- 
able as the advice to consult a physician. This sounds 
banal, but the author refers to a custom which should be 
generally established, whereby every person should re- 
ceive a thorough annual physical examination, especially 
after the age of forty. The establishment of state health 
officers for the purpose of keeping people well, rather than 
trying to patch them up when sick, is more or less in use 
in Europe, and is sure to be extended as time goes on. 296 
THE PREVENTION OF DISEASE 
Some of the large life insurance companies in this 
country are examining their policy holders without 
charge at stated intervals as a matter of economy. 
. It is not at all uncommon for a person, conscientiously 
presenting himself as a good risk for life insurance 
examination, to find that he is the subject of Bright’s 
disease, heart trouble, arteriosclerosis, or diabetes, much 
to his surprise and distress. 
But knowledge of the existence of a serious disease, 
after the first alarm passes, is of greatest value in the 
early stages when much may be done to mitigate the 
symptoms and to prolong the life of the patient. In 
fact, though the sound of Bright’s disease and other 
well-known serious maladies strikes terror to the heart 
of the subject when he hears such a verdict officially 
announced, yet the name itself does not mean much. 
The outlook in any individual case depends upon many 
factors. It is recognized that persons with well-marked 
cases of Bright’s disease may live for twenty years or 
more in comparative health, and individuals with 
diabetes often attain a comfortable old age if they can 
properly care for themselves. 
Modern methods of diagnosis are so much more deli- 
cate and precise than formerly that it is possible to detect 
disease in its early stages long before such a diagnosis 
could have been made, even a few years ago. The dis- 
covery of the blood-pressure instrument, for example, has 
been of the greatest importance in enabling doctors to 
warn their patients against the dangers of arteriosclerosis 
and its consequent brain, heart, and kidney troubles. 
The prevention of hardening of the arteries or, in other 
words, the attainment of old age cannot be consummated 
by any new or mysterious means. “A quiet, well- 
regulated life” is the chief desideratum. PREVENTION OF ARTERIOSCLEROSIS 
297 
Quiet, perhaps the most difficult of attainment, ranks 
of first import in the prevention of arteriosclerosis. This 
means abstention from hurry and worry, from anxiety 
and nervous tension, from overwork and overexcitement. 
The effects of nervous influences upon the blood-vessels 
and heart are shown so graphically by the blood-pressure 
apparatus that he who runs may read. The blood- 
pressure in an impressionable woman rose from 130 to 
180 after receiving some bad news. It fell a like amount 
in the case of a criminal given a reprieve from death at 
the last moment. A rise of 40 is recorded in the person 
of a foreigner who thought he was to have his leg ampu- 
tated simply because he was taken into an operating- 
room for removal of a surgical dressing. A patient of 
the writer’s, having a high blood-pressure, was taken into 
an operating-room to have some stitches removed after 
a capital operation, and became excited to such a degree 
that his blood-pressure was raised suddenly to the point 
that a blood-vessel broke in his brain. He became at 
once unconscious from the pressure of the blood-clot 
on his brain (apoplexy) and died within a few hours 
after having recovered from the effects of a tremendous 
surgical operation. It must be freely admitted that it is 
much easier to point out the cause than to achieve its 
removal. But “where there’s will there’s a way” 
will apply to many persons. 
The diet is of great importance. Moderation is the 
first concern in persons over forty. Eat less, and particu- 
larly less meat. Meat is largely composed of protein. 
This is the chief nutrient in many of the vegetable foods 
(especially dried peas and beans) and in fish, eggs, cheese, 
and milk, and it acts the same whether it be taken in 
any of these foods. There is probably no difference in 
the action of white meat or dark meat, according to the 298 
THE PREVENTION OF DISEASE 
best authorities. The reasons for middle-aged persons 
not eating much meat are several: First, because meats 
are among the most palatable foods, are very rich in 
protein, and are apt, therefore, to be eaten too largely. 
Second, meats are more prone to cause intestinal putre- 
faction than other foods. Furthermore, there are two 
other bodies in meat not found in fruits or vegetables,1 
milk, cheese, or eggs, and these are the harmful so- 
called extractives which exist in large quantities in meat 
extracts and clear soup; and allied substances known 
as purins which are the cause of gout, and are found in 
greatest amount in liver, brain, kidneys, and pancreas. 
Both these substances favor arteriosclerosis, so that a 
moderate amount of meat once daily is sufficient, and 
when there is any marked change in the vessels or sus- 
picion of kidney trouble, meat should be largely excluded 
from the diet and the protein element in food be taken 
in the form of milk, eggs, and vegetables (excluding 
dried peas and beans or soups made from them). In such 
cases it is best that neither fish nor eggs be taken the 
same day that meat is eaten, nor is it wise to eat eggs 
and fish both on the same day. Two or three glasses 
of milk daily may be drunk to advantage, and a glass 
of milk is equal in nourishment to two slices of bread or 
to two moderate-sized potatoes, or a generous helping of 
meat. In other words, the ideal diet for persons of 
middle age and past should be composed chiefly of fruits, 
vegetables (except dried peas and beans), cereals, eggs, 
and milk, with a minimum of fish or meat. 
In regard to diet in arteriosclerosis, Sir William Osier 
says: “He will often be surprised to find that it is one- 
third or one-fourth of that which he has been taking 
(i. e., ‘the minimum on which he can maintain mental 
1 Except in slight quantities, and as noted below. PREVENTION OF ARTERIOSCLEROSIS 
299 
and bodily vigor’). Pie may take a cup of tea, a boiled 
egg, and a couple of slices of toast for breakfast; a vege- 
table soup and a rice pudding for luncheon; a piece of 
fish, a couple of vegetables, and stewed fruit for dinner, 
with a glass of hot milk at night or a bowl of bread and 
milk. With a diet along these lines an arteriosclerotic 
may successfully pray the prayer of Hezekiah, and get, 
like him, a fifteen year extension.” 
It might be added that some fish are rich in purins to 
quite the extent that they exist in meat, notably salmon 
and halibut. That while most vegetables are poor in 
purins and some are purin-free as cabbage, cauliflower, 
lettuce, etc., there are a few which contain a considerable 
amount, as dried peas and beans, asparagus, and onions. 
Only the dried peas and beans should be excluded 
because of their richness in both protein and purins. 
Onions and asparagus both contain over 90 per cent, of 
water when cooked. 
The quantity of liquid taken is of moment. The fad 
of drinking unlimited amounts of water is far from 
desirable in the middle aged. 
An amount of fluid equal to 8 glasses or 2 quarts, in- 
cluding tea, coffee, milk, and water, is about the proper 
daily quantity. The drinking of too much water overfills 
the blood-vessels and so strains them and the heart. The 
drinking of too little fluid is harmful in that there is an 
insufficient amount to dilute the material eliminated by 
the kidneys and formation of stone in the kidney may 
result. The skin should be kept active by daily warm 
baths taken for five minutes at a temperature of 96° 
to 100° F. Hot baths are too depressing. Warm baths 
may be taken before retiring. They favor sleep and 
at this time are less likely to render the skin susceptible 
to cold and the subject to colds. 300 
THE PREVENTION OF DISEASE 
Cold baths put a good deal of strain on the heart and 
contract the blood-vessels, while warm baths tend to 
dilate the blood-vessels and reduce blood-pressure. 
In persons with high blood-pressure warm baths should 
be taken twice daily. The avoidance of constipation is 
necessary and this may be secured as advised in another 
place (see page 319). Straining during movement of 
the bowels may raise the blood-pressure from 140 to 
180, and apoplexy is not uncommon at such times. Then 
we have noted the fact that poisons derived from delayed 
putrefactive intestinal contents may favor hardening 
of the arteries. 
Sufficient sleep is important, since rest is the best cure 
for arterial strain. The warm bath and a warm glass of 
milk at bedtime may aid in this respect. A hot bath will 
favor insominia because it is apt to lead to increase in the 
blood-supply of the brain. The application of a cold 
sponge or cloth to the head may be useful in persons 
taking even a warm bath before retiring. In elderly 
individuals who have a habit of waking early in the 
morning a nap during the day is advisable. 
Moderate exercise is desirable, as in walking and 
golfing. Severe exercise, such as required by tennis and 
swimming, etc., are undesirable in putting altogether too 
much strain on the arteries and heart. 
Swimming in cold water is particularly dangerous on 
account of the temperature contracting the blood-vessels 
on the surface and the strenuous exertion, both necessi- 
tating very considerable strain on the vessels and heart. 
Alcohol, tea, coffee, and tobacco are all injurious in 
those suffering from arteriosclerosis. Whether these 
amenities should be absolutely abstained from depends 
largely on the individual temperament and will. If their 
extremely moderate use, as a single cup of tea or coffee ora PREVENTION OF ARTERIOSCLEROSIS 
301 
single cigar daily, cannot be enjoyed without the danger 
of exceeding these limits, the only sensible course is to 
abjure them altogether. The avoidance of chilling the 
bodjr is essential, as this leads to marked changes in the 
circulation and strain of the blood-vessels. An even, 
comparatively warm, dry climate is most conducive to 
health, and persons living by necessity in a cold climate 
should take a vacation when possible during the colder 
months and visit a warmer country. The wearing of 
wool underclothing is advisable, and some forms are made 
which do not cause irritation of the skin, which has led 
many persons to discard their use. 
Finally, it may be said that while one should escape the 
wear and tear of life as much as possible to avert the effects 
of the vessel changes, yet it is unwise to give up active 
work and interest in pursuits not necessarily involving 
great responsibility, anxiety, worry, or excitement. The 
surest way to attain a rapid and genuine old age is to 
“retire,” in the popular meaning of the word. The 
leaders in our country today, as Charles W. Eliot and 
Thomas A. Edison, are the grand old men who never 
retire except from the more arduous duties of life. 
There are other common diseases that threaten those in 
middle or advanced life which either cannot be appropri- 
ately considered in a work of this kind or which have 
been discussed in other parts of the book. 
Among the latter may be included cancer (see page 215) 
and prostatic enlargement, so prevalent among old men. 
The end-results of arteriosclerosis—apoplexy, heart 
failure, and Bright’s disease—are avoided to a consider- 
able extent by following the course advised in this 
chapter. Pneumonia is one of the most frequent causes 
of death in old people. One who has lived in towns com- 
posed largely of elderly people, and such are not by any 302 
THE PREVENTION OF DISEASE 
means infrequent in New England, will be impressed with 
the great toll which pneumonia exacts in the later winter 
months, especially February and March. It is probable 
that the enforced confinement to the house (with battened 
double windows) for a long period is the cause of the 
lessened resistance to the germ of pneumonia, and also 
the want of free ventilation permits the accumulation 
of the germs in dwelling rooms, as pneumonia germs are 
very common inhabitants of the nose and throat in 
healthy persons and in those with head-colds. When 
possible an annual migration to a warm climate, where an 
outdoor life may be indulged in, will be the best means of 
prolonging life. 
It seems probable that all the causes of heart, blood- 
vessel, and kidney disease are but predisposing, except 
germs; and we shall find ultimately that the lodgment of 
germs (circulating in the blood) in these organs is the 
direct cause of their disease. Metchnikoff long ago 
affirmed that the changes in the arteries from old age 
were due to germ growth, and recently Rosenow has 
found some forms of Bright’s disease of the kidneys and 
valvular heart disease to be due to direct infection with 
germs from the tonsil, abscessed teeth, or other infections. 
The eradication of chronic infections is therefore of the 
utmost importance in order to attain long life since the 
more common diseases of middle age (except cancer) are 
chiefly of germ origin. The heart-kidney-blood vessel 
disease, which often causes apoplexy, is considered 
an inheritance. Yet in a family where the father 
and four children developed this disease at about 
the same age tonsil infection had been marked in all 
for years. 
Chronic inflammation of the gall bladde'r is a well 
known cause of enlarged and degenerated heart through PREVENTION OF ARTERIOSCLEROSIS 
303 
transference of the germs in the gall bladder and their 
poisons through the blood. 
In middle age pyorrhea and abscessed teeth are more 
often present than not and are by far the most common 
infections to fear at this time and in later life. 
Proper mode of living and avoidance of infections 
constitute the chief means of attaining longevity. CHAPTER XIII 
THE PREVENTION OF NERVOUS AND MENTAL 
DISEASES 
INTRODUCTORY NOTE 
This chapter on the prevention of nervous and mental diseases 
seems to embody in concise and terse form the chief points that 
need emphasis in a discussion of such matters before a popular 
audience. It is admirably written and the details as to the man- 
agement of the nervous child are practical and sensible. 
I like particularly the stress laid upon the sexual life, and upon 
alcohol and syphilis in relation to the prevention of nervous dis- 
orders. 
It is true that from the standpoint of surgery correct diagnosis 
and operation may often relieve what appear to be neurasthenic or 
hysteric symptoms; on the other hand, the tendency seems to be 
to rely too much on surgical procedures, and many operations are 
unfortunately performed which are found to have been unnecessary. 
There are many mental causes of nervous disorders, and the 
physician needs to keep this in view, as well as all possible physical 
features. 
Frederick Peterson. 
Neurasthenia, Hysteria, Paresis, Dementia Praecox, Paranoia, 
Mania, Melancholia 
Under this caption we have in mind chiefly the preven- 
tion of functional nervous disorders, especially neuras- 
thenia or nervous prostration and hysteria, together with 
some of the more common forms of mental disorder. 
Unfortunately, a defective nervous system is more cer- 
tainly inherited than any other bodily abnormality. To 
begin preventive treatment in the case of the offspring of 
neurasthenic, neurotic, or “nervous” parents one should 
304 NERVOUS AND MENTAL DISEASES 
305 
begin some generations back to secure the best results. 
But the outlook is by no means hopeless, or even precari- 
ous, if the children can be reared in a way to counteract 
their probable inherited weakness. If only one parent is 
neurasthenic, the chances of nervous weakness in the 
progeny is correspondingly less, and if the neurasthenia in 
the parent is acquired and has been cured or improved, 
the likelihood of any inherited weakness in the offspring is 
much less than if the parent had inherited the taint. 
Neurasthenia.—In neurasthenia there is a loss of nerv- 
ous force and control. Persons with a tendency to the 
trouble have only a small nervous capital, and when it is 
heavily drawn upon, through emotional or physical strain 
of any kind, they become nervous bankrupts. 
Some nationalities are conspicuously subject to neuras- 
thenia, and these are the Americans, Hebrews, Slavs, 
Poles, and Russians. It is seen commonly in immigrants 
in large cities, living in unhygienic surroundings and 
pressed for the necessities of life under strange social and 
economic conditions. The physical and mental strain is 
too great for their already impoverished physiques. In 
former times the unfit perished, but now, owing to a more 
(and too?) humane environment, many of the unfit 
survive. 
The more common causes of acquired nervous break- 
down are included in sexual agencies; constant mental 
and physical strain, care, and worry; poisons, as alcohol, 
morphin, tobacco; and those generated by germs in 
typhoid fever, malaria, influenza, and syphilis. So 
illustrious and sane an authority as Sir William Osier 
states that sexual factors are of “the first importance” 
in the production of the so-called neuroses or functional 
nervous disorders. Some authors pass them over as 
being but unimportant factors among a host of causes, 306 
THE PREVENTION OF DISEASE 
but the writer has been strongly impressed with the 
sexual origin of a large proportion of cases of nervous 
prostration. Crile’s theory of nervous shock, which is 
largely accepted today, postulates the disturbing effect 
of stimuli on the brain which cannot be transformed into 
action even when the subject is unconscious, as during 
a surgical operation under ether. He finds that constant 
mental strain, or anxiety, or excessive muscular activity 
lead to actual microscopic changes in the brain, liver, 
and other glands which result in nervous exhaustion. 
He finds that when the stimulus to the brain can result 
in normal activity, as when an animal is hurt and escapes, 
the harm does not occur, but when the stimuli may not 
be turned into the normal paths of expression, then 
damages ensues. Thus, stimulation of the sexual organs 
lead to nervous impulses which must be constantly 
repressed under civilized conditions, but the result may 
be grave injury to the nervous system. The only 
remedy is to avoid undue sexual stimulation until such 
a time as the sexual functions are normally active and 
productive in marriage. Sexual excitement in marriage 
engagements results so commonly in neurasthenia that 
this form has been given a special name. The emotions 
are not so commonly and strongly influenced by any other 
agency as by the sexual passions. To quote Osier again: 
“Cherchez la femme is a safe rule in investigating a neu- 
rotic case.” The reader is referred to the section on 
Sexual Hygiene for more detailed consideration of this 
subject. 
The treatment for the prevention of nervous disorders 
in the susceptible offspring of neurotic (pertaining to the 
nerves) parents should begin at birth, but as it is just the 
sort of treatment that is most beneficial for any child, 
there is every reason for enforcing it. NERVOUS AND MENTAL DISEASES 
307 
The infant should have proper discipline from the 
start, and not be fondled, held, or nursed every time it 
shows restlessness or cries. As the mother is often neu- 
rotic, it is important to have a kind, matter-of-fact, firm 
nurse who is not given to sentimental, romantic, or 
religious tendencies. Children should be reared in the 
country if possible. The matters of proper food at 
regular hours, abundance of sleep, fresh air, and daily 
bathing are of importance. 
Avoidance of all means tending to indulge or literally 
“spoil” the child is, of course, essential. When the child 
becomes sulky or stormy because his wants are not sup- 
plied, it is wise to ignore him for a time and show such 
apparent sorrow at his behavior that the child will himself 
repent and then be in a suitable mood to receive proper 
correction. The sense of duty, obedience, unselfishness, 
selfdenial, and responsibility should be inculcated at an 
early age. Any tendency to brood over fancied slights 
inflicted by others should be combated emphatically. 
Association with other children in school and play is 
essential, more particularly in the case of the “only 
child.” Competitive games, walking, riding, swimming, 
rowing, tennis, bicycling (with companions) are all 
desirable. 
Games requiring fierce competition in the presence of 
audiences are, however, very undesirable in leading to 
great mental and physical strain. School should not be 
begun before the seventh year, and it is a great question 
what sort of school is best. The public schools are good 
in their democracy and competition, but represent a low 
standard; the private schools give more individual atten- 
tion and are on a higher level, while the small private 
school or tutor afford the greatest amount of individual 
attention to the pupil and represent the highest standard 308 
THE PREVENTION OF DISEASE 
of instruction. Preparatory schools in the country offer 
by far the best environment for youth in question, in 
affording competition, a high standard of instruction, 
and a large degree of individual attention from the masters 
in the matter of teaching, morals, manners, physical 
training, and sports. Discipline, self-confidence, modesty, 
a sense of responsibility, good manners, health, and 
character are obtained at such schools as Rugby, Eton, 
and Harrow, in England, and at Groton, St. Mark’s, 
St. Paul, Exeter, etc., in the United States. Being 
situated in the country, the pupils are not subjected 
to the unhealthy attractions of the city, and give their 
time to study and sport outdoors, and receive a much 
more wholesome diet and training than at home. Our 
state universities are mostly located in country towns, 
and offer to a considerable degree the same environment 
as the large private preparatory schools, but to co-educa- 
tional feature is extremely objectionable. It is during 
the period of puberty (twelve to seventeen) that special 
instruction should be given both boys and girls concern- 
ing their developing sexual functions (see pages 234, 
240) to avoid the formation of false ideas and bad habits. 
At most of the best preparatory schools the pupils have 
such instruction given in the proper manner by a 
physician. 
That school should be selected which subordinates 
book knowledge to the moral and physical training, and 
this is the tendency of the great English public schools. 
The choosing of the proper kind of a career is of 
moment. It should be one as free as may be from 
unusual strain and worry and, preferably, not largely 
sedentary. Relaxation in regular outdoor sport is 
essential; also eight to ten hours’ sleep. Indulgence in 
alcohol is particularly undesirable in nervous persons, NERVOUS AND MENTAL DISEASES 
309 
because there is an unusual longing for it at times to 
supply temporary strength in bridging over a period of 
strain. 
The temptation to repeat the remedy is too great to 
allow of its use. Excess in coffee, tea, or tobacco is 
especially prejudicial to the nerves. The same may be 
said of sexual excess. The long engagement is to be 
tabooed, and a simple wedding and wholesome honey- 
moon in the country (and not a tiresome journey) are 
indicated (see page 234). In the case of the woman, rest, 
quiet, and freedom from anxiety are peculiarly necessary 
during menstruation, pregnancy, and following child- 
birth. Early consultation with a physician in suspected 
pregnancy will often give relief and a feeling of security. 
Prevention of neurasthenia in the adult is usually only 
attempted after an attack has been experienced. Treat- 
ment of local troubles will often relieve the general 
neurasthenia, and in no case is a thorough physical 
examination from head to foot more essential to discover 
a local trouble masquerading as nervous prostration. 
Nervous prostration, to those who have never experi- 
enced it, often seems an inexcusable and incomprehensi- 
ble mental state which could be prevented by exercise of 
will power and common sense. It is as real a condition 
as a toothache to the patient, and his will power is so 
weakened that trying to exert it is much like trying to 
lift himself by his own boot-straps. 
There is a loss of self-reliance, and little everyday tasks 
and responsibilities become overwhelming burdens. The 
patient neglects his business, procrastinates, and often 
shuns society. The nervous system has no resistance 
and is peculiarly susceptible to every influence or irrita- 
tion. Women are often emotional, cry and throw 
themselves about, and have suicidal ideas. There is 310 
THE PREVENTION OF DISEASE 
usually mental depression. A feeling of pressure or 
constriction in the back of the head or neck, and some- 
times in other parts of the head, is the most common 
symptom. The patient easily tires and sometimes is so 
exhausted as to be unable to walk. Special fears are 
characteristic, as fear of being alone, of being in a crowd 
or open place, of being in the cars, of lightning, etc. The 
memory is poor. Sleeplessness is the rule. Pains may 
occur in almost any organ and part of the body and 
simulate organic disease, and this is why a thorough 
physical examination is required to surely determine 
that the neurasthenia is not secondary to some local 
trouble. Correction of local sources of irritation, as 
stated above, may wholly cure neurasthenia, especially if 
it is of the acquired and not of the inherited variety. 
Local disease of the sexual organs in man is a most fre- 
quent cause, as has been already noted and emphasized. 
Since abdominal surgery has made the diagnosis of 
abdominal troubles often possible in disease formerly 
subject to guesswork, it has been found that many of the 
so-called cases of nervous dyspepsia were, in reality, 
due to ulcer of the stomach, chronic appendicitis, etc. 
On the other hand, many persons with neurasthenia 
have been subjected to much surgery for suppositious 
organic diseases which never existed except in the 
mind of more or less ignorant or mercenary operators. 
The leading surgeons are always on their guard against 
falling into such errors. 
The prevention of neurasthenia means practically 
proper living. Cabot regards four elements as essential 
to proper living, and has recently written a book (“What 
Men Live By”) in which he amplifies his ideas on the 
practical application of these—work, play, love, and 
worship. All are necessary in proper proportion for NERVOUS AND MENTAL DISEASES 
311 
preserving the normal moral, mental, and physical state 
we denote as “mens sana in corpore sano,” a healthy 
mind in a healthy body. The older methods of treat- 
ment of neurasthenia included largely the Weir-Mitchell 
rest cure, in which the patient remained in bed for three 
to six weeks in a sanatorium away from home, in the 
hands of a doctor and nurse, and was stuffed with food, 
given massage and electricity, and kept away from cares 
and worries. This treatment no man would stand, and 
it is usually inadvisable except in women who are much 
emaciated and who suffer from malnutrition. The more 
modern method is that by which the patient is gradually 
directed into a normal manner of living by finding some 
sort of work which will interest him or her, so that 
it will not be drudgery, and combining this with a proper 
amount of recreation. Such treatment sounds very 
simple, but it requires all the tact and wisdom of an 
experienced physician to guide a neurasthenic person 
back to health, and there will be required many mental 
boosts from the doctor and many relapses on the part 
of the patient before the end is secured. This re-educa- 
tion is best accomplished when the patient can put 
himself in the hands of the physician specializing in this 
matter, and having all the facilities of a sanatorium in 
the country, with its various outdoor and indoor arrange- 
ments for work and play. Modern society is responsible 
for much neurasthenia, especially among women, owing 
to the unhealthy life which results from excitement, 
late hours, the use of alcohol, and lack of restful occupa- 
tion. The “coming out” of the young woman is 
attended by so much gaiety and late hours that only the 
unusually strong female can stand the ordeal, and 
when this is combined with a prolonged round of enter- 
tainments prior to marriage and its attendant demands 312 
THE PREVENTION OF DISEASE 
for extra exertion and excitement, the whole culminating 
in a final burst of social pyrotechnics at the wedding, we 
have all the ingredients for producing a beautiful case of 
nervous exhaustion at the worst possible time. 
Insanity may be defined as the sudden or gradual 
development in a person of more or less permanent 
peculiarities in thought, feeling, and action. This 
definition indicates a decided change in the normal 
character of the person, whatever that may have been. 
Unfortunately, heredity is here a more unquestionable 
and paramount cause than in the case of any other 
disease. In asylums it has been found that the history 
of mental trouble can be traced in the forebears of half 
the inmates, and it is estimated that from 50 to 70 per 
cent, of cases of mental trouble owe their origin to 
inherited mental defects. The brain development of 
the child is imperfect owing to the defective germ 
material from the parents (egg of the mother, sperm cell 
of the father). Observers have noted diminution in 
the number, together with imperfect development and 
irregularity, of the brain cells in mental defectives. 
Such conditions are also produced by the influence of 
alcohol on the parents at the time of conception of the 
child, or bad health of the mother while she is carrying 
the child, or diseases of the subject in childhood, such as 
convulsions, scarlet fever, influenza, and meningitis. 
The care and surroundings of the child and method of its 
unbringing as to diet, food, habits, work, play, diseases, 
schooling, and home life have naturally an important 
bearing in favoring or hindering the advent of mental 
breakdowns. If the conditions are bad they may be 
sufficient in themselves to cause insanity, and with an 
added inherited taint, would be pretty certain to do so. NERVOUS AND MENTAL DISEASES 
313 
Many immigrants become insane probably from their 
unfavorable environment alone. 
Causes of Insanity.—Bad habits are the cause of 
’about one-quarter of all cases of insanity, and these 
include the abuse of alcohol, morphin, cocain, and self- 
abuse, but the chief of these is alcohol. Alcohol, in the 
report of the Massachusetts Commission of 1910 on the 
reason for the increase of criminal and mental defectives, 
was found the essential cause—“ Indeed it is the belief 
of this commission, based upon long personal observation, 
that the abuse of alcohol directly and indirectly does more 
to fill our prisons, insane hospitals, institutions for the 
feeble minded, and alms-houses than all other causes 
combined. We are unable to formulate any recom- 
mendations as to legislation which we believe would 
materially modify this deplorable condition. It is 
probable that long-continued education of the young 
as to the mental, moral, physical and economic results of 
the abuse of alcohol will be the mose effective method of 
dealing with the subject.” 
It is hard for persons living in refined and comfortable 
circumstances to realize the full meaning of this opinion, 
but if one actually sees the innumerable cases or delirium 
tremens which enter large city hospitals every day of the 
year, and follows then into the courts and thence into the 
asylums (those who do not stop at the morgue), its true 
impressiveness becomes very poignant. During holiday 
seasons, as about Christmas and New Years, the number 
of such cases is sickening and appalling. 
Alcohol is the cause of 20 per cent, of all cases of in- 
sanity according to a well-known alienist. 
Another fruitful but preventable cause of insanity is 
syphilis, which we have stated elsewhere (see page 234) 
is practically the sole cause of locomotor ataxia and pare- 314 
THE PREVENTION OF DISEASE 
sis (or general paralysis of the insane, or softening of the 
brain). Paresis occurs in middle life and terminates in 
death in three to five years. About 14 per cent, of the 
inmates of New York State hospitals have this disease, 
and there are probably about 10,000 deaths in the United 
States annually from this cause, if the same rate prevails 
as in New York State. Locomotor ataxia is syphilis of 
the spinal cord. Paresis is syphilis of the brain. 
Certain epochs are favorable for the development of 
insanity. In women the age of puberty (twelve to four- 
teen), pregnancy and childbirth, and the period of change 
of life (forty-five to fifty-five) are danger periods; while in 
men middle life (thirty-five to fifty) is the more frequent 
age at which insanity appears. 
Forms of Insanity.—During youth one of the com- 
monest forms of insanity, known as 'precocious dementia 
(dementia praecox), begins. This is seen especially in 
those with hereditary tendencies to mental or nervous 
disease or in the progeny of alcoholic forebears. Suf- 
ferers from this form of mental impairment are long lived 
and accumulate in institutions, so that they comprise 
about 40 per cent, of the inmates. The forming of proper 
mental habits is to a considerable extent possible, and 
may avert-such types of precocious mental breakdown. 
One must not permit worries, cares, anxieties, and desires 
to become obsessions by brooding over them, but use will 
and self-control in banishing them by directing the 
thoughts into other channels, by work, by interest in 
others, and by confessing one’s troubles to a sympathetic 
friend which will often clear the mental atmosphere and 
aid in establishing mental equilibrium. Then, again, 
oversensitiveness to fancied slights and offense may lead 
in the susceptible to the actual delusions of the insane that 
the subject is being persecuted by imaginary persons, or 315 
NERVOUS AND MENTAL DISEASES 
the constant mental warfare with the obsessing thoughts 
or desires may result in perversions of the senses so that 
the patient hears imaginary voices or sees imaginary ob- 
jects (hallucinations). 
While the intellect, will, and memory are so impaired 
in dementia that the patient’s mental condition is patent 
to all, yet in another less common form of insanity, 
paranoia, the subject may show no mental deterioration. 
These are the persons who commit crimes, while their 
apparent mental acuteness deceives juries, and they 
escape commitment to institutions for the criminal 
insane notwithstanding the absolute certainty as to 
diagnosis in the opinion of unbiased experts. The latter 
are rarely called in such cases, however. One notable 
example is that of a paranoiac who murdered a leading 
professional man of this country and, constantly trying 
to escape incarceration for years, has recently succeeded 
—owing to the influence of money. In every community 
there are lamentable instances of miscarriage of justice 
in the case of criminal paranoiacs. They are frequent 
litigants and difficult to convict. The paranoiac imagines 
he is being persecuted and deprived of his property, 
business, or professional rights, or that one is alienating 
the affections of his wife or fiancee. It is for this 
reason that he is dangerous and is apt to make sudden 
murderous assaults upon his fancied enemies. Paranoiacs 
are often able to attened to their business, talk quietly 
and well upon current topics, and thus commonly delude 
the casual observer. They are, however, born with a 
defective nervous anatomy and show faulty develop- 
ment and peculiarities in childhood, and though bright 
in school, are self-conceited, suspicious, and morbid. 
Later the paranoiac discovers that he is an exalted 
character—of noble birth, a prophet, or Christ. In 316 
THE PREVENTION OF DISEASE 
killing prominent persons the paranoiac believes himself 
a public benefactor. Being impressionable, paranoiacs 
are ready tools for anarchists and unprincipled men. 
There is a large class of cases comprising the type of 
manic-depressive insanity. This is peculiarly an inherit- 
ance which curses many families. In the form of mania 
the patient may be noisy, restless, and violent, destroying 
furniture. But often in this phase he is onty in an excited 
and pleasurable state of mind. He thinks he is rich and 
gives money away in an absurd fashion, talks constantly, 
makes friends without discrimination, and sleeps poorly. 
In the depressive form, or melancholia, there is the opposite 
condition. Here the patient may sit motionless and 
brooding in gloom and despondency. He imagines he is 
worthless or has committed the unpardonable crime; or 
there may be signs of deep distress, restlessness, the 
subject moving back and forth and wringing his hands and 
moaning. The tendency to suicide is common. Some- 
times periods of exaltation alternate with those of depress 
ion after an intervening period of normality (circular 
insanity). Victims of the manic-depressive insanity 
tend to recover in a variable time—from weeks to a year 
or so. Finally, there is the senile dementia, in which 
degenerative changes occur in the brain cells and 
narrowing of the blood-vessels in the brain as a part of 
old age. 
Treatment of Insanity.—The laity have extraordinary 
ideas about the insane. They think that they may be 
argued out of delusions, depression, etc. It is useless to 
argue and combat imaginary fixed ideas or delusions, 
and may cause the patient to become violent. In a 
general way the insane should be treated like anybody 
else, so far as is compatible with safety regarding them- 
selves and others. Individuals who show great depres- NERVOUS AND MENTAL DISEASES 
317 
sion should, however, be carefully watched to prevent 
them from committing suicide, and those laboring under 
the delusion that they are being persecuted or wronged 
should be put under restraint lest they become guilty of 
homicide. 
The sanatorium or hospital is the only place for persons 
with disordered minds, as the chances of recovery are 
much better away from their ordinary environment, 
and they are.thus protected from doing violence to them- 
selves or others. 
There are probably 250,000 insane people in the 
United States today, and, including the feeble-minded, 
epileptics, and mental defectives, there are some 750,000 
patients afflicted with mental defects and disease who 
should be in institutions in this country (Mullan). A 
large percentage of these cases might be prevented if the 
various causes enumerated were removed and if proper 
living and mental and physical training were taught and 
practiced. Heredity being the most potent cause of 
insanity the logical means to prevent it is sterilization of 
the mentally defective. Segregation is not possible, 
except in about 25 per cent, of defectives, because the law 
does not deprive a person of liberty unless dangerous 
to others. Vasectomy in the male, or removal of part of 
the vessels leading from the testicles, and salipingect- 
omy, or the same operation on the .tubes leading from the 
ovaries in the female, are simple, sure and safe operations, 
do not interfere with sexual intercourse and only deprive 
the individual of the power to reproduce. Laws have 
been passed in some states legalizing sterilization of 
mental defectives. These operations should be univer- 
sally performed under the supervisor of properly appoint- 
ed boards. Only in this way can increase in idiots, 
imbeciles and the insane be stopped. 318 
THE PREVENTION OF DISEASE 
There is great interest in this subject at present, and 
State societies for mental hygiene are being established to 
protect the mental health of the public, to study and 
spread abroad knowledge of the causes, prevention, and 
treatment of mental disorders, and to better the con- 
ditions of the mentally defective. We have made a 
similar brief attempt in the foregoing pages in reference 
to individual prevention of mental diseases. CHAPTER XIV 
THE PREVENTION OF DISEASES OF DIGESTION 
Constipation, Ulcer, Gastritis, Gall-stones, Appendicitis, Stone in 
the Kidney, Nervous Indigestion, Visceroptosis 
CONSTIPATION 
Constipation is the most common and radical diges- 
tive disorder. It is impossible to say precisely how much 
harm may be accomplished by habitual constipation, but 
a large part of known diseases has been attributed by 
authorities to it. We do know positively that mental 
depression, physical weakness and loss of energy, head- 
ache, foul tongue, taste, and breath are often immediate 
results of constipation. Also that inflammation of the 
bowels, diarrhea, and piles result from long-continued 
stagnation of the bowel contents. 
Many of the common abdominal disease, as gall- 
stones, appendicitis, etc., are thought to originate in 
chronic constipation by leading medical authorities, while 
from constant absorption of poisons due to bacterial 
growth or putrefaction of delayed intestinal contents all 
kinds of constitutional diseases may arise. The chronic 
joint troubles known as chronic rheumatism or rheu- 
matic gout, and even hardening of arteries and premature 
old age, are commonly believed by noted physicians to be 
caused by chronic constipation. It is an unfortunate 
fact that we are continually taking one-sided views of all 
sorts of matters, so that each specialist, medical or other- 
wise, in apt to exaggerate his own specialty and attribute 
to it all possible effects, to the exculsion of all others. 
319 320 
THE PREVENTION OF DISEASE 
In chronic constipation it is the colon or large intestine 
which is at fault, and the taking of buttermilk has been 
much in vogue, with the idea, originated by Metchnikoff, 
that its sour-milk germs (lactobacilli) would the 
germs in the bowels which were thought to bring about 
the changes in old age. Osier thus characterizes the fad, 
which is now waning, as follows, “Captivated by the 
theories of Metchnikoff, we have been for some years on 
the crest of a colonic wave, and intestinal toxemia 
(poisoning) has been held responsible for many of the 
worst of the ills that flesh is heir to, more particularly 
arteriosclerosis and old age. The seniles and preseniles of 
two continents have been taking sour milk and lacto- 
bacillary compounds, to the great benefit of the manufac- 
turing chemists. But the fad is passing, not, as I hope, 
to be replaced by one even more serious, in which opera- 
tion is advised for every case of intestinal stasis 
(stagnation).” 
Without going into further discussion as to the possi- 
bilities of remote harm from constipation, it seems 
reasonable to believe that there is no other disorder which 
is so generally preventable and at the same time so 
common and so likely to be prevocative of serious local 
and remote diseases. By constipation is meant retention 
of the intestinal contents. This may be due either to 
infrequent action of the bowels or to insufficient action; 
that is, the bowels may move daily, but not sufficiently, 
so that material may remain for months in the intestines 
while a part of the contents is passing through or around 
that left behind. The natural action occurs owing to the 
contractions and secretions of the bowels. 
In constipation one or both are deficient. The con- 
tractions may fail for lack of the stimulus of sufficient 
coarse residue and too good digestion, or sometimes from CONSTIPATION 
321 
too much residue in overeating. In many cases too little 
water is taken. Constipation is growing more common 
because of the increase of sedentary lives in cities, and 
because we eat too little coarse food, such as is still 
used by the peasantry of many countries. 
The constipating foods are the digestible foods which 
leave little residue in the bowels. Thus, meat, fish, and 
eggs are notably constipating. Among other causes of 
constipation is failure in attending to nature’s needs at a 
regular time each day. The school girl is too hurried or 
modest to make her wants known; the businessman is too 
busy to attend to such a trifling matter as nature’s most 
imperative requirement, he must catch a train or perform 
some other important act. Persons may be so interested 
in reading while in the closet that the bowels become 
insensitive. 
Frequently the taking of powerful pills establishes con- 
stipation as a habit, because the intestines come to rely 
on unnatural stimulation. 
In the milder forms of constipation simple measures 
may remedy the trouble. Thus, drinking a glass of hot 
or cold water containing a pinch of salt on rising and at 
bedtime, taking exercise on horseback (“the outside of a 
horse is the best thing for the inside of a man”), in tennis, 
swimming, baseball, golf, and eating stewed or raw fruit 
at each meal may be sufficient. Cooked fruit is more 
digestible, as apple-sauce, baked apples, stewed prunes. 
An attempt should be made at a regular hour each day, 
and no alarm need be felt if for two or three days there 
is no bowel movement after beginning treatment. 
Proper diet will cure most cases of constipation. This 
treatment depends upon the fact that certain articles of 
food tend to overcome constipation in different ways. 
Fruits and some vegetables contain cathartic principles, 322 
THE PREVENTION OF DISEASE 
and other vegetables act chiefly because they leave a 
coarse residue to stimulate the bowels. Among the 
fruits and vegetables containing cathartic principles may 
be included oranges, grapefruit, apples, grapes, peaches, 
pears, prunes, melons, tomatoes, cucumbers, onions, beets, 
carrots, potatoes, and spinach; while turnips and squash, 
Brussel sprouts, string beans, green peas, and oyster 
plant stimulate the bowels by their residue. In addition, 
acids are laxative, so that pickles, vinegar, and acid 
fruits and buttermilk act through their acidity. Oils, 
as in salad, lubricate the contents of the bowels and are 
laxative, together with butter, cream, and bacon. Coarse 
bread containing the hulls of grain is perhaps the most 
effective laxative in stimulating the coats of the bowels. 
If a person can eat six slices of rye, whole wheat, gra- 
ham, or “brown” bread daily, that in itself is often 
sufficient to cure constipation. 
The constipating articles of food include milk, eggs, 
cheese, meat, fish, tea (tannin), cocoa, chocolate, red 
wine, macaroni, spaghetti, etc. It is not possible to 
eliminate these wholly from the diet, but they should be 
eaten in moderation, while there should be a corres- 
ponding increase in the amount of coarse bread, fruit, 
and vegetables. Sweets are also laxative. 
We may give a sample diet list as follows. It is not 
intended that a person should eat every article included 
under each meal, but he can vary his diet according to the 
dishes recommended. 
On rising, a glass of cold or hot water, according to 
preference, containing a pinch of salt. 
Breakfast 
Oatmeal with syrup or cream and sugar, one or two 
slices of graham, rye, wheat bread, corn bread, or Boston CONSTIPATION 
323 
brown bread. Cracked wheat, hominy grits, or graham 
meal may be used in place of oatmeal. 
Fruit raw or cooked, or marmalade, or honey. Eggs 
with bacon or omelet with apple-sauce (which is excel- 
lent). Coffee, cream, and sugar. 
Luncheon 
Fish, as mackerel, salmon, halibut, herring, or sardines. 
One of the coarse breads, as at breakfast, or gingerbread. 
Two green vegetables or salad. Jam or marmalade, 
Fruit, as stewed apples, figs, or apricots, etc. Cider, 
lemonade, or weak Oolong tea with cream and sugar, 
or a glass or two of buttermilk. 
Dinner 
Thick or thin vegetable soups. Green vegetables and 
potatoes, fish or meat, and salad and pickles. Two slices 
of coarse bread. Desserts of fruit or puddings of coarse 
meals, as Indian meal, or fruit puddings, as apple Char- 
lotte, brown Betty, etc. 
At bedtime a glass of buttermilk, or figs, seedless 
raisins, or stewed prunes. 
The only objection to this diet is that some persons are 
unable to take it because the coarse food gives them 
flatulence and pain and the acid fruits occasion heart- 
burn. Then, again, if an individual is traveling or not 
living at home it may be impossible for him to obtain 
such a diet. In these cases the patient should take a diet 
as near that described as he can secure or digest, and, in 
addition, one of the remedies which I am about to recom- 
mend. Heartburn from acid may be relieved by Hus- 
band’s magnesia, cooking soda, or a few soda-mints. 324 
THE PREVENTION OF DISEASE 
While there is a well-founded popular prejudice 
against the taking of physics for habitual constipation, in 
the case of powerful drugs in pills, there is no reason 
why the active laxative principles of vegetables should 
be more harmful than the eating of the vegetables 
themselves. 
This is particularly true with certain drugs which act 
more to tone up the muscular coat of the bowel in atonic 
(lack of tone) conditions than to irritate the bowels. 
Such drugs may be rightly looked upon in the light of 
intestinal tonics, and they may be used daily for years 
without increasing the dose, and often prove effective in 
smaller dose as time goes on. Such a drug is cascara 
sagrada, and the writer has found the aromatic fluid- 
extract of cascara sagrada, made by Sharpe and Dohme, 
the most reliable preparation. The dose is half a teas- 
poonful to a teaspoonful taken at bedtime without water. 
Some persons find that a teaspoonful, more or less, of one 
of the common salts (Epsom, Glaubers, or artificial 
Carlsbad) each morning on rising in a whole glass of hot or 
cold water is effective. 
Or one of the laxative mineral waters, as Hunyadi 
Janos, Pluto, Congress, Hathorn, Crab, Carlsbad, 
Apenta, Marienbad, Kissingen, Friedrichshall, Condal, 
Caribana, Rakoczy, etc., taken on rising in hot water, 
may be used. 
It often happens that the effect of these salines wears 
away in time and one must change to another. Recently 
the use of agar-agar, obtained from Japanese seaweed, 
has become deservedly popular. It may be used daily 
without harm, as it passes through the bowel unchanged, 
but in so doing absorbs much water and swells and acts 
by increasing the bulk of the intestinal contents. The 
writer has found that a mixture of agar-agar, cut in half- CONSTIPATION 
325 
inch lengths and mixed with an equal amount of sterilized 
bran (sold by grocers in tight packages for laxative use), 
is most efficient when taken with a little salt and mixed 
with hot water like mush or more like a bran-mash for 
equine use. Two or more tablespoonfuls of each are thus 
eaten at bedtime or breakfast with sugar. The mix- 
ture usually causes large normal, formed movements. 
In many persons the agar-agar alone will suffice taken 
in the same way. It may be bought by the pound of 
druggists, but the finely powdered is useless. Another 
serviceable and harmless remedy is paraffin oil or albo- 
lene. This is sold by druggists, flavored for internal use, 
under the name aromatic paraffin oil. It is practically a 
liquid vaselin and passes through the bowels unchanged, 
lubricating their contents and thus facilitating expulsion 
of them. 
A tablespoonful, more or less, may be taken thrice 
daily, or a third to half a glass at night. In some persons 
the remedy causes griping and discomfort, but in many it 
forms an excellent remedy. I have found either cascara 
sagrada, one of the salines, or agar-agar and bran the 
most valuable remedies in habitual constipation. 
Sulphur is useful in teaspoonful doses at night in cases 
of hemorrhoids or piles. Senna is a serviceable drug in 
chronic constipation. From ten to twenty-five leaves 
may be chewed at night, or two tablespoonfuls of senna 
leaves are stewed with three dozen prunes, the leaves 
being temporarily placed in a cheese-cloth bag in the 
stew as it is not necessary to eat them. 
The dose is ten prunes with their juice one or twice 
daily, and after a time the prunes may be taken alone by 
gradually cutting out the senna. The fig syrup given 
children for occasional constipation is, in reality, a 
preparation of senna. 326 
THE PREVENTION OF DISEASE 
Thin olive oil (grown on the hills) may be of worth in 
combating chronic constipation, but, like albolene, causes 
griping and flatulence in some individuals. 
A tablespoonful should be taken thrice daily after 
meals, but it is wise to begin with but a teaspoonful 
and gradually increase the dose. 
Exercise is useful in almost all cases of habitual con- 
stipation, and it not infrequently happens that persons 
find constipation a thing of the past during vacation 
while camping and exercising outdoors. 
Outdoor exercise and games are always best for young 
persons, as baseball, tennis, swimming, and horseback 
riding. In middle-aged and elderly individuals golf is 
one of the most satisfactory exercises, since violent 
exertion is contraindicated. Walking, though good for 
the general health, is rarely effective in overcoming 
habitual constipation. 
Gymnasium and home exercises are of advantage when 
outdoor exercise or games are not practical. I have 
taken the following exercises from Gant’s work on “ Con- 
stipation.” They should be practiced, one after the 
other, for fifteen to thirty minutes once daily, “and, as 
a rule, if persisted in they become a habit, and the 
exercise is looked forward to with pleasure (Bettmann) 
(1) Stand erect with the legs together, and slowly bend 
the upper part of the body to the left as far as possible, 
and then to the right in the same manner. 
(2) Assume the erect posture and rotate or turn the 
body upon the hip. 
(3) Take the same position, and, without bending the 
knees, slowly lean forward and downward until the tips 
of the fingers touch the floor in front of the toes. 
(4) Lie flat upon a firm bed, table, or couch, with the 
legs held rigidly together, and raise the body until it is CONSTIPATION 
327 
at a right angle with the limbs. (This is accomplished 
more readily if the toes are held down by some object.) 
(5) Reverse the procedure by raising the stiffened 
limbs until they are at a right angle to the body. 
(6) While still in the recumbent posture bend the knees 
and draw the thighs closely up against the abdomen. 
(7) Kneel upon the floor and, with the hips fixed, bend 
the body in succession forward, backward, from side to 
side, and then rotate as far as possible first in one direction 
and then in the other. 
(8) Standing erect, with hands crossed behind or ex- 
tended fully above the head, quickly change to the 
squatting posture. 
(9) Lean slantingly forward and repeatedly draw up the 
abdominal muscles, and then relax, taking deep breaths, 
to exercise the diaphragm and the abdominal muscles. 
(10) Extend both arms at a right angle with the body 
so as to form a straight horizontal line, and, with the 
arms in this position walk six or eight times, on tiptoes, 
from one end of the room to the other. 
Abdominal massage may be beneficial in some cases, 
but as a rule is not at all necessary, except in much weak- 
ened women, when it should be given for fifteen minutes 
before rising; or a cannon ball, weighing about 5 pounds, 
may be rolled about over the abdomen for this time. 
Injections of water into the rectum generally lose their 
effect in time and are awkward to take. The fad of 
injecting large amounts of water high up in the bowel does 
harm if persisted in for anytime, as the bowels become too 
distended. 
Constipation is more common in brunettes. It may 
itself be caused by many diseases in which there is general 
lack of tone. It is exceedingly common in anemia and 
may, indeed, lead to impoverishment of the blood, so we 328 
THE PREVENTION OF DISEASE 
have a vicious circle established. Then constipation may 
be due to faulty development of the intestines which is 
common in certain builds (see page 336), so that kinking 
and partial obstruction occurs at certain points in the 
course of the large intestine. For this reason no case of 
chronic constipation of any intensity should be allowed 
to continue without recourse to examination with the 
z-rays, by which means the whole course of the large 
bowel may be readily outlined and the rate of progress of 
the intestinal contents precisely estimated. In chronic 
constipation, in which there is almost obstruction, the 
patient’s skin is very sallow and bronzed, he becomes 
greatly emaciated and suffers from weakness, headache, 
and digestive disturbances. 
There is a form of constipation (spasmodic) common in 
nervous women in which the bowel becomes contracted 
into a cord, and this leads to attacks of colic; the move- 
ments are ribbon-like or ocur as small, hard, round 
pellets, and at times much mucus or slime may be passed 
from the bowels. 
These cases require special treatment by a physician. 
Constipation in Children.—The feeding of pasteurized, 
or boiled milk to infants may lead to constipation but 
in any case, it is safer to give cooked milk, rather than 
run the risks of using milk which may cause a fatal 
diarrhea and many other dangerous diseases. Consti- 
pation is infinitely preferable to diarrhea in an infant. 
Increasing the amount of cream in infants’ milk may 
cure constipation, but this again is usually undesirable 
in babies fed on cows’ milk, because an increase of fat to 
an extent greater than 3.5 per cent, is apt to produce 
digestive disturbance. 
The addition of malted milk or Mellin’s food (in place 
of milk-sugar when it is used) to the bottled milk will CONSTIPATION 
329 
often act as a sufficient laxative to combat constipation in 
infants; or 3 teaspoonfuls of malted milk in 4 ounces of 
water may be given once daily in place of a milk feed- 
ing. Then orange-juice, 2 tablespoonfuls twice daily, is 
generally beneficial for infants and will tend to overcome 
costiveness. A small piece of soap, molded in conical 
shape, may be introduced into the bowel at the regular 
time at which the movement should occur, or a glycerin 
suppository, made for infants use, may be introduced 
once daily. 
The best internal remedy for constipation is Phillips 
milk of magnesia, in the dose of 1 to 2 teaspoonfuls, 
added to one of the bottles of milk once daily. When 
olive oil works satisfactorily it may be given in place of 
the magnesia, since it is a food as well as medicine. From 
to 2 teaspoonfuls of oil may be given after the bottle 
feeding three times daily. 
It is best to begin with not more than teaspoonful. 
Instead of oil, Squibb’s liquid vaselin may be employed 
in a dose of from 2 teaspoonfuls to 2 tablespoonfuls once 
daily. It will be remembered that vaselin is not 
absorbed by the patient and is absolutely harmless, and 
passes through the bowels unchanged, acting simply as 
a lubricant. But it is by no means always effective 
and may cause nausea and gas, and discomfort in the 
bowels. 
Older children running about may receive to advan- 
tage 2 or 3 teaspoonfuls of olive oil, after eating, thrice 
daily, and should be given orange-juice, baked apple or 
stewed rhubarb, prunes, or other fruit daily. Fifteen to 
thirty drops of the aromatic fluidextract of cascara 
sagrada, recommended above, may be appropriately 
given to children each night for chronic constipation not 
relieved by the additions to diet. 330 
THE PREVENTION OF DISEASE 
DIGESTIVE DISEASES 
Digestive diseases are commonly divided into func- 
tional and organic. In the functional forms there are 
no changes in the anatomy of the stomach or intestines, 
whereas in the organic forms there are marked changes, 
as in ulcer and cancer of the stomach. Ulcer and cancer 
constitute the serious organic stomach troubles, but 
compose only about 10 per cent, of stomach diseases as a 
whole. The remaining nine-tenths of stomach disorders 
are functional. One-third of these functional disorders is 
due to general diseases, one-third is caused by prolapse 
of the abdominal organs associated with inherited 
nervous weakness, and classified roughly as nervous 
dyspepsia, while the remaining stomach troubles (20 
per cent, of the whole) are secondary (reflex) and the 
result of diseases in other parts of the abdomen, especially 
gall-stones and chronic appendicitis. In regard to 
cancer of the stomach all we can do in the way of preven- 
tion is to treat ulcer, because we know that a large 
percentage of cancers of the stomach are due to the 
chronic irritation of ulcers (Mayo clinic). On the other 
hand, the proportion of ulcers, considered as a whole, 
which eventuate in cancers is, of course, very slight. 
Ulcer of the Stomach.—While ulcer should be cured to 
relieve patients of suffering, the danger of cancer should 
be an added incentive to obtain a complete cure. 
At the Mayo clinic the proportion of cures following 
operation for ulcer (stomach and duodenum) after two 
years and longer in 600 cases is reported to be 67 per cent., 
and 96 per cent, of the patients were benefited. 
Whether medical or surgical treatment of stomach or 
duodenal ulcer is preferable has been one of the com- 
monest subjects of controversy in the medical pro- 
fession for years. Now, owing to the remarkably DIGESTIVE DISEASES 
331 
successful results of the Sippy method of cure in 
ulcer of the stomach and duodenum, it is found that 
medical treatment is indicated in most ulcers, unless 
there is a probability of beginning cancer (occurring only 
in stomach ulcers, not in duodenal), of perforation, or 
of marked obstruction of the outlet of the stomach. 
Bevan of Chicago states that 90 per cent, of ulcers may 
be best treated medically, and this from one of our 
leading surgeons. Each case must be treated on its 
own merits after careful examination by an expert. 
In the prevention of ulcer of the stomach we are handi- 
capped because there is as yet no exact knowledge as to 
the cause of ulcer. 
The probability of infection, that is, the lodging of 
germs in the walls of the stomach or bowel, is now com- 
monly accepted (see page 194). 
The occurrence of anemia in young women and possibly 
the secretion of excessive acid in the stomach have a pre- 
disposing influence. These conditions should be com- 
bated. The recent remarkable experiments of Rosenow 
appear to point to ulcer as being at times caused by the 
germs found in tonsillitis (streptococci), abscessed 
teeth, pyorrhea and other focal infections in the body 
and therefore the removal of these may be the means of 
preventing gastric and duodenal ulcer and, indirectly, 
cancer of the stomach. Infected tonsils, teeth and other 
focal infections, it is the rule always to eradicate in the 
treatment of gall bladder inflammation, or ulcer of the 
stomach or duodenum. This may even cure mild cases 
of gall bladder trouble and prevent recurrence of medi- 
cally treated ulcer of stomach. The Sippy treatment 
of ulcer consists in giving enough alkali to wholly neutral- 
ize the acid in the stomach, and feeding milk and cream 
often and in small amounts. 332 
THE PREVENTION OF DISEASE 
Gastritis.—The only other organic disease of the stom- 
ach of importance (besides ulcer and cancer) is gastritis. 
Any case of chronic stomach indigestion was called gas- 
tritis when the author began his medical studies. Now 
we know that only the most careful examination of the 
stomach contents will suffice for a diagnosis, and the 
symptoms may be latent, so that many cases of gastritis 
exist without symptoms. It is far less common than 
formerly thought and taught, and in most cases it is 
secondary to other diseases, as ulcer and cancer of the 
stomach or diseases of the lungs, kidneys, etc. 
Acute gastritis with vomiting is common owing to 
errors in diet, the swallowing of food poisons and chemi- 
cals, as alcohol and poisons. Primary chronic gastritis 
is most frequently due to abuse of alcohol, tea, coffee, and 
chewing tobacco, the taking of large amounts of ice- 
water, or to overeating or the eating of indigestible 
food. It occurs in some persons without any apparent 
cause. 
Gall-stones, Appendicitis, Stone in the Kidney.—So 
much for the organic diseases of the stomach. Now we 
will consider the three groups of functional stomach indi- 
gestion. The first group, in which the stomach is upset 
by diseases in other parts of the abdomen, as gall-stones, 
chronic appendicitis, stone in the kidney, and diseases of 
the female sexual organs, we may dismiss in a few words 
because of our ignorance of the cause of some of these dis- 
eases. There is no exact knowledge pertaining to the 
origin of appendicitis and gall-stones. At present it 
appears that infections in the mouth and throat may at 
times be a source of these diseases (see page 194), but the 
causation of gall-stones and appendicitis is still a debat- 
able question. Little positive can be yet affirmed. Being 
unaware of the cause of many ailments, we naturally DIGESTIVE DISEASES 
333 
are unable to prevent them; but as 90 per cent, of 
stomach troubles are caused by diseases situated outside 
of the stomach, it logically follows that the most careful 
examination of the whole body should be made in every 
case of chronic indigestion. 
This statement is true not only because of the abdom- 
inal disorders which lead to disturbance of the stomach, 
but also because of the general diseases which sometimes 
give rise to stomach trouble as their chief symptom. The 
writer can think of patients coming to him for stomach 
trouble caused by eye-strain, by a tumor of the womb, by 
consumption, by Bright’s disease, by stone in the kidney, 
by tuberculosis, peritonitis, etc., etc. Many of the stom- 
ach specialists have in the past failed to make correct 
diagnoses because of lack of knowledge now possessed by 
the abdominal surgeon, and because they relied overmuch 
on the findings of analysis of the stomach contents, and 
took too narrow a view of the matter. One skilled and 
broadly experienced in general medical work and who 
keeps in touch with the surgeon is the best physician for 
the diagnosis of stomach troubles. There are certain 
broad differences in the history of digestive diseases 
that may enable one to classify cases by the history 
alone. Thus chronic digestive troubles occur in attacks 
with intervals of freedom intervening. In nervous or 
functional disorders of the stomach the symptoms change 
in different attacks, one time heart burn, another press- 
ure, discomfort, bloating over stomach, or nausea, etc. 
In organic disease, as ulcer of the stomach and duodenum 
chronic appendicitis, and gall-bladder trouble, the sym- 
ptoms are similar in different attacks but, as time goes 
on the attacks tend to increase in severity and frequency. 
In cancer of the stomach the patient is usually of middle 
age and the stomach trouble is continuous and prog- 334 
THE PREVENTION OF DISEASE 
Profile in normal person. 
Profile in visceroptosis. 
Visceroptosis. 
Fig. 8. 
Normal. DIGESTIVE DISEASES 
335 
ressive with marked weakness, less of weight and appetite. 
Of course there are many exceptions to these general state- 
ments but long experience has proven their practical value 
to be considerable. 
A leading Southern surgeon tells the story of a patient 
with stomach trouble who went from doctor to doctor 
without relief, and as no organic disease was discovered, 
the general verdict was nervous dyspepsia. At last the 
patient had a perfectly plain attack of appendicitis, his 
appendix was removed, and recovery from his digestive 
symptoms was expected. But before long all the old pain 
and trouble began, and the original diagnosis of nervous 
dyspepsia was again pronounced with added vigor and 
confidence. While going the rounds of the medical 
profession the patient suddenly developed symptoms of 
gall-stones, and these were removed by another surgeon, 
who thought he had at last performed a permanent cure. 
But in a short time the same distress again appeared, and 
then the doctors knew the patient was a “neuro” or nerv- 
ous subject. The patient still persevered with the pro- 
fession, not driven to quackery by his unfortunate 
experiences as so many are, and came to a doctor who 
suggested an x-ray picture of his kidneys. The finding 
of a stone in the kidney was the reward, and on its 
removal the patient made at last a permanent recovery. 
The stone was present during the whole period of the 
patient’s illness, and a thorough and complete examin- 
Fig. 8.—3 shows the long, narrow chest and abdomen and the nar- 
row angle formed by the lower border of the tibs at A, the so-called 
costal angle; 2 shows the flat back as compared with the profile of the 
normal back in 1. The internal organs—large intestine, kidneys, 
liver—lie on this shelf at B, and are not so likely to prolapse as when 
attached to a perpendicular back, as shown in 1. In 4 is shown the 
normal broad chest and broad costal angle at A. The width of this 
angle alone is sufficient to exclude the presence of visceroptosis in most 
cases, as seen in 4 at A. 336 
THE PREVENTION OF DISEASE 
ation of his case had never been made, because it is so 
much easier to use the phrase “nervous,” which throws 
the onus on the patient and makes him feel properly 
humiliated. No diagnosis of chronic stomach trouble is 
complete until not only a general examination of the 
body has been made, including that of the bowel contents 
blood, urine, and expectoration (if there is any), but also 
until plates have been taken with the x-ray of the abdom- 
inal organs, and the movements of the stomach should be 
observed at the time of taking the pictures with the x-ray 
machine. 
All this is essential before pronouncing the case one of 
“nerves. ” 
Nervous Dyspepsia and Visceroptosis.—This brings us 
at last to the subject of nervous dyspepsia. All persons 
may be divided into two classes for this purpose. There 
are the normal, with broad chests and well-developed 
bodies (Fig. 8, 1 and 4), and the others. The second 
class have long narrow chest and bellies. They are 
thin, often stoop, and have projecting shoulder-blades. 
Their bellies are large in proportion to the rest of their 
bodies, and instead of projecting more above the navel, the 
belly is more prominent below the navel. Their backs 
are straight below the shoulder-blades, lacking the proper 
curve in the “small of the back” (Fig. 8, 2). 
A special diagnostic point is the fact of the narrow angle 
to be observed at the upper part of the belly formed by the 
lower border of the ribs. This is of such importance that 
there is an instrument made for determining the angle 
(Fig. 8, 3). In the normal person this angle is broad 
(Fig. 8. 4). In children we find frailness, lack of fat, 
slenderness of muscle, and lack of vigor. In the adult 
there is a falling downward of the abdominal organs, as 
the stomach, large intestine, liver, and kidney. In the DIGESTIVE DISEASES 
337 
child who creeps like a quadruped there is little distur- 
bance, but when it assumes the erect posture digestive 
troubles begin. There are developmental defects in 
these patients. The attachments of the organs are long, 
lax or defective, the back is straight (Fig. 8, 2), and the 
angle or shelf normally present in the upper part of the 
back is absent and the organs sag directly downward. 
The narrow chest (i. e., from side to side) gives less room 
for the organs in the upper part of the belly, as the 
kidneys, liver, and stomach, another reason for down- 
ward displacement of these organs. Persons with these 
various abnormalities of build are said to have viscer- 
optosis or, falling of the viscera. In this class of patients, 
which one can recognize (even when they are dressed) by 
their build and more certainly if one can observe the 
angle of the lower border of the ribs, functional digestive 
disorders are to be expected. 
These are included in the group of nervous dyspepsias. 
There is another division of persons with visceroptosis 
depending upon the fact that they are of normal build, but 
owing to marked relaxation of the abdominal walls the 
organs have sagged downward and become displaced. 
This condition more often follows pregnancy in which 
there is great distention of the abodmen with stretching 
of the walls, followed by sudden relief from pressure and 
muscular flabbiness of the abdominal walls after child- 
birth. 
After a long, debilitating disease, especially typhoid 
fever, the same result may occur. Faulty, stooping 
posture in young persons favors visceroptosis by crowd- 
ing down the abdominal organs. Loss of weight removes 
fat about the abdominal organs and allows them to sag. 
Corsets compressing the upper part of the abdomen 
tends to force down the organs. Constipation loads the 338 
THE PREVENTION OF DISEASE 
bowel with an extra weight of contents which aids its pro- 
lapse. But in most cases the faulty development of the 
supports of the abdominal organs and the build of the 
patient are the primary causes. Indeed, the defective 
build and the defective nervous organization which accom- 
panies it are frequently hereditary. About 1 in every 
4 women has defects in her build and abdominal supports 
which lead to visceroptosis. But not all these per- 
sons become patients. About 1 in every 6 patients com- 
ing to the stomach specialist is suffering from the effects 
of visceroptosis, and the disease is seven times more 
frequent in women than in men (Lockwood). 
The symptoms do not usually appear until early adult 
life, when the effects of stress and strain become evident. 
The sagging of the abdominal organs causes kinks in the 
intestines and so gives rise to constipation. The absence 
of general nervous and muscular vigor favors loss of tone 
in the stomach and the most frequent form of indigestion, 
i. e., atonic (without tone), dyspepsia characterized by a 
feeling of fulness and distention in the stomach, belch- 
ing of gas and heart-burn, loss of appetite, nausea, 
vomiting, etc. 
Patients with visceroptosis exhibit another common 
symptom, although this may be present in any case 
where there is loss of tone in the stomach. If such a one 
lies down on his back on a bed and the abdominal wall is 
suddenly pushed inward over the stomach, a splashing 
sound will be elicited. This may occur in any one immedi- 
iately after drinking, but in persons with loss of tone in 
the walls of the stomach it may be heard at almost any 
time between meals. 
But many persons with visceroptosis do not suffer from 
the sagging organs, and others recover from their symp- 
toms while the state of their abdominal organs remains DIGESTIVE DISEASES 
339 
unchanged. So that it will be seen in any given case one 
cannot certainly say that the faulty position of the ab- 
dominal organs is responsible for the presence of symp- 
toms, but that the symptoms may result from fatigue 
due to a weak nervous system. The same symptoms, as 
constipation and indigestion, may occur in persons free 
from visceroptosis. We can definitely affirm, however, 
that persons born with visceroptosis are pretty sure to be 
thin and nervous, and that to cure them not only must the 
abdominal organs be pushed up into place, but treatment 
for weak nerves must also be pursued. Visceroptosis 
occurs more often in small, poorly nouished females 
(90-100 lbs.), never robust and easily tired. Treatment 
will greatly improve their health but these subjects can, 
never be made over into “husky” individuals. In some 
patients this treatment consists in the wearing of the right 
kind of abdominal belt and rest in bed, accompanied by a 
fattening diet, which accomplishes two ends first, the 
formation of fat within the abdomen, which holds the 
organs up in place, and, second, the rest and forced 
feeding, which is the best method of treating nervous 
weakness. 
We may define visceroptosis, then, as a condition in 
which there are anatomic displacements of the abdominal 
organs combined with a tendency to nervous derange- 
ments, usually inherited, but sometimes acquired. A 
large proportion of such patients are subject to func- 
tional or so-called nervous indigestion. 
It by no means follows that nervous indigestion is 
always due to visceroptosis, however, but any causes 
tending to lower the tone of the nervous system are 
capable of causing nervous dyspepsia. 
Nervous dyspepsia is then brought on by physical or 
mental overwork, dissipation, strain of any kind, as from 340 
THE PREVENTION OF DISEASE 
family troubles (sickness and death), an unhappy love 
affair, or business difficulties, certain debilitating dis- 
eases predisposed to nervous indigestion, as tuberculosis 
or anemia. 
The chief difference between functional and organic 
diseases of the stomach lies in the fact that the patient 
suffers genuine pain in organic disease, whereas in func- 
tional stomach trouble there maybe great discomfort from 
a feeling of fulness, distention, heart-burn, nausea, vomit- 
ing, belching of gas, and bringing up of acid in the throat, 
etc., but not real hard pain at any time. Then another 
important distinction, which has already been made, is 
that the presence of visceroptosis is itself presumptive of 
functional rather than organic disease, since in subjects 
of this habit one expects functional dyspepsia to occur. 
On the other hand, of course, it does not follow that a 
person with visceroptosis may not have organic disease 
of the stomach, but the chances are that any digestive 
disturbance is much more likely to be functional than 
organic in the case of such individuals. 
The prevention of nervous functional dyspepsia should 
begin in infancy in children who have inherited the tend- 
ency, as shown by the build which we have described 
above. In general, the same care should be given them 
as we have already recommended in another place for the 
progeny of nervous parents (see page 304). A full nour- 
ishing diet, with plenty of cream and butter and a 
healthy outdoor life, with sufficient rest and sleep, are 
especially desirable. The clothing should not hang from 
the outer part of the shoulder, but from straps coming 
over the shoulders close to the neck so as not to make the 
shoulders droop. The child should be taught to stand 
and sit erect, as in stooping the abdominal organs are 
pushed downward out of place. If the child cannot DIGESTIVE DISEASES 
341 
be made to stand erect in any other way a brace may 
have to be fitted by a doctor. To assume the proper 
position the endeavor should be made to stand as if one 
were attempting to be as tall as possible without raising 
the heels from the ground. This brings the head up 
and back. The common directions to “throw the 
shoulders back” are not sufficient, and do not cause the 
head to be held erect nor the stomach to be held in, as is 
accomplished by the other position. The drinking 
of large amounts of water between meals is detrimental to 
persons with visceroptosis in favoring sagging of the 
stomach. After any long, weakening illness, as typhoid 
fever, the patient should not be permitted to get up until 
his normal weight has been restored, because otherwise 
the abdominal organs may prolapse from lack of the 
abdominal fat-padding which naturally holds them up in 
place. 
Following childbirth it is always advisable for women 
to wear a proper abdominal belt, as the so-called Storm 
binder, in order that they may not suffer from sagging of 
the stomach and other abdominal organs which is so com- 
mon at this time. When the disease of visceroptosis is 
present in an aggravated form with nervous symptoms, 
emaciation, and digestive disturbances, such as we have 
already enumerated, treatment of the patient while up 
and about is so unsatisfactory that no physician should 
attempt it. In the milder degrees of the trouble a good 
fitting belt may be sufficient, with rest and drinking of a 
pint of cream daily, but in the severe forms only a course 
of a month or six weeks in bed with the rest treatment in a 
sanatorium, followed by the use of a belt, will suffice. 
The question of operation will arise in . cases in which 
there is loss of appetite, vomiting (sometimes of blood), 
emaciation, great apathy, persistent constipation, flatu- 342 
THE PREVENTION OF DISEASE 
lence, muscular and joint pains, and in women, inflamma- 
tion of the breasts. Surgery is generally harmful to 
nervous persons and visceroptosis is usually relieved 
by the means outlined above. One of the chief reasons 
for resort to the surgeon is because the patient and 
physician have tired of each other, according to one 
authority. There should be very good reasons for 
operating, and it should be undertaken only after a 
consultation with conservative men and after a thorough 
trial of medical treatment. Operation for the cure of 
visceroptosis is in disrepute with most of the leading 
surgeons, unless there is sufficient displacement of the 
bowels to produce actual obstruction in them. 
The cases of nervous dyspepsia which are not part of a 
visceroptosis are practically due to the same causes as 
nervous prostration or neurasthenia. The prevention of 
this class of cases is described under Neurasthenia. 
While some of the causes may be removed, such as 
mental and physical overwork, dissipation, sexual abuse 
or excess, yet worry and strain consequent upon love 
affairs, family or business troubles, or poverty are often 
beyond our power to aid. CHAPTER XV 
FOOD POISONING 
INTRODUCTORY NOTE 
There are few fields of household hygiene, household sanitation, 
or household medicine in which sound popular teaching is so im- 
portant as in that which relates to the sanitation of food. 
Right knowledge of this subject is not only clouded by lack of 
information, but obstructed by definite misinformation freely dis- 
pensed by pseudosanitarians, who make this subject their happy 
hunting-ground. It is, therefore, a special pleasure to commend 
to the public so clear and so well-balanced a statement as that 
which follows. 
Milk is very wisely placed in the forefront in discussing the 
dangers from food, and the author’s strong recommendation of 
pasteurization must be heartily endorsed by all familiar with the 
subject. Experience in public health teaches me more and more 
clearly that no raw milk is a safe food and that pasteurization by 
the heating system (140° F. for twenty minutes) should be every- 
where insisted on. This process destroys all disease germs without 
altering the food value of milk, except in one respect. The pecu- 
liar bodies, known as vitamins, which milk contains, are destroyed 
by heating, and infants fed on boiled and pasteurized milk alone 
may suffer from scurvy as a result. The loss of vitamins has no 
significance, however, for adults, and in the case of infants the 
remedy is to give orange-juice (containing vitamins) along with 
the pasteurized milk—not to risk fatal intestinal or other disorders 
by feeding raw milk. 
In general, cookery is one of the most important of sanitary 
arts and makes safe many of our foods which would otherwise be 
dangerous. It must be remembered, however, that any food, 
cooked or uncooked, may be infected by the “carrier in the 
kitchen.” The safeguards against this danger are the cultivation 
of habits, of personal cleanliness, the regular washing of the hands 
343 344 
THE PREVENTION OF DISEASE 
before handling food, and the exclusion (so far as possible) of those 
persons who are suffering from any symptoms of communicable 
disease from the preparation and handling of food for others. 
Charles-Edward Amory Winslow. 
Milk Poisoning, Ptomain Poisoning, Meat, Fish, Fruit, and Vege- 
table Poisoning 
Food poisoning is really a misnomer. What we mean 
when we use these words is poisoning by germs, or their 
toxins, contaminating food before or after cooking. 
Food is merely the vehicle for poisoning by germs or 
their toxins. It would be as sensible to-speak of bread 
poisoning if someone had placed arsenic in bread. 
Occasionally pure food does cause poisoning in persons 
abnormally hypersensitive (See Asthma), and rarely 
accidental or intentional poisoning of food does happen, 
or poisoning may occur through unwise adulteration of 
food with chemical agents. 
MILK POISONING 
Poisoning occurs more often from milk.than from any 
other food. It is a wonderfully good food for germs as 
well as for man, and the germs not only live in it, but 
multiply tremendously. There are always germs in milk, 
even in boiled milk, unless it has been boiled several days 
in succession. Raw milk contains to the teaspoonful from 
5000 bacteria, in the very cleanest and most expensive 
certified milk, to 5,000,000 or more bacteria in market 
milk. In fact, the poorer samples of market milk contain 
more germs than sewage. The germs are derived from 
the surface of the cow, from the air and dust, from flies, 
from the inside of the cow’s udder, from the inside of the 
bowel (in manure), and from milkers, dairy employees, 
milk utensils, and water. MILK POISONING 
345 
The chief source of infant mortality in the past has 
been through diarrheal disease in summer, due almost 
wholly to the contamination of milk with cow manure 
which contains putrefactive germs from the cow’s bowels. 
It has been estimated that ten tons of manure have been 
sold daily in the milk of our largest city in years gone by. 
Conditions have enormously improved. The infant 
mortality has been reduced one-half or more by the 
enforcement of sanitary conditions and the improvement 
in the milk supply. This was notably so in the case of 
Rochester, N. Y., during Dr. Goler’s regime. The other 
disease most frequently taken from the cow is tuberculo- 
sis. This chiefly affects children, as there is little danger 
to adults in drinking milk, since they are comparatively 
immune to such infection by the time they have reached 
maturity. About 15 per cent, of the deaths from tuber- 
culosis in infants is due to cows’ milk. Another frequent 
danger from milk is infection with the diseases of man. 
Thus, there have been recorded within the past few years 
outbreaks of thousands of cases of scarlet fever, diph- 
theria, typhoid fever, and tonsillitis from drinking milk. 
Among 253 such epidemics (Trask) there were 179 
of typhoid fever, 51 of scarlet fever, and 23 of diphtheria. 
Typhoid fever is contracted from milk more commonly 
than from any other source in New York City today. 
Within five years in Boston there have been some 3000 
cases of typhoid and scarlet fever and diphtheria traced 
to milk alone. 
These diseases are conveyed to milk by the hands, by 
the mouth in tasting milk, by bowel discharges of man 
(sewage) in the water used to wash dairy utensils, and by 
infection of milk in return bottles from homes in which 
disease exists. The particular danger which it seems 
practically impossible to avert is from “carriers”— 346 
THE PREVENTION OF DISEASE 
apparently healthy dairy employees who carry about 
disease germs in their throats (diphtheria, tonsillitis), 
or are passing them continually from their bowels years 
after recovery from typhoid fever. We have alluded in 
another place (see page 259) to the 1911 outbreak of 
tonsillitis or septic sore throat in Boston, consisting of 
1048 cases with 48 deaths, due to infection of milk from 
an apparently healthy employee at a show farm. Then 
there was the typhoid epidemic of several hundred 
cases the same year in New York, originating from a 
healthy farmer who had been discharging typhoid germs 
from his bowels for twenty-six years since his sickness, 
thus contaminating his own milk supply. 
Now, in the cleanest milk it may be impossible to 
eliminate some of these dangers. Manure may be 
usually kept out of it sufficiently to prevent infantile 
diarrheas, but accidents occur. Disease of the cow’s 
udder may appear and pus escape in milk long before the 
most careful supervision detects it. A leading sanitary 
milk expert, Dr. North, figures that a ton of pus, blood, 
and bacteria from diseased udders, together with other 
dirt, might be separated from New York’s weekly milk 
supply. Inflammation of the udder (garget, mastitis) 
is a common trouble in cows. An expert may find 
one or more cases in every considerable herd. The 
germs (streptococci) in milk from an inflamed udder may 
also cause outbreaks of severe sore throat or tonsillitis 
in man just as do the same germs from the human throat 
which accidentally contaminate milk (see above). Cows 
may be taken into herds which are tuberculous before 
the test can show this condition. North estimates the 
existence of 5 per cent, of tuberculous cows in tested 
herds supplying certified milk—20 to 40 per cent, of 
cows have been found tuberculous in famous certified Milk poisoning 
347 
herds (see page 163). Finally, employees infect milk 
unknowingly and so produce thousands of cases of illness. 
All these accidents being possible in the best dairies and 
actually occurring, how can they be stopped? By only 
one measure, and that is, cooking the milk. 
This means boiling, or pasteurizing milk, i. e. heating it to 
145° F. for thirty minutes, followed by rapid cooling. By 
this degree and duration of heating disease germs of all 
kinds are unquestionably destroyed. 
The proportion of germs, other than disease germs, 
which are killed varies, and the more germ-laden the 
milk before heating, the more so is it apt to be after 
pasteurization. 
In other words, but a certain percentage of the miscel- 
laneous germs are killed. Thus, in a sample of milk 
containing 400,000 germs per 34 teaspoonful before pas- 
teurization there were 23,000 after its completion; while 
a sample of milk holding 40,000 germs to the 34 tea- 
spoonful before pasteurization was found to contain 
3000 afterward. But commercial pasteurization is 
uncertain, and through carelessness and break-downs in 
the machinery the product is often unsafe. Moreover, 
outbreaks of disease have occurred from pasteurized milk 
which was infected by handling it during the subsequent 
bottling. The only safe commercially pasteurized milk 
is that bottled at the farm or dairy and then pasteurized 
in the bottle, as is done at the Deerfoot farm in South- 
boro, Mass., and in a few other places. 
But it is perfectly possible to secure a safe milk by 
buying the best to be obtained and pasteurizing it at 
home. I find by boiling water in the outer part of a 
2-quart double boiler, (as much water as it will hold 
with the inner receptacle in place), and then remov- 
ing it from the stove and placing a quart of milk in the 348 
THE PREVENTION OP DISEASE 
covered inner part, that the milk may be brought to 
140° or 145° F. within ten minutes and retained at this 
point for thirty minutes, with the exception of a loss of 2 
degrees during the last five minutes. The milk should 
be kept during this time in a warm place or covered with 
a blanket. 
By the use of a dairy thermometer, sold by druggists, 
any intelligent persons can secure this result, and by 
taking the same quantity of milk and water each day, 
after the proper conditions have been fulfilled, one may 
repeat the process indefinitely without recourse to the 
thermometer. 
The cleanest milk is that most suitable for pasteuriza- 
tion since the heating only destroys a percentage of 
bacteria, and the poisons which the germs produce in 
their growth are not necessarily destroyed by heat, 
although usually they are. 
So that one should buy certified milk if it is within one’s 
means, or the best milk obtainable, and then pasteurize it. 
For pasteurizing milk for babies the Freeman pasteurizer 
is most convenient, as the process is done by simply filling 
the nursing bottles with milk for the twenty-four hours’ 
use, and placing them in boiling water in his machine 
after it has been removed from the stove. It is just as 
important that cream and milk for making butter and 
cheese be pasteurized, as disease germs live in these articles 
for months. This is not, however, generally done in this 
country. 
Ice-cream is a frequent cause of poisoning when it has 
been stored for some time before using. The most enor- 
mous number of germs ever found in (sweet) milk prod- 
ucts exist in ice-cream after it has been kept for some 
time, even at zero temperatures. Over 100,000,000 
bacteria to the teaspoonful is not unusual, as the intense MILK POISONING 
349 
cold does not prevent the multiplication of bacteria (in 
the course of time). The safeguard is to make ice-cream 
from fresh pasteurized cream at home, or to only buy 
it from dealers upon whose word one may place depend- 
ence. The greatest danger lurks in the street and small 
store vendor, who hawk unknown and questionable 
products about among the poor and serve them broad- 
cast in the popular “cones.” Ice-cream, cream-puffs, 
and custards, made from germ-laden milk or cream, are 
capable of producing the most intense digestive distur- 
bances, with vomiting, colic, diarrhea, and even death. 
Considering the opportunities at every soda-water 
fountain, and the fact that fragile children are the 
victims, it is a marvel that the sickness and death result- 
ing are not greater. The Chinese are much more 
advanced than ourselves in some respects, despite our 
boasted civilization, for they drink no uncooked milk 
or water, and thus escape typhoid fever, which is com- 
mon among the Europeans in China. 
The poisoning from eating ice-cream, cheese, cream- 
puffs, frozen puddings, and custards is more often due to 
milk contaminated with the discharges of cows (manure, 
etc.), and sometimes is derived from milk of diseased cows. 
The germs inhabiting the bowels of the cow are those 
chiefly responsible (B. enteritidis, etc.). These organ- 
isms produce poisons or toxins leading to vomiting, colic, 
diarrhea, great prostration, and weakness of the heart. 
If the mjlk were pastuerized in the beginning it is probable 
that the poisons would not be formed. Poisoning from 
ice-cream, cheese, and custard was formerly attributed by 
its discoverer, Dr. Vaughan, to a special chemical sub- 
stance (tyrotoxicon), but it is now recognized that 
various toxins formed by a variety of germs are responsi- 
ble for the' poisoning, and usually not tyrotoxicon. The 350 
THE PREVENTION OF DISEASE 
author confesses that the milk question is a special 
personal hobby upon which he is more or less of an 
authority,1 but the enormous hygienic importance of a 
clean milk supply has become more and more evident 
with the passing of the years and as a result of experience 
and study. 
PTOMAIN POISONING 
Ptomain poisoning is a fashionable term covering, in 
popular usage, symptoms produced by almost any 
unknown germ disease with abdominal symptoms. As a 
matter of fact, it does not even mean food poisoning, 
for food poisoning is germ poisoning and means damage 
done by a great variety of poisons or toxins produced by 
a corresponding variety of germs. 
Ptomains are certain definite chemical bodies (basic 
alkaloidal products) formed in the putrefaction of meat or 
vegetables. Only a few instances are known where food 
poisoning has been due to ptomains, and no statement is 
correct that such has occurred without an elaborate con- 
firmative chemical analysis. Ordinarily the cultivation 
of germs from an offending food will explain the cause of 
poisoning, so that the bacteriologic rather than the chem- 
ical laboratory is the authority in such cases. 
Ptomain poisoning is an unfortunate word, because, 
while it may please the patient to be a victim of such a 
patrician disorder, it permits the doctor to make a 
wrong diagnosis without let or hindrance. In the writer’s 
experience, ptomain poisoning has most often proved to be 
appendicitis, gall-bladder trouble, or obstruction of the 
bowels, and the unnecessary delay has frequently resulted 
1 “The Production and Handling of Clean Milk,” by Ivenelin 
Winslow, M. D., B. A. S., M. D. V., W. R. Jenkins Co., New York, 
third edition. PTOMAIN POISONING 
351 
in the patient’s death, which might have been prevented 
by timely surgery. Ptomain poisoning is a cloak of ignor- 
ance in the doctor’s lexicon, and must be relegated to the 
same category as “grip” and rheumatism, which include 
a host of germ infections capable of being recognized. It 
is somewhat difficult to be certain that illness is due to 
food poisoning. 
The occurrence of a number of cases of vomiting, colic, 
and diarrhea at about the same time in a number of persons 
who have eaten the same food (or of nervous symp- 
toms, as in sausage poisoning, appearing some twenty- 
four to forty-eight hours after eating the food, and 
consisting in dryness of the mouth, disturbed vision, 
drooping eyelids, loss of the voice, difficult swallowing, 
etc.) would be strongly suggestive of food poisoning. 
The character of the food and the attending circum- 
stances, and, above all, the bacteriologic examination of 
the suspected food will positively determine the diagnosis. 
Meat Poisoning.—Four-fifths of all cases of meat 
poisoning are due to eating the flesh of animals suffering 
from one of the germ diseases, more often cows killed 
because of udder disease, blood-poisoning following 
calving, or intestinal diseases, and calves with a form of 
blood-poisoning common during the first few weeks of 
life. 
Unfortunately, the meat is not altered in appearance in 
such cases, nor is cooking by any means a sure preventive 
against poisoning. Even poisoning by meat which has 
decomposed from too long keeping is much more fre- 
quent in the case of animals diseased before slaughter. 
Expert veterinary inspection of the various organs of 
slaughtered animals will detect disease and prevent the 
killing of sick animals for food, which is most apt to occur 
in small towns where meat for local use is not properly 352 
THE PREVENTION OF DISEASE 
inspected. Only about half the animals slaughtered in 
the United States come within the jurisdiction of federal 
inspection of interstate meat industry. Eating meat 
from diseased animals is dangerous. It is especially 
so when eaten raw. For this reason the popular “raw 
beef sandwich” is particularly to be avoided. 
Poisoning from meat which has putrefied from long 
keeping is more common in the warm months and in the 
case of chopped meat or sausage. 
Putrid meat is usually recognized, if not chopped, by 
softness and bad odor, especially about the bones and fat. 
Boiling, roasting, or frying lessens the danger from 
putrefying meat, but does not absolutely prevent it. 
Proper refrigeration in the household, both before and 
after cooking meat, is essential in order to preserve it, 
otherwise it should be eaten fresh. Meat poisoning is 
often reported from the use of soup kept for days in a 
“stock kettle.” This soup is like the medium on which 
germs are grown in laboratories and disease germs will 
multiply enormously in it. It is also advisable to clean 
refrigerators frequently with a hot solution of washing 
soda. Meat poisoning is due to toxins or poisons produced 
by germs which originate in diseased animals, or con- 
taminate the meat after slaughter and grow luxuriantly 
when refrigeration is imperfect. 
It is well known that persons eat game when it is 
“high” with impunity in most cases, but such meat is 
usually “hung” in cold weather. 
Pork, veal, and beef are the source of meat poisoning, 
while mutton and lamb are almost safe, partly be- 
cause these are free from the diseases of bovines. Pork 
causes poisoning because it is imperfectly preserved by 
salt or smoking, and is often eaten insufficiently cooked 
in sausage and other forms. Cold storage of chickens, PTOMAIN POISONING 
353 
turkey, and other fowl is undesirable because their vis- 
cera are not removed. The enormous multiplication of 
germs at zero which occurs after a considerable period is 
exemplified in the case of ice-cream noted above. Num- 
bers of instances of poisoning by cold-storage fowl are 
reported. The government has issued a bulletin on the 
matter, in which it is pointed out that if the internal 
organs were removed before storage, and if the fowl were 
sold frozen and immediately cooked and eaten, such food 
would be very desirable. As a matter of fact, the dealer 
often allows the bird to thaw out to improve its appearance 
before sale. He may then replace the fowl in cold stor- 
age and repeat the process several times if a sale is not 
made. 
Canned meat and canned vegetables prepared by reli- 
able makers are usually wholesome because thoroughly 
cooked, and poisoning has been more frequent in the case 
of home-made products. Usually if the contents are bad 
the ends of the can will bulge, or the can be “blown,” 
and putrid gas will escape when it is opened. Dishonest 
dealers are known to have bought blown cans and to have 
let out the gas and soldered them again. In this case there 
will be two soldered holes in a can, and such should always 
excite suspicion. Canned fish and pork and beans have 
produced reported cases of poisoning. But it is not un- 
usual for the poisoning to follow carelessness in keeping 
the contents of the can too long after opening. Violent 
and fatal poisoning has originated from canned string 
beans, which has a rancid odor when opened. It is 
always wise to cook all canned vegetables again, as the 
cases of poisoning have often been caused by eating the 
product in salad or otherwise without recooking. Of 
course “blown” cans should always be rejected, and 
makers should be required to record the date of canning 354 
THE PREVENTION OF DISEASE 
on each package, as the danger, together with loss of 
flavor, increases with age. 
SAUSAGE POISONING OR BOTULISM 
This is a form of food poisoning caused by the poison 
or toxin of a special germ. Bacillus botulinus. The 
poison is thought to be already formed by the germ in the 
food before it is taken. Botulism may be caused by 
eating raw or imperfectly cooked meats, fruits or vege- 
tables, or imperfectly prepared canned meats, fruits or 
vegetables. Several instances of botulism poisoning 
from ripe olives have been recorded in this country. 
The germ is killed by a temperature ranging from 
140°-158° F. 
The peculiar feature of the poisoning is the length of 
time that may elapse after eating the infected food, from 
12 to 70 hours. 
Vomiting and moderate colic may precede or follow 
the characteristic nervous symptoms, or digestive symp- 
toms may be absent. 
The nervous symptoms occur more often after 2 or 3 
days with a tired feeling and “seeing double, ” that is two 
objects when only one is present. Dizziness, dimness of 
vision, drooping of an eyelid and partial paralysis of 
one side of the face, difficulty of swallowing and articu- 
lation, staggering gait and muscular weakness are 
especially common. 
The death rate is high, varying from 40 to 60 per cent. 
The stomach should be washed out as soon as possible, 
and an ounce of Epsom salts should then be given. 
It may be necessary to feed patients through a tube if 
they are unable to swallow. An antitoxin is made to 
offset the action of the poison. SAUSAGE POISONING OR BOTULISM 
355 
If food which had unusual odor or taste were rejected 
botulism would not often occur. 
Canned food should be cooked again and should never 
be kept after being opened, and should not be eaten 
directly from the can without recooking. Most of 
the poisoning from canned food is due to changes 
occurring in food which is kept a day or two after the 
cans have been opened. With modern methods of 
canning meat, vegetables or fruit the danger of poisoning 
is very remote if the product is eaten at once, and none 
at all if it be recooked. It is safer to also recook home 
canned products before use to avoid poisoning. 
Fish and Shell-fish.—There are certain parts of fish in 
certain countries and at certain seasons which are poison- 
ous, as the roe of the Japanese fugu, the roe of the 
German barbs, and the roe of pike and meat of sturgeon in 
the spawning season. The chief cause of poisoning by 
fish is through disease germs conveyed to fish by the 
handling of fishermen, dealers or cooks before it is cooked. 
Also fish is kept too long, before or after cooking, in hot 
weather. Another cause of poisoning is from diseases 
of fish which are not very well understood. 
Fish should be killed immediately they are caught as 
is required by law in Europe. If they die slowly they 
more rapidly decay. 
It is a good rule that fish or shell-fish should be eaten in 
warm weather within twenty-four hours after they have 
been cooked. I have seen cases of poisoning from boiled 
crab where it was kept for three days or more and then 
served in some new style. This keeping of shell-fish is 
extremely dangerous, as bacteria grow most luxuriantly 
in cooked fish. In the same way poisoning from canned 
salmon or other fish is more often due to keeping the fish 
too long after opening the can. The safest method of 356 
THE PREVENTION OF DISEASE 
using canned fish is to recook it and eat it immediately. 
All fish (not preserved or canned) should be freshly 
killed and have firmness of flesh, pink gills, and bright 
eyes. An unpleasant odor would naturally be sufficient 
to condemn any fish. 
Many persons have idiosyncrasies concerning fish and 
shell-fish, so that an attack of nettle-rash or hives will 
follow their use. Crabs and lobsters should always be 
boiled alive and eaten within twenty-four hours after- 
ward, even if kept on ice, although trouble arises chiefly 
in warm weather and warm climates. When oysters, 
clams, or mussels live in filthy water they become poison- 
ous through infection with germs from the intestinal 
discharges of man and other sources, so that poison- 
ing may be produced when they are eaten. Special 
diseases, as typhoid fever and cholera, are thus con- 
veyed to man by oysters; and mussels under such 
conditions may induce the most fatal form of food 
poisoning known owing to a recognized true ptomain, 
“mytilotoxin. ” 
Such poisoning may not be prevented by thorough 
cooking. There is some suspicion attaching to the 
whole supply of shell fish in the United States owing to the 
contamination of the waters by the sewage of the growing 
population. This applies particularly to the use of raw 
oysters or clams but also to cooked oysters, clams, 
lobsters, shrimps, and crabs, because cooking is not 
absolutely certain to make such food safe but is a great 
safeguard. 
Vegetable and Fruit Poisoning.—Vegetables and fruit 
eaten raw should be protected from contact with manure, 
as strawberries, lettuce, and celery, because food poison- 
ing is chiefly due to a germ (Bacillus enteritidis) found in 
the feces of cattle. Also they should be protected from VEGETABLE AND FRUIT POISONING 
357 
handling by diseased persons or carriers, and from dirt 
and dust when exposed for sale. The danger from eating 
raw vegetables or fruit (except oranges or bananas) 
is so great that in the tropics food is not eaten unless 
cooked to avoid cholera, dysentery, etc. This protection 
is now impossible in food bought in the open market. 
Lettuce should be most thoroughly washed, leaf by leaf 
and celery and strawberries had better be cooked. 
To go into the details of fungi poisoning is hardly 
within the province of this work. Of mushrooms and 
toadstools ten varieties are poisonous, one hundred and 
fifty are edible, and fifty are of doubtful character among 
the one thousand varieties in the United States. 
One should avoid eating mushrooms which are not 
familiar unless supplied from a reliable source. The five 
more common species of edible mushroom in the United 
States are the ordinary field mushroom (Agaricus campes- 
tris), the horse mushroom (A. arvensis), the shaggy mane 
(Coprinus comatus), the fairy-ring (Marasmius oreades), 
and the edible puffball (Lycoperdon cyathiforme). Such 
popular tests concerning the safety of fungi, as their 
odor, taste, properties of blackening silver in cooking, 
etc., are wholly unreliable. If the novice wishes to gather 
mushrooms to eat he should first receive field instruction 
by an expert and not trust wholly to book learning. The 
swallowing of one-sixth of a mushroom has caused death, 
so that this is no matter for trifling (see Bull. No. 15, U. S. 
Dept. Agric., “Some Edible and Poisonous Fungi”). 
Poisoning sometimes occurs from potatoes, surprising 
as this may seem. Potatoes belong to the family 
(Solanacese) of poisonous plants containing belladonna, 
hyoscyamus, and stramonium. However, it is not 
always the poison (solanin) which causes poisoning in 
those eating potatoes, but a variety of toxins produced by 358 
THE PREVENTION OF DISEASE 
a variety of bacteria conveyed to potatoes by handling 
them after cooking. Solanin is found chiefly under the 
skin of potatoes and diminishes to nothing in the center 
of the tuber. It is only present in harmful amounts and 
on rare occasions in sprouting potatoes, in green potatoes 
growing uncovered by earth, and sometimes in young 
potatoes. The sprouts, especially the purple ones, are 
apt to contain more of the poison. Poisoning from 
potatoes is most common in warm weather and has often 
happened in potatoes which have been kept for a day or 
two after boiling and then made into salad. 
The bacteria were probably conveyed to the cooked 
potatoes by persons with unclean hands. While severe 
vomiting, colic, diarrhea, and great weakness have been 
caused by potato poisoning in large numbers of persons, 
there has been no fatal result in 600 recorded cases. To 
prevent poisoning green potatoes and all those badly 
sprouted should be rejected, and other potatoes should 
have all sprouts cut out and the peel widely removed be- 
fore boiling. There have been no cases of solanin 
poisoning from baked potatoes To avoid poisoning from 
cooked potatoes they should not be kept any length of 
time after boiling, and great cleanliness of the hands is 
necessary in handling them, as germs grow and multiply 
enormously on the potato, especially in warm weather, 
hence the reason for potato-salad poisoning. 
A mild poisoning is commoner after eating strawberries 
than any other vegetable food. Indigestion and par- 
ticularly hives or nettle-rash are the more frequent results. 
Strawberries lie on the ground and come in contact with 
animal and sometimes human excrement used for fertil- 
izer. 
They are eaten raw, and it is remarkable that more 
cases of severe poisoning do not occur, as the more com- VEGETABLE AND FRUIT POISONING 
359 
mon forms of food poisoning are due to contamination 
with bacteria from the intestines of animals and man. 
Metchnikoff believes the eating of uncooked straw- 
berries a very dangerous matter, and goes so far as to 
attribute appendicitis to the fruit. Many persons cannot 
eat strawberries unless cooked. CHAPTER XVI 
DEFICIENCY DISEASES AND DISORDERS OF 
NUTRITION 
Beriberi, Scurvy, Rickets, Pellagra, Adolescent Goiter, Obesity, 
Diabetes 
BERIBERI 
Beriberi is a peculiar disease resulting from disorder 
of nutrition owing to the absence of certain unknown ele- 
ments, or vitamins, in the food. 
Vitamins are substances existing in food and essential 
to growth and life. Certain disorders, as rickets and 
scurvy in children, scurvy in adults, softening of the 
bones in pregnant women, pellagra, and beriberi are 
caused by food deficient in these substances. Grains 
when deprived of their germ and outer coating, as wheat, 
rice, barley, and oats, will produce beriberi in many 
birds and animals. Vitamins are also destroyed by 
heat and by drying and pickling. 
In the case of beriberi experience and experiments 
show that a diet of rice, from which the outer coat and 
germ have been removed, is the more common cause. 
This is called white rice or polished rice, and is what we 
ordinarily use. In preparing white rice it is steamed, the 
outer red covering bursts, the grain is dried, the hulls, 
with germ, removed, and the rice is polished in milling. 
Red rice, covered by its natural coats, will not induce 
360 BERIBERI 
361 
beriberi. The most interesting experiments have been 
tried, as in the case of the inmates of the insane asylum 
at Singapore, where formerly half died of beriberi. It 
was found that the disease could be produced or cured 
at will by feeding first polished rice and then unpolished 
rice. 
In India a group of men was given polished white Siam 
rice and developed beriberi in sixty days, while another 
group living under the same condition, but eating only 
unpolished rice, remained free from the disease. But 
when this second group was fed polished white rice beri- 
beri developed within two months. By exchange of 
clothing and contact of the well with the sick it was shown 
that the disease was not infectious or contagious. 
The same results have been obtained in Japan and the 
Philippines. As many as 50,000 cases of beriberi arose 
from the feeding of polished rice to the Japanese during 
the Russian War, but recent knowledge of the cause of the 
disease has enabled the authorities to stamp it out. 
Osier states that “there has been no more remarkable 
triumph of modern hygiene than Takagi’s dietetic 
reforms in the Japanese navy.” Schaumann and others 
went further, and concluded that deficiency in phos- 
phorus, as it occurs in combination in vegetable or animal 
tissue, is the true cause and found that rice which contained 
less than 0.4 of 1 per cent, of phosphorus is likely to 
produce berberi. This is true and upon it depends the 
test to determine the suitability of rice as an exclusive 
article of diet, that it should contain over 0.4 per cent, 
of phosphorus pentoxide to be safe. Of course for the 
person living on the usual varied diet of civilization it 
makes no difference whether rice is polished or not. 
But it has been found that it is not phosphorus but 
another substance containing no phosphorus which 362 
THE PREVENTION OF DISEASE 
prevents beriberi. This was first isolated in crystalline 
form from the polishings, or germs and hulls of rice, 
by Funk in 1911 and called by him vitamin (vita, life) 
because essential to life. It was Funk’s discovery 
that led to the knowledge of these substances in food 
so essential to growth and life. Funk’s vitamin has 
been isolated by many investigators but as only a 
fraction of a grain can be recovered from several hundred 
pounds of rice hulls or polishings, its precise chemical 
composition is unknown (allied to pyrimidine group 
of organic bases). This special substance in food 
preventing beriberi is often called antineuritic vitamin 
but is identical with what is now generally known as 
water soluble B (see p. 48). 
This vitamin is deficient in fine wheat flour bread, 
biscuit, macaroni, sugar, molasses, and in animal and 
vegetable oils. It is destroyed by heat used in sterilizing 
and canning food but not by short boiling. A diet 
consisting largely of white bread or of canned meat and 
vegetables may cause beriberi. Beriberi appeared in 
British troops (in Mesopotamia in the Great war) 
living chiefly on white bread and canned goods. 
Beriberi sometimes develops in this country where 
white bread is the main article of diet as in asylums, 
prisons, almshouses, and also on shipboard where the 
crew live on white bread and biscuit, pickled meat, 
dried potatoes and rice. 
White bread (deprived of the bran and the embryo or 
germ of wheat) is the most important food from which 
vitamin is removed, but all sorts of prepared foods in 
which the hulls are taken from grains or in which heat is 
used, as condensed and dried milk, dried eggs, infant 
and invalid foods, vegetable and meat extracts, and 
canned food or dried or pickled meat, are deficient in BERIBERI 
363 
vitamins and instrumental in causing the diseases noted 
above. 
Beriberi has occurred most extensively in the Orient, 
the Chinese and Japanese subsisting largely on a rice 
diet. The disease has existed in the Philippines, India, 
and South America, among fishermen in Europe and on 
the Newfoundland Banks, on shipboard. It does not 
develop in persons living on a varied and mixed diet 
and in good surroundings and circumstances. The 
lack of vitamins is only felt by those on a restricted 
diet, usually from poverty. Poor children are stunted 
from being fed largely on white bread. The poor of 
the South develop pellagra from a diet of starch and 
sugar. Babies fed on heated milk have scurvy (see 
p. 366). Starch and sugar contain no vitamins. Fresh 
meat, milk, eggs, vegetables, fruits, and germs of grain 
abound in them. 
Symptoms.-—Beriberi is from twenty days to two to 
four months in developing and may last many weeks 
or months. The death-rate varies tremendously—from 
2 to 50 per cent. Beriberi is caused by degeneration 
of the nervous system, and heart and is often associated 
with dropsy. There is a generalized neutritis (poly- 
neuritis) shown by pains and tenderness in the muscles. 
There are dry beriberi and wet, the latter without swelling 
of limbs and fluid in the belly. When death occurs it 
is always from failure of the heart due to weakness 
and dilatation from degeneration of the heart muscle. 
The disease begins very insiduously and slowly with 
weakness, loss of energy, heaviness and stiffness in the 
legs and shortness of breath and palpitation on exertion. 
Nausea, diarrhea and vomiting are common. 
Pain, numbness, crawling and tingling sensations 
occur in the limbs with loss of power and loss of sensation 364 
THE PREVENTION OF DISEASE 
particularly to pinpricks over the front of the shins. 
Squeezing the calf muscles causes pain and this is one of 
the most diagnostic signs. The legs often swell, or the 
whole body, in the wet cases. In dry beriberi the muscles 
may be seen to waste away, or after disappearance of 
fluid, in the wet cases. In bad cases the trouble is 
chiefly with the heart and shortness of breath, palpita- 
tion and intense pain about the heart are common 
symptoms, with sudden death from heart failure. 
Only about 10 per cent, of patients are completely 
disabled but manage to shuffle about with a cane for 
months. The liberal use of peas and beans and whole 
barley, with meat eggs fresh mlk and vegetables is most 
desirable in the treatment of beriberi. Rice is not to 
be used except by natives who cannot do without it, 
and only the unmilled rice is suitable. 
In institutions the use of whole wheat flour for bread, 
fresh meat, eggs, milk, and vegetables, with whole barley 
in all soups and beans, or peas once a week will prevent 
the disease. Where transport is difficult yeast and 
dried eggs supply the necessary vitamin B. Patients 
who are dropsical require hospital treatment, and those 
with bad hearts. 
Prevention consists in phange in the diet depending 
upon the cause. In most cases this has been extensive 
use of polished white rice, and the substitution of this 
for unpolished rice is usually sufficient. 
The government in the Philippines has forbidden 
the use of polished rice among the native troops and 
in its institutions. Thus, in the leper colony there 
were 309 deaths in 1910 from beriberi, but after 
changing the diet from polished to unpolished rice not 
a single case of the disease developed in the following 
year. SCURVY 
365 
SCURVY 
Scurvy has been called “the calamity of sailors.” It 
occurs in cities, during sieges, in armies, almshouses, 
mining camps, and wherever the diet is deficient in fresh 
meat, milk, vegetables, or fruit. Certain other circum- 
stances predispose to scurvy, as depressing conditions, 
homesickness, fatigue, and exposure to wet. 
Persons with scurvy become pale, weak, and emaciated. 
Their gums are swollen, soft and bleed easily and their 
teeth loosen. Purple spots are seen on the skin which do 
not disappear on pressure. The ankles swell and open 
sores may develop on the legs. Apathy, headache, 
palpitation or fluttering of the heart, and occasionally 
delirium occur. 
Scurvy is due to deficiency of an essential substance 
in the food or of vitamin C (see page 48). Cooking, 
heating, drying, and processing in the course of manu- 
facturing food products destroy the substances which 
prevent scurvy. Food which is kept a long time may 
cause scurvy, so it is substances which exist in fresh 
food that protect against scurvy; fresh meat and blood in 
the Nansen expedition prevented scurvy in the absence of 
vegetables and fruit juices. Fresh onions, potatoes, cab- 
bages, carrots, and dandelions are commonly used to cure 
or prevent scurvy. 
Animals fed for weeks on flours of various grains minus 
germs and hulls, or on potatoes which have been dried 
and then boiled, develop scurvy. It has long been taught 
that only milk heated to high temperature (208° F.) or 
boiled caused scurvy. Hess has recently shown that 
heating milk to 145° F. (pasteurized milk) will kill vita- 
mins, and produce scurvy in infants taking it exclusively 
without orange juice. 366 
THE PREVENTION OF DISEASE 
Scurvy in infants is usually caused by heated, con- 
densed or boiled milk or infant foods of all kinds, although 
it occasionally develops when the baby is on its mother’s 
breast milk, probably depending on lack of vitamins in 
the mother’s food. Cabbage juice loses its antiscorbutic 
(against scurvy) action when it is heated to 145° F., but 
lime juice boiled one hour still contains its vitamin 
against scurvy. For the reason that lime juice holds its 
antiscurvy property so tenaciously it is the great preven- 
tive of scurvy in English ships, called popularly “lime 
juicers.” 
It is now known that the sole cause of scurvy is the 
water soluble vitamin C found in raw fruits and vege- 
tables, especially in the orange, lime, lemon and tomato, 
destroyed by cooking, canning and salting. The cooking 
of fresh meat will destroy this substance if prolonged. 
Thus in a camp where stew was served of fresh meat and 
vegetables scurvy developed which proved to be due 
to five hours of cooking. A dried orange juice has been 
prepared for those going on expeditions in remote parts. 
Scurvy is seen in infants between the ages of six and 
eighteen months usually, and in those who have lived on 
boiled or condensed or proprietary foods. 
The first symptom is shown by the baby crying on being 
moved or handled, and the pain is chiefly in the legs. 
The baby is then thought to have rheumatism. At first 
the baby lies with the legs drawn up, but after a while 
the thighs or legs swell and the limbs are held out straight 
and rigid, with the toes pointing outward. Neither does 
the baby voluntarily move the affected leg freely. One 
limb is more often involved, but in bad cases both 
arms and legs are attacked. The swelling may be about 
the joints or of the whole limb. When there are teeth the 
gums bleed easily and there may be purple spots on the RICKETS 
367 
skin, blood in the urine, and rarely in the bowel discharges. 
In scurvy in adults and infants there is alteration in the 
blood and vessels, and a tendency to hemorrhages. In 
scurvy of infants the ends of the bones often break 
without any apparent cause. 
Prevention of scurvy in infants may be absolutely 
assured by feeding, after the first month, 2 teaspoonfuls 
of orange juice or juice squeezed from fresh beef three 
times daily. Orange juice is best and should always be 
given when pasteurized, boiled or condensed milk, milk 
powders or patent foods are used. The same treatment 
will cure babies of scurvy within a few days after putting 
the patient on a diet of unheated milk. 
Scurvy in adults is prevented by a diet containing 
either fresh meat, milk, vegetables, or fruit, or by lime 
juice or other antiscorbutic articles required on ship- 
board. In adults very sick with scurvy the use of fresh 
milk, meat juice, and scraped beef, followed by potatoes, 
lettuce, and cabbage when the digestion is stronger, will 
rapidly cure the disease. 
RICKETS 
Rickets is a common disease of infants (occurring in 50 
to 80 per cent, of babies) between the ages of three months 
and two years among the less favored classes in large cities. 
It is essentially a disease caused by improper diet, usu- 
ally occurring in infants fed on condensed milk, pro- 
prietary foods, or on cows’ milk not properly diluted 
to suit the digestion. When an infant nurses the breast 
more than nine months the milk will usually be found 
deficient in quality. Babies who are fed only milk when 
over a year old or largely starchy proprietary foods 
are prone to rickets. No infant who receives a well- 
balanced diet and assimilates it will develop rickets. 368 
THE PREVENTION OF DISEASE 
Breast fed infants do not develop rickets, except in the 
case of poorly fed negresses. 
Rickets is improperly classed in the category of diseases 
caused by lack of vitamins. There is no sufficient 
evidence to prove that the disease is due to absence of 
any known vitamin, although attributed to want of 
vitamin fat soluble A. 
Cod liver oil is the most successful medicinal agent 
both for prevention and treatment of rickets but why 
we do not know. Rickets appears to be due to a combi- 
nation of causes: poor hygiene and care and want of 
sunshine, fresh air and bathing, and a faulty diet con- 
taining improper proportions of proteid and fat, and 
perhaps deficient in lime. 
In rickets there is absorption of bone already formed 
and impairment in the bone-making functions, so that 
lime salts are not readily assimilated. 
Symptoms.—No single symptom will enable us to diag- 
nose rickets, but only the general picture is characteristic. 
The infant is pale and puny, with soft, flabby flesh. He 
seems sore on being handled and often has a temperature 
of 100° to 101° F. at night. The head is large for the 
body and face, teething is much delayed, and the soft 
spot in the top of the skull may not close until the third 
or fourth year. The normal child’s head increases in 
circumference about 4 inches the first year (3 inches the 
first six months) and but 1 inch the second year, and 
when the growth is much greater the case is apt to be one 
of hydrocephalus rather than rickets. Normally the 
first teeth (the two lower front teeth) appear from the 
sixth to the eight month, and the soft area in the top of 
the head is closed with bone by the twentieth month. 
The baby is fretful, subject to colds, does not sleep well, 
and sweats about the head and neck at night. RICKETS 
369 
The chest is often deformed, so that the breast bone 
projects (pigeon-breasted), and the spine may be bowed. 
There is often a vertical row of little lumps on the ribs on 
either side of the breast bone. The child is pot-bellied 
and bow-legged, less often knock-kneed. There is a 
tendency to attacks in which the child loses its breath 
and gets black in the face, and convulsions are not 
infrequent. 
Prevention.—If the infant is on cow’s milk it is probably 
improperly diluted. Cow’s milk contains approximately 
4 per cent, each of protein, fat and carbohydrates, while 
human milk contains 3.5 per cent, fat, 1.5 per cent, pro- 
tein and 6.34 F. carbohydrates sugar. The modification 
of milk is done to dilute milk to get the right amount of 
protein, and sugar and cream are added, to secure the 
proper proportion of fat found in human milk (see p. 277). 
Artificial foods and condensed milk must be discontinued. 
After the first year meat juice, scraped beef, oatmeal, 
boiled egg, and butter should be added to the milk diet. 
Pure cod-liver oil (Peter Moller’s) in doses of 10 to 30 
drops at six months; or, from six to twenty months, 20 to 
60 drops (or a teaspoonful), given three times daily after 
meals, is most beneficial. The baby should be bathed in 
a brine bath at night, consisting of water at 95° F. to 
which is added a level tablespoonful of salt to the gallon. 
Following this 2 teaspoonfuls of lard or cacao-butter 
should be thoroughly rubbed into the skin for ten 
minutes. The systematic exposure of babies to sun- 
light has shown it to have remarkable curative effects 
in rickets. 
If there is deformity in the legs or back the child should 
be kept on his back most of the time, not being allowed to 
stand until some three or four months of treatment have 
elapsed. There should be plenty of fresh air in the room. 370 
THE PREVENTION OF DISEASE 
PELLAGRA 
This is a peculiar disease, beginning in Spain (1762), 
spreading to Italy and France, and since 1905, becoming 
quite prevalent in the southeastern part of the United 
States. 
The digestion, skin, and nervous system are particu- 
larly affected. The disease is more common in the spring 
and fall and return of the disorder is also frequent at 
these seasons. It occurs in persons more often between 
the ages of twenty and forty. The patient feels weak 
and depressed and has headache; the digestion fails and 
there is soreness in the mouth, nausea, vomiting, and 
painful watery or bloody diarrhea; the skin on the backs 
of the hands, face, neck, and feet becomes red and puffy 
and looks as if it were badly sunburned, and later peels, 
and the skin is left thickened and reddened. In the more 
severe cases blisters form. The nervous symptoms 
include headache, dizziness, mental depression, irrita- 
bility, change in disposition, and failure in mental powers, 
so that the patient hears imaginary voices or sees 
imaginary objects. Severe cases occur with fever, stupor 
delirium, and death within a few weeks. Chronic cases 
recur in spring and fall from year to year, with failing 
mentality in many instances, so that patients become 
inmates of insane asylums. 
Pellagra is not contagious nor is it conveyed by flies or 
other means. It was formerly thought to be due to 
eating Indian corn, especially spoiled corn. Recently 
the United States Public Health Service has declared the 
cause of pellagra to be the eating of too much starch 
or, in other words, the lack of vitamins (A and B) and 
protein, especially during the winter months in the 
South. PELLAGRA 
371 
It is affirmed that if the inhabitants in the pellagra sec- 
tion will eat sufficient lean meat, eggs, milk, and fresh or 
dried peas and beans the disease will be prevented and in 
most cases patients will be cured by such a regime. A 
daily winter diet for patients of 6 glasses of milk, 4 eggs, 
and pound of lean meat, with dried peas and beans or 
pea or bean soup, is used for cure. Patients with little 
digestive difficulty may take, in addition to the fore- 
going, fruits, potatoes, onions, rice, oatmeal, and wheat 
and rye bread, but no corn in any form. Healthy per- 
sons living in the pellagra section should see that their 
diet contains a liberal amount of lean fresh meat, milk, 
eggs, and in winter beans and peas, dried but not canned. 
By such means the disease may be prevented. Corn 
should be eaten in but small amounts, as it is too rich in 
starch. The Japanese beriberi is an analogous disease 
apparently caused by eating polished rice, a pure starch 
diet. Pure starch and sugar are absolutely wanting in 
vitamins (see page 48). Still more recently (1915) the 
United States Public Health Service has proved their 
contention apparently as to pellagra being a dietetic 
disease. Feeding 11 prisoners at Jackson, Miss., on 
cereals, molasses, potatoes, sugar, and syrup for six 
months 6 contracted pellagra. Some 20 men living 
under precisely the same conditions in the same peniten- 
tiary, except for the special diet, failed to develop the 
disease in a single instance. It is only proper to say that 
many students of the cause of pellagra differ from the 
government authorities as to its origin, believing it to 
be due to some specific germ. It may very well be that 
there is a specific germ of pellagra which only attacks 
persons when weakened by the deficient diet used by most 
of pellagrins. 372 
THE PREVENTION OF DISEASE 
ADOLESCENT GOITER 
Goiter is an abnormal enlargement of the thyroid 
gland surrounding the windpipe in the middle part of the 
front of the neck, and just below what is popularly 
known as the “ Adam’s apple.” 
The goiter, or enlarged thyroid gland, becomes espe- 
cially visible to the eye, and palpable to the finger, during 
the act of swallowing. Swallowing causes the gland to 
rise. After the act it falls to its normal position. 
There are many diseased conditions of the thyroid 
gland in which it enlarges and so forms a goiter. The 
condition herein described is adolescent or endemic goiter 
because it occurs in the young in many parts of the world, 
where it is endemic, or constantly prevalent in the region. 
Adolescent goiter is about 6 times more prevalent in 
the female than in the male, it appear toward the latter 
part of the first decade and usually disappears in large 
part by the twenty fifth year. But on the other hand it 
does not wholly disappear and it usually persists large 
enough to be felt. 
If the gland remains much enlarged a very serious 
condition may ensue, after the course of 12 years or so, 
which may require its surgical removal. The prevention 
and cure of adolescent goiter are therefore most desirable. 
In some regions small goiters occur in 30 to 50 per cent, of 
girls at school or college. Endemic goiter is prevalent in the 
United States chiefly in the region of the Great Lakes and 
Pacific Northwest, especially in Washington and Oregon. 
The secretion of the thyroid gland (thyroxin) is 
dependent upon iodin for its production. When iodin 
is deficient in food or water, or cannot be absorbed from 
the digestive canal, then the gland naturally tries to 
overcome the deficiency by enlarging (compensatory OBESITY 
373 
enlargement) and goiter occurs. When iodin is artifi- 
cially supplied the body this over stimulation of the 
gland (in nature’s vain attempt to supply the iodin 
deficiency) ceases, and the enlargement subsides. 
Owing to the investigations of goiter by Marine and 
Lenhart in this country it has been found that, when 
school children are given small doses of sodium iodid 
to furnish iodin (sodium iodid, 2 grains once daily for 
2 weeks, every six months), goiter is prevented in 99 
per cent, of those thus treated. Also about 50 per cent, 
of children with small goiters are cured by this method. 
However, children should not be given iodin without 
medical advice. There is an accurate machine now in use 
for determining the metabolic rate and need of the subject 
tested for iodin. 
In regions in which goiter is prevalent there is either 
deficiency of iodin in the food and water, or else certain 
bacteria in the water of these regions cause fermentation 
in the intestines of persons whereby the iodin is used 
up and does not enter the body as it should. It is found 
that boiling water prevents goiter, and that matter 
filtered out of water will cause goiter when fed to man. 
Iodin is chiefly found in sea water, and about the seaside 
in drinking water and in sea food. People living by the 
seaside rarely have adolescent goiter. Also where the 
land has been most recently submerged there will be 
most' iodin in the soil and drinking water and least 
goiter, as in the southern belt of this country. 
OBESITY 
To estimate the meaning of obesity a knowledge of the 
normal weight is necessary. In the table on page 375 is 
given the average weight of healthy men for different 
ages and heights. 374 
THE PREVENTION OF DISEASE 
A simple rule of insurance companies is that a weight of 
over 3 pounds to the inch in height is excessive, while a 
weight under 2 pounds to the inch in height is below nor- 
mal. Weight is of importance in respect to age. Heavy 
weight in persons over forty is a decided disadvantage 
from a life insurance point of view, their death-rate being 
much above the average. On the other hand, individuals 
of light weight past middle age have as good an expec- 
tancy of life as those of normal weight. Young persons 
under weight, especially if there is a history of consump- 
tion in the family, have a mortality much above the 
average. In young individuals, otherwise healthy and of 
good physique, overweight is not unfavorable from the 
insurance viewpoint unless the abdominal measure exceeds 
that of the chest, which is undesirable at all ages. Insur- 
ance statistics show that certain diseases occur more 
often in the stout after middle age, as heart disease, 
bronchitis, constipation, piles, diabetes, gout, stone in 
the kidney, and Bright’s disease of the kidney. Harden- 
ing of the arteries and apoplexy are more frequent in the 
obese, and they have less resistance to surgical opera- 
tions and acute diseases, as pneumonia and typhoid fever. 
For these reasons the insurance companies reject or 
handicap overweight individuals at or after middle age 
unless there is a family history of obesity with longevity. 
As to the cause of obesity: In a general way overeating 
and lack of exercise are responsible for much fatness. 
Heredity is important. The secretions of certain glands 
in the body are absorbed into the blood and increase or 
diminish the tendency to fat formation. Thus, when 
either sex is castrated (removal of either the testicles or 
ovaries) the secretions of these glands are stopped and 
stoutness is apt to follow. The same result occurs at 
the change of life in women when the ovaries cease to OBESITY 
375 
TABLE OF HEIGHTS AND WEIGHTS 
Showing the Variations from Light to Heavy Weight. Within 
these Limits Build is Assumed to be Normal. (Fidelity Mutual 
Life Insurance Co.) 
Ages 
Height 
15-29 
30-34 
35-39 
40-49 
50-60 
5 ft , . i 
f 117 
114 
110 
106 
103 
[ 154 
152 
148 
146 
143 
5 ft. 1 in 1 
1 118 
116 
111 
108 
104 
[ 156 
155 
151 
149 
145 
5 ft, 2 in 1 
C 120 
118 
113 
110 
106 
1 159 
157 
153 
151 
147 
5 ft. 3 in 1 
! 123 
121 
116 
112 
108 
162 
161 
156 
154 
151 
5 ft, 4 in 1 
! 126 
123 
119 
114 
110 
166 
164 
161 
157 
154 
5 ft, 5 in 1 
* 130 
127 
122 
118 
113 
171 
169 
166 
162 
158 
5 ft. 6 in 1 
! 133 
131 
126 
121 
116 
1 176 
174 
160 
166 
162 
5 ft, 7 in 1 
1 137 
134 
129 
124 
120 
1 181 
179 
175 
171 
167 
5 ft, 8 in 1 
i 141 
139 
133 
128 
124 
186 
185 
181 
176 
173 
5 ft. 9 in 1 
f 145 
142 
138 
132 
128 
191 
190 
186 
182 
178 
5 ft, 10 in 1 
> 149 
147 
142 
136 
131 
196 
196 
192 
187 
183 
5 ft. 11 in 1 
" 153 
151 
146 
141 
135 
1 202 
202 
198 
194 
189 
6 ft 1 
' 159 
157 
150 
146 
140 
1 210 
209 
205 
200 
195 
6 ft. 1 in 1 
f 165 
162 
156 
151 
145 
! 217 
216 
212 
210 
202 
6 ft. 2 in 
f 170 
167 
162 
157 
150 
1 224 
223 
220 
216 
210 
6 ft. 3 in 
f 176 
173 
167 
162 
155 
J 
f 232 
230 
227 
223 
217 376 
THE PREVENTION OF DISEASE 
secrete. Stoutness is seen in eunuchs and in women 
whose ovaries are removed in early life for dise.ase. With 
partial removal (posterior lobe) or disease of the pituitary 
gland at the base of the brain there is great increase in 
weight. Giants are formed through disease of this gland. 
Children sometimes become extraordinarily fat with 
non-development of the sexual organs. The blood pres- 
sure is subnormal and the pulse is slow. The fat accumu- 
lates chiefly about the body from the region of the navel 
down to the lower part of the thighs (girdle fat). This 
condition is called Frohlich’s disease and is due to under 
secretion of the pituitary gland. This same condition 
occurs in women after maturity with an enormous 
accumulation of fat about the abdomen, hips and thighs, 
and cessation of menstruation. In either children or adults 
with this form of girdle obesity from deficient secretion of 
the pituitary gland the reduction of fat by diet is usually 
unsuccessful. Treatment with extract of the pituitary 
gland, and sometimes thyroid gland, may be remedial. 
On the other hand, an excess of secretion of the thyroid 
gland in the neck produces emaciation in some forms of 
goiter, and the dried sheep’ thyroid gland is sometimes 
given to reduce obesity in man. 
Symptoms.—The physical inconvenience caused by 
obesity and the injury to the figure in women are the com- 
mon complaints. Walking and exertion of all kinds are 
difficult, while the breathing is short and the heart’s 
action is embarrassed. The pulse is apt to be more 
rapid, and the urine is scanty compared to the amount of 
fluid taken, because of easy perspiration, and, for the 
same reason, colds are more frequent. Indigestion may 
develop and constipation and piles are common. Impo- 
tence sometimes occurs in the male. Sleepiness is fre- 
quent in fat young people, as made famous by the fat OBESITY 
377 
boy in “ Pickwick Papers.” Common observation shows 
us, however, that obesity is compatible with not only 
long life but great activity and vigor. 
Treatment.—All reduction cures are starvation cures. 
None supply enough food for the permanent needs of the 
body. It is a reduction of quantity rather than quality 
of food which counts. Still, the kind of food is of impor- 
tance. The amount of food given in reduction cures is 
equal to from one-half to as low as one-third of that 
required to maintain a normal individual. The fat of the 
body is thus burned up to supply the individual’s needs. 
The danger lies in the fact that not only the fat, but the 
substance of the muscles and tissues generally may also 
be broken up if the starving is continued too long. If 
this happens, the subject will feel weaker. No reduction 
cure should be continued unless the patient feels stronger 
for it. Frequent meals tend to prevent a feeling of 
weakness. As a general rule dieting is not advisable 
for persons over fifty or under twenty. Those who have 
been fat for a great many years are not favorable subjects 
for reduction. Reduction is always better undertaken 
under a physician’s care, and it should never be carried 
out by the patient unless otherwise in good general 
health. The reduction of fat in certain disorders, as in 
tuberculosis, might be fatal. 
A patient should not lose more than 6 to 8 pounds a 
month for two or three months. Then the diet may be 
increased so that the weight is maintained at a level for 
two months and the cure instituted again. None but 
robust individuals should lose as much as 40 or 50 pounds 
in a year, and they should feel the stronger for it. Fat- 
ness in children should be discouraged by the avoidance 
of sweets, starches, as cereals and fats, and by the use of 
outdoor exercises, but not by a strict diet. 378 
THE PREVENTION OF DISEASE 
Food is generally divided into fats, starches and sugar, 
and proteins. The latter include pure meat and fish free 
from fat, skimmed milk, white of egg, and a portion of 
vegetables, as gluten in flour. Proteins build tissue in the 
growing, and repair it in adults, but do not make fat. 
Sugar, starches, and fat make fat and must be chiefly 
cut out in the reduction diets. In the following diet list 
the fat is but one-third to one-half and the starches and 
sugars but one-fifth to one-half of what are required in a 
normal diet, while the amount of proteins is about the 
standard for normal adults. The special diets given in 
most medical text-books are of German origin, as Oertel’s, 
von Noorden’s, Epstein’s, etc., and include articles often 
not palatable to use, as cold meat for breakfast, Rhine 
wines in considerable amount, etc. 
The following diets are those particularly in vogue. 
The Oertel cure requires that the liquid be reduced to 
2V2 pints, including water and all other fluids taken in the 
twenty-four hours, thus: 
Breakfast: 6 ounces of tea or coffee with milk and 3 
ounces of bread. 
Lunch: 3 to 4 ounces of soup, 7 to 8 ounces of meat, a 
little fish, 1 ounce of bread or sago, rice, tapioca 
pudding, 3 to 6 ounces of fruit for dessert, 1 glass of 
water. 
Afternoon Tea: 6 ounces of tea and a glass of water, 1 
ounce of bread. 
Supper: 1 or 2 soft-boiled eggs, 1 ounce of bread, small 
slice of cheese, salad and fruit, 1 to 2 glasses of liquid, 
von Noorden’s diet follows: 
Breakfast (8 A. M.): Lean meat 2% ounces, 1 cup of tea 
with spoonful of milk, no sugar, bread Ye> ounce 
10 A. M.: One egg. OBESITY 
379 
12 M.: A cup of strong meat broth. 
1 P. M. \ A small plate of vegetable and meat soup, 5 
ounces of meat and fish, 3 ounces of potatoes with 
salad, 3H ounces of fresh fruit without sugar. 
4 P. M.: ounces of fresh fruit. 
6 P. M.: K pint of milk with tea. 
8 P. M.: 4 ounces of cold meat or 6 ounces of raw meat 
cooked and eaten with salad, 1 ounce of Graham 
bread and 2 or 3 spoonfuls of cooked fruit without 
sugar. 
The amount of liquids, as water, weak tea or lemonade, 
at or between meals is not limited, von Noorden 
believes the numerous small meals prevent weakness. 
Bouchard’s diet consists wholly of 2k£» pints of milk 
and 5 eggs per day; in other words, a glass of milk and 1 
egg at 7 and 11a. m. and 3, 7 and 11 p. m. for twenty days. 
Most of the diets cut down on starches, fat and sugar 
required in a normal diet, while increasing from one-third 
to one-half the amount of proteins are represented by 
meat, fish, milk, and egg. They represent about one- 
half the food value required by the normal person. 
The so-called milk-cure is one of the simplest and may 
be used even in disease of the heart or kidneys (with a 
doctor’s permission), as it increases the action of the kid- 
neys and is particularly applicable in the case of persons 
with abdominal fat. 
Breakfast: 1 pint of milk. 
Lunch: 6 ounces of lean meat with green vegetables, as 
spinach, green peas, string beans, lettuce. (No 
bread or potatoes, but beets, turnips, parsnips, cab- 
bage, Brussels sprouts, carrots may be used in place 
of green vegetables.) One-half pint of milk, 2 
glasses of water or cups of tea with a little sugar. 380 
THE PREVENTION OF DISEASE 
Tea (5 P. M.): pint of milk or junket, 2 cups of tea 
with a little sugar. 
Supper (7 P. M.): 1 pint of milk and 2 apples (they 
may be cooked). 
In place of the midday meal only 1 pint of milk may 
be taken in the case of robust persons. If the subject 
remains at home he may take the milk more frequently, 
8 to 9 glasses daily, with only the apples, tea, and water, if 
the noon meal is abstained from. 
Ebstein’s diet contains 3 pints of liquid, including 2 
cups of tea, as follows: 
Breakfast: Bread 2 ounces, with plenty of butter (bread 
may be toasted); large cup of tea at end of meal, 
without sugar. 
Lunch: Fat meat, ham, or fish, 4 ounces, or 1 egg, bread 
and butter, 1 ounce; green vegetables or salad and 
fruit. 
Tea: Cup of tea, one slice of bread and butter, or biscuit. 
Dinner: Clean soup, meat 5 or 6 ounces, cabbage, peas 
string beans or spinach, as much as wanted, raw 
fruit or salad, small piece of cheese and a cup of 
tea at end of meal, 5 glasses of water should be taken 
between meals. This diet allows fats, but excludes 
starches and sugar, and contains half the normal food 
requirements. 
Dr. E. A. Locke’s diet has been found by the writer the 
most sensible and is in accord with our customs. It 
follows: 
Breakfast: 1 cup of black coffee (no cream or sugar), 
1 or 2 boiled or poached eggs, 1 or 2 small slices of 
toast without butter, an drange, apple, pear, or one- 
half a grapefruit. OBESITY 
381 
11.30 A. M.: A glass of milk, buttermilk, or some fruit. 
Luncheon: One cup of clear soup, 3 ounces of meat, eggs, 
or fish, two varieties of green vegetables, 2 to 4 
ounces each, raw fruit. 
5 P. M.: Tea without cream or sugar, one small slice of 
toast. 
Dinner: Raw oysters, lean meat or fish, 4 to 5 ounces, two 
green vegetables, 2 to 4 ounces each, salad of fruit or 
vegetables with a small amount of French dressing, 
raw or unsweetened cooked fruit, demi-tasse of black 
coffee. 
The following articles are to be avoided: 
Starches.—White potatoes, except in small amount, 
bread, crackers, cereals, macaroni, vermicelli, spaghetti, 
sago, tapioca, cornstarch, sweet potatoes, shell beans, 
dried peas or beans, corn, and nuts. 
Sweets.—Sugar, candy, dried fruits, syrups, fruit pre- 
serves, honey, marmalade, and sweet sauces. 
Meat.—Pork, bacon, goose, sausage, croquettes. 
Fish.—Shad, fresh salmon, eels, sardines, mackerel, 
bluefish, and fried fish. 
Fats.—Butter, cream, olive oil, bacon, lard, fat meat, 
and fish. 
Dessert.—Ices, rich puddings, cake. 
Miscellaneous.—Chocolate, alcoholic drinks, except 
claret and Rhine wines, thick soups, milk, cheese, pickles, 
condiments. 
This diet contains a third to a little over one-half the 
food value required by a normal person weighing 150 
pounds. For a heavy person the food is correspondingly 
deficient, so that he will live on his fat while on the diet. 382 
THE PREVENTION OF DISEASE 
Water is not curtailed in Locke’s diet, as in many diets 
for reducing fat, but water should only be taken after 
rising and between meals and at bedtime. 
Water taken at meals increases the appetite, and some 
authorities believe the absorption of food as well. 
It is advisable that the patient should actually weigh 
his food at first and then he can judge later of the amount 
he should take by bulk. The patient should weigh 
himself daily and keep a weekly chart of his weight. The 
appetite will be hard to curb at first, but after a few 
weeks there should be no trouble on this score and the 
score and the strength and appearance should improve. 
Prolonged chewing lessens the appetite. 
The diet may be followed until the weight becomes 
normal for the height of the subject. Then the diet may 
be somewhat increased, being careful not to take too 
much sugar, fat, and starches, as potatoes and bread. 
Exercise is most important during the cure, and 
swimming, riding, golf, and walking, as three-quarters 
of an hour in the morning and one-half hour in the after- 
noon, are to be recommended. Exercise with a heavy 
sweater on will greatly reduce weight through perspiration, 
providing water is taken but moderately. Massage 
will to some extent reduce local accumulations of fat, as 
on the abdomen, but it must be given daily and very 
vigorously for this purpose. Special exercises are more 
efficient, as exercises in bending over for removal of fat on 
the abdomen (see constipation). Sometimes cathartics 
are necessary, especially on cutting down the bulk of food. 
Some saline, as Carlsbad salts in doses 
(more or less) in a glass of cold water on rising is 
suitable. 
The whole success of the treatment depends upon the 
faithfulness with which it is carried out. If thoroughly DIABETES 
383 
done the habits will become so changed that it will not 
be difficult to adhere to a proper diet thereafter. 
DIABETES 
Diabetes (diabetes mellitus) is a disease in which 
there is a great increase of sugar in the blood which 
escapes into the urine where it is not normally present. 
It is due to morbid changes with destruction of parts 
(islands of Langerhans) of the pancreas, the gland that 
lies in the belly behind the stomach and is sometimes 
called the sweetbread in animals. There is an internal 
secretion of the gland which enables sugar to be stored 
in the liver and utilized by combustion in the muscles 
in health. In diabetes the sugar taken as food (and also 
that which is formed in the body from starch, proteids 
and fat in the food) is not capable of being so utilized 
but escapes into the blood and thence into the urine. 
This loss of sugar causes many of the symptoms of 
diabetes. 
Diabetes is largely a disease of obesity. Diabetes 
rarely develops in a person over 20 who is habitually 
underweight. Joslin says that in the next generation 
“one may almost be ashamed to have diabetes” because 
by avoiding fatness one may largely avoid diabetes. The 
Jews have long been known as especially liable to dia- 
betes, and also it is common in both husband and wife of 
any race. Again, diabetes has been thought to be an 
hereditary disease. Simply in all these instances 
because the subject is fat. Jews are fat because large 
eaters and prosperous, husband and wife are fat because 
both live on the same fattening food, and inherited 
tendency is a tendency to fat because of food and environ- 
ment. So to prevent diabetes avoid being fat. 384 
THE PREVENTION OF DISEASE 
Obesity is a prediqBetic state. There is a test for 
such in giving stout persons an amount of sugar utilized 
in the normal person but causing an increase of sugar in 
the blood, and perhaps in the urine, in the near diabetic. 
This test should be made in stout persons. 
Prevention applies especially to the children of diabetic 
parents. These should be brought up on a diet from 
which candy, cake, and sweets generally are largely 
excluded. Testing the urine at least four times a year in 
the children of diabetics, in fat adults and in their 
children, and in those who have previously had sugar in 
their urine, is of the utmost importance. 
Since 1914 when the Allen treatment of diabetes was 
introduced the life of the diabetic case has been almost 
doubled. This consists in a low diet usually attended 
with loss of weight. In 1920 Banting and Best dis- 
covered insulin, an alcoholic extract of the calf’s pancreas 
which takes the place of the destroyed gland. This is 
injected under the skin in diabetics and is another 
revolutionary advance in treatment. It cannot usurp 
the place of special diet but it will save the lives of 
children, in whom diabetes has always hitherto been 
rapidly fatal, and also the desperate adult cases. CHAPTER XVII 
THE PREVENTION OF ASTHMA, HAY FEVER 
AND HOOKWORM DISEASE 
ASTHMA AND HAY FEVER 
Asthma is a disorder in which acute or chronic attacks 
of difficult breathing are produced by spasm and swelling 
of the mucous membrane of the finer bronchial tubes. 
The caliber of the air tubes being thus narrowed there is 
obstruction to the free passage of air. Asthma is 
common both in children and adults. 
It occurs usually in attacks which come on suddenly, 
more often at night, with a feeling of tightness in the 
chest and difficult breathing so that the patient feels, 
suffocated and often rushes to an open window for 
air. Both inspiration and expiration are difficult— 
more so expiration, which is prolonged and wheezy. 
The face becomes pale, anxious and covered with sweat, 
the hands and feet are cold, the lips blue, the voice is 
faint and hoarse, and speech may be impossible. 
Just as the patient appears to be suffocating the attack 
subsides with coughing and spitting of minute sticky 
balls of mucus floating in a thinner secretion. The 
attacks are of varying severity and last from a few 
minutes to 1 or 2 hours and return at longer or shorter 
intervals. Although most alarming, attacks are practi- 
cally never fatal. In the course of time, after many 
seizures, the breathing becomes short and wheezy 
owing to the presence of chronic bronchitis. 
385 386 
THE PREVENTION OF DISEASE 
As the causes of hay fever and asthma are almost 
identical we will consider them together. Hay fever 
is usually seasonal, that is occurring at certain regular 
times of year. It is twice as frequent in males, and 
attacks the well educated and nervous, between 15 and 
30 years of age. 
Abnormalities in the nose, as polyps, spurs, enlarge- 
ments of the turbinates, render the mucous membrane 
more susceptible to pollen of trees and plants, and in- 
halation of pollen is the cause of three quarters of all 
cases of hay fever. 
Hay fever begins like an ordinary cold in the head 
associated with red, inflamed and weeping eyes which 
are very sensitive to light. The nose is also red. There 
are in addition, headache, sneezing and coughing, and 
fever of 100° F. to 101° F. Asthma may accompany or 
follow hay fever. Attacks are apt to recur but the disease 
tends to disappear with advancing age. 
Early attacks of hay fever, before May, are more 
often due to the pollen of trees as maple, birch, willow 
and oak. In April, May and June to the pollen of the 
grasses, dandelion, daisy, oak, rose, privet, maple 
and poplar, while in the late summer hay fever is caused 
by pollen of ragweed, sage brush, golden rod and other 
fall flowers. 
During the past few years great advances have been 
made in our knowledge of the causes and prevention 
of asthma and hay fever and other disorders produced 
by the same causes, as some skin eruptions, particularly 
hives and eczema. 
It has been discovered that some persons are hyper- 
sensitive to certain vegetable and animal proteids 
(like white of egg, casein of milk, proteids of wheat, 
serum of blood, pollen and dandruff from skin) introduced ASTHMA AND HAY FEVER 
387 
into the body by inhalation, by the mouth in food, or 
under the skin in injections of horse serum. This 
hypersensitiveness may either be natural and inherited 
(allergy), or it may rarely be artificially acquired, as 
when antitoxin or horse serum is injected without 
causing any disturbance and, at later time, the same 
amount injected into the same person may cause serious 
trouble or even death. This artificially acquired 
hypersensitiveness is known as anaphylaxis, and is a 
very unusual occurrence, the vast majority of persons 
being able to have serum injected into them repeatedly 
without any serious disturbance. Hypersensitiveness 
to animals, food, pollen and bacterial proteids causes 
in human beings hay fever, and asthma. 
We may classify the causes of asthma and hay fever as 
follows: (1) Inhalation of emanations from the skin of 
animals (in dandruff, hair, fur and feathers), as the 
horse, cat, cow, birds, rabbit, chicken, guinea pig and 
goose. (2) Inhalation of pollen, and rarely perfumes 
and sachets. (3) Ingestion or swallowing of certain food 
proteids, as those in egg, milk, fish, shell fish, wheat, 
etc. Also some drugs, as aspirin and quinine. (4) 
Absorption of the products of bacterial or germ growth 
from local infections in the body, as in infected sinuses 
of the head, and infected teeth and tonsils, chronic 
appendicitis or chronic inflammation of the gall bladder. 
The same foods that cause asthma or hay fever may, 
at the same time, cause acute indigestion with gas, 
nausea and vomiting, or severe pain simulating appendix 
or gall bladder inflammation. 
5. Injection of horse serum into the body, as with 
diphtheria and tetanus antitoxin or antimeningitis 
serum. These may very rarely cause a sudden and 
even fatal form of asthma in subjects hypersensitive 388 
THE PREVENTION OF DISEASE 
to horse emanations, or in those who have become hyper- 
sensitive by a second injection. More often sensitive- 
ness is shown by the appearance of hives, skin eruptions, 
vomiting, pain in the nerves and joints some days or a 
week after the injection of horse serum. 
Now in a general way, when asthma or hay fever occur 
at certain regular growing seasons, pollen should be 
suspected as the cause. 
But if these diseases happen throughout the year, 
or in winter, then food, animal emanations or bacterial 
infections in the body, should be considered the prob- 
able causes. Finally, if the following tests are made 
and only the bacterial skin tests are positive, or no test 
is positive, then the source of hay fever or asthma must 
be attributed to bacteria. This follows because patients 
with bacterial infections are often not sensitive to skin 
tests made with them. 
To determine the cause of hay fever or asthma in any 
given person skin tests should be made with all the 
substances known to produce these diseases. These 
tests are made commonly in so-called clinical laboratories, 
and by some physicians. The substances, including 
food proteins, dandruff, hair and fur and feathers from 
animals, pollen and offending bacteria, may all be bought 
in powdered form for this test. 
In doubtful cases it may be advisable to use all of 
these available substances on each patient, at present 
approximately 157 food proteins, 128 pollens, 10 different 
animal hair, dandruff, fur and feather products, and 15 
bacterial and miscellaneous proteins from sachets and 
perfumes, and certain drugs, as quinin and aspirin. A 
minute amount of each of these separate powders is mixed 
with a little alkaline solution and is rubbed into a 
small scratch on the upper surface of the forearm about ASTHMA AND HAY FEVER 
389 
}4 of an inch long. A different substance on each of 
these scratches. 
After half an hour the scratches are washed off. If 
the test is positive a little, white, raised lump about 
of an inch in diameter is seen. If the test is negative 
the skin remains unchanged, or like scratches made 
on the arm for comparison in which no powder has been 
rubbed. The tests should not be made during or directly 
after atacks of hay fever or asthma, as then the patients 
often shows no response to them. 
If now the patient is found to be sensitive to one or 
more foods he may be cured of asthma, or hay fever, 
or eczema, or hives and indigestion, by total avoidance 
in future of the food or foods. Efforts to make the 
subject become non-sensitive to the offending food, 
by giving small and increasing amounts, are generally 
unsuccessful. 
If the patient is found to react positively to skin tests 
with one or more pollens then he may be desensitized to 
these pollens by injection under the skin of very weak 
but increasingly strong dilutions of the offending pollens. 
This method is used both for prevention and treatment 
but is not very successful in treatment because the patient 
is very likely getting more of the same pollen from 
inhalation of that in the air. 
For prevention of asthma and hay fever due to pollen 
injections of the offending pollen are wonderfully suc- 
cessful. 
Patients found sensitive to the skin test with emana- 
tions from one or more animals should avoid contact 
with them so far as possible. If sensitive to the horse 
then one may be sensitive to hair mattresses, furniture, 
pillows, dust in the street etc., and one should be desensi- 
tized by injections of solutions of material from the horses 390 
THE PREVENTION OF DISEASE 
skin in gradually increasing doses. For persons whose 
livelihood depends upon being about animals, as horse 
cattle or chicken raisers, hostlers, and stable employees, 
desensitization may be accomplished by injections under 
the skin, in gradually increasing strength, of dilutions 
of the skin emanations of these animals. The writer 
has cured a case of eczema in a baby by substituting 
a mattress and pillow of cotton and silk floss for those 
of horse hair previously used. Some cases of asthma in 
babies have been reported from rabbit fur in pillows, sup- 
posedly of feathers. 
Patients with hay fever and asthma who react to 
no skin tests with food proteids, animal emanations, 
pollen or bacteria, or who only react to bacteria should 
be treated for bacterial focal infections. These are 
more often found in the sinuses of the head, in the ton- 
sils, teeth, gall bladder or appendix, and their surgical 
removal may cure the asthma or hay fever. Removal 
of infected tonsils in children quite commonly is curative 
in asthma. 
In the absence of such focal infections, or when there 
is a bronchitis present, the use of vaccines made 
from the germs found in the secretion from the nose and 
sputum, may prove curative when injected under the 
skin at intervals of a few days. The removal of infec- 
tion is more logical and curative than the use of vaccines. 
Even the bronchitis may be relieved by eradication of 
infection in sinus or tonsil. 
These skin tests with food proteids are as valu- 
able in the prevention of eczema, indigestion and 
hives or urticaria, because these disorders are fre- 
quently caused by hypersensitiveness to certain food 
proteids. Such diseases are also very often associated 
with asthma. ASTHMA AND HAY FEVER 
391 
Face powders, tooth pastes and sachets may cause 
asthma owing to contained proteids, as orris root or 
rice powder, and when persons give a positive skin 
test to them they may be easily avoided. Some patients 
with asthma are sensitive to various dusts which may 
precipitate an attack. Persons must either be desensi- 
tized to such dusts, after making skin tests to determine 
their identity, or also the subject may avoid them by 
changing residence or occupation. 
Asthma was formerly considered a rather incurable 
disease but now the larger number of sufferers may be 
partially or completely relieved. The skin tests are 
rarely of much value in persons who develop asthma 
after 50 because they do not react. Asthma in them is 
chiefly of bacterial origin or due to other diseases. In 
order to secure the proper pollens they should come from 
the same region in which the patient lives and are best 
made to order by physicians who specialize in this work. 
Finally it should be said that certain diseases produce 
symptoms closely resembling ordinary asthma. These 
should always be excluded before the modern method of 
treating asthma is even considered. 
A proper examination always includes an rr-ray of 
the chest because enlargement of the great artery in 
the chest (aneurism of the aorta), tumors or tuberculosis 
of the lungs, and disease of the heart often cause a 
kind of asthma. So also patients with high blood 
pressure and Bright’s disease of the kidneys may have 
asthmatic symptoms. 
Asthma beginning late in life is more apt to be second- 
ary to one of these organic diseases and is not at all 
amenable to injections of the substances considered in this 
article. A competent diagnosis is the first essential to 
treatment of any disease. 392 
THE PREVENTION OF DISEASE 
HOOKWORM DISEASE. ANKLOSTOMIASIS 
UNCINARIASIS 
The writer was greatly struck by the vast difference 
in the general appearance of the population in various 
parts of the South as compared with those in the North- 
west of this country from which he had been transferred 
during the war. 
In the South so many of the population, especially 
children, were anemic, puny, pale and without life or 
energy. After seeing the rosy, robust, vigorous, large 
specimens of youth and manhood in Washington and 
Oregon the young of the Carolinas were a pitiful sight, 
and often in a most healthful climate among the moun- 
tains. 
Stiles has estimated that two million are infected with 
hookworm in the United States alone. It together with 
malaria, are called The Captains Of The Men Of Death. 
In Porto Rico about 90 per cent, of the population are 
infected with hookworm, 15 per cent, in the Philippines, 
and it is most common in our South where from 20 
to 80 per cent, of young people have been found infected. 
It is responsible for an enormous amount of bad health 
in this region. 
The worm is called Necator americanus, the adult male 
3d* in., the female, % to Yh in. long. The larval or imma- 
ture worm enters the body through the skin of the hands 
and feet, usually owing to the subject going bare- 
footed. From the venous blood the parasite lodges in 
the lungs and thence is coughed up and swallowed 
and attaches itself to the first six feet of the small 
intestines where it is destructive to the host by absorb- 
ing blood, causing bleeding and infection, and lessening 
the coagulability of the blood by a poison it produces. 
The female worm yields enormous quantities of eggs HOOKWORM DISEASE 
393 
which escape in the feces. It is estimated as many as 
4 million may be contained in one bowel discharge. 
The eggs are from Moo to 34 oo inch in diameter and 
may be readily recognized by a microscope. They 
contain 4 to 8 segments and sometimes the embryo 
nearly ready to burst its shell. 
The eggs live in moist warm soil and water (65°-85° F.) 
but may be killed by dryness and sunlight. Under 
favorable conditions the eggs hatch out in 24 to 48 
hours and the young worms or larvae are at first Moo 
of an inch long but at the end of 5 to 10 days, are Ho 
in. long and ready to enter the body through the skin. 
In penetrating the skin the worms produce irritation, 
particularly between the toes, known as “ground itch.” 
This consists in the formation of little blisters and pus- 
tules with sticky discharge, swelling and itching. The 
eruption dries up in about 10 days. In persons working 
in the soil with bare hands the worms may enter the 
skin of these parts. From 7 to 10 weeks elapse from the 
time when the worms penetrate the skin and find their 
way into the bowel, until the eggs begin to escape from 
the intestines. 
The patients are pale, greatly dwarfed in growth, and 
underdeveloped (the young), and are lazy and apathetic. 
The eyes have a dull and fish-like stare. There may 
be loss of appetite, and some discomfort in the region of 
the stomach or colic, and diarrhea. The appetite may be 
perverted so that subjects eat earth, clay, hair, paper, 
starch and chalk. Persons infected with hookworm 
constituted the “clay eaters” of the south. 
The disease is shown by pallor, anemia, underdevelop- 
ment, weakness and by a history of ground itch in those 
living in badly infected regions. Its presence is confirmed 
by the finding of the eggs in the feces of the subject. 394 
THE PREVENTION OF DISEASE 
One to two teaspoonfuls of bowel discharge may be 
placed in a wide mouth bottle and corked and sent to a 
doctor for microscopic examination. 
The presence of blood in the feces is significant of 
hookworm: A simple test for blood is to place a bit of 
bowel discharge on a piece of white blotting paper and 
if a rusty stain appears after an hour or so, it is evidence 
of blood in the feces. In severe cases patients may become 
bedridden with great weakness, pallor, and swelling of 
the feet and other parts of the body. It should be noted 
that a considerable portion of the adult population of 
the regions infected with hookworm may appear healthy, 
the only means of diagnosis being examination of the 
feces for eggs. 
The prevention of hookworm disease may be secured 
first by the wearing of shoes and stockings in infected 
regions. Second by disposal of bowel discharges in 
properly constructed privies (see Typhoid Fever) and 
so preventing the dispersion of the hookworm eggs in 
the soil. If these two measures were enforced hookworm 
disease would be abolished. Education is the essential 
means for prevention. The Rockefeller Foundation has 
done the most splendid and important work in extensive 
hookworm demonstrations in infected regions. 
Besides the two preventive measures mentioned it is 
always wise to thoughly wash the hands before eating 
in infected regions, and to boil the drinking water, 
as eggs may be conveyed to the intestines directly 
although this is not a common method of infection. 
The bowel discharges in privies should be covered with 
milk of lime made by adding one part of freshly slaked 
lime to four parts of water. 
Treatment as laid down in the simple rules of the 
Porto Rico Commission follow: The patient should take HOOKWORM DISEASE 
395 
a tablespoonful of Epsom salts in a whole glass of water 
before eating in the evening. At 6 A. M. next morning 
one half the dose of thymol in capsules is taken. At 8 A. 
M. next morning the other half of the dose of thymol is 
swallowed. At 10 A. M. another similar dose of Epsom 
salts is taken. The dose of thymol varies from seven 
grains for children under five years of age, to sixty 
grains for adults. No wine or other form of alcohol 
should be taken while the medicines are acting. This 
treatment should be continued at intervals until the 
patient is cured. 
The directions end by requiring a privy attached to 
the patient’s abode and the wearing of shoes. “Wear 
shoes and you will never suffer from anemia.” CHAPTER XVIII 
THE PREVENTION OF SOME DEFORMITIES 
INTRODUCTORY NOTE 
The way the human body is used is of the utmost importance if 
proper health and efficiency of the individual are to exist, and to 
prevent the common deformities seen in human beings the appre- 
ciation of this fact is of the greatest consequence. 
If the body is used fully erect the muscles as a whole are in 
their best position for development. The ligaments naturally 
strengthen, the bones develop without deformity, and the greatest 
amount of physical energy is available for work. In this position 
also the chest is so held that the lungs develop properly, the heart 
is free to perform its work, and the abdomen is so shaped that none 
of its organs is harmfully interfered with. 
If the body is drooped, however, not only are the shoulders 
thrown forward, but the spine is curved, the knees and ankles are 
sprung, and the chest is flattened—embarrassing the action of the 
lung—so that in consequence the diaphragm is forced downward 
and the abdominal wall is relaxed, with the natural effect that the 
abdominal organs are not properly supported and are crowded out 
of their normal position, frequently resulting in disaster. 
The chapter which follows admirably suggests the different 
features which are of importance in this matter of the prevention 
of deformities. These if recognized in childhood and properly 
treated will result in our seeing develop about us strong and healthy 
boys and girls. 
Joel E. Goldthwait. 
Round Shoulders, Lateral Curvature of the Spine, Humpback, 
Knock-knees, Bow-legs, Weak Ankles, Weak Feet and Flat-feet 
Deformities depend upon weakness of the muscles and 
ligaments and upon disease of the bones. Bad hygiene 
in the child favors general weakness and thus deformities. 
396 ROUND SHOULDERS AND SPINAL CURVATURE 
397 
That is, lack of proper food, exercise outdoors, fresh air, 
etc. The special diseases of infancy predisposing to 
deformities are rickets and scurvy, which are considered in 
another place. In rickets, where the bones are soft, the 
child should be encouraged to creep and discouraged to 
stand. Rest in bed until a cure is obtained is often ad- 
visable. The diseases which directly cause deformities 
are infantile paralysis from weakness and paralysis of 
the muscles, and tuberculosis, syphilis, and gonorrhea, 
which primarily produce disease of the bones. 
But the more common deformities which we will con- 
sider are those caused by general weakness or faulty pos- 
tures assumed during standing, sitting, walking, sleeping, 
playing, or working. These include round shoulders 
curvature of the spine, bow-legs, knock-knees, weak 
ankles, and flat-feet. 
Round Shoulders and Spinal Curvature.—Round shoul- 
ders and lateral curvatures of the spine are exceedingly 
common. Many of the same causes act to produce one or 
both of these deformities. In round back or round shoul- 
ders the subject assumes a position shown in Figs. 8 (p. 334) 
9 and 10, with back arched, chin thrust forward, chest flat, 
and lower belly prominent. It follows that if the back is 
bowed backward the lower part of the abdomen must be 
carried forward to preserve the proper balance. This 
position, besides being a great deformity, interferes with 
the free action of the lungs and heart and causes the 
abdominal organs to be pushed downward, leading to one 
of the most common forms of indigestion and having far- 
reaching consequences (see page 336). In lateral curva- 
ture the spinal column, instead of occupying a vertical 
position, becomes deviated from side to side so that it has 
a more or less S-shape when viewed from behind. This 
deformity is more frequent in young girls (from ten to 398 
THE PREVENTION OF DISEASE 
fifteen years) and is often first noticed by the dressmaker, 
because one breast is more prominent than the other or 
because one hip or shoulder is higher than its mate. In 
Fig. 11 is shown an outline of the back in a case of lateral 
curvature. In the uper part of the back the deviation is 
toward the right and in the lower part toward the left. 
Fig. 9. 
Fig. 10. 
The right shoulder and left hip are higher than their 
mates and the left breast (not shown in the diagram) is 
also more prominent. When this patient stoops, holding 
the heels together without bending the knees and inclines 
the body forward from the hips with the head and arms 
hanging down, we will observe the deformity of the back 
as in Fig. 12. This outline shows the ribs bulging outward 
to the right of the spinal column owing to the fact that 
some of the vertebrae are twisted to the right side in 
addition to the deviation of the whole spinal column. By ROUND SHOULDERS AND SPINAL CURVATURE 
399 
marking with ink the bony prominences along the spine 
from the neck downward one can readily see whether the 
spine is straight or not, as in Fig. 11. 
Fig. 11. 
Fig. 12. 
Lateral curvature of the spine is capable of causing 
the most frightful deformity if it becomes marked, al- 
though, considering its frequency, this does not often 
Fig. 13.—Humpback in early stage, showing sharp projection in back 
bone. 
occur. It also gives rise to pain in the back as a common 
symptom. 
The ordinary humpback (Figs. 13, 14 ) is, of course, not 
due to the subject’s weakness and slovenliness, and is gen- 400 
THE PREVENTION OF DISEASE 
erally much more marked than in round shoulders or 
stoopback. The distinction between the two is that in 
humpback the projection in the back is sharp in the 
beginning, owing to tuberculosis of one or more ver- 
tebrae, and the back is painful and stiff on movement, and 
pains are felt in the abdomen. In the 
course of time the deformity becomes 
much greater than in round shoulders, 
although there are some cases which 
at first sight look like humpback, but 
the history of the case and lack of 
pain and stiffness in round-back will 
serve to distinguish it from humpback. 
Prevention of back deformities must 
begin in infancy by the use of proper 
diet, and by giving the child proper 
care generally, to avoid such con- 
ditions as malnutrition, anemia, rick- 
ets, and scurvy, in which the soft 
tissues become weakened (muscles 
and ligaments) and the bones soft. 
Mothers will find such a book as 
“Holt’s Care of the Baby” invaluable 
in this connection. Tuberculosis in 
children is the commonest cause of 
bone diseases and may be avoided 
by the exclusive use of properly pasteurized milk 
(see page 347) in many cases. It is still more im- 
portant to prevent exposure of a child to a tuberculous 
patient in the home. This matter has been discussed 
under Tuberculosis. Other common causes of joint 
and bone diseases are syphilis and gonorrhea described 
elsewhere. Infantile paralysis is usually followed by 
deformities and must be avoided if possible (see page 
Fig. 14. — Hump- 
back, showing distinct 
the s re0^ectl0n from ROUND SHOULDERS AND SPINAL CURVATURE 
401 
190). As round-back and lateral curvature of the spine 
are due in large part to general weakness, the encourage- 
ment of the general development and vigor are of prime 
importance by means of proper physical training, games, 
and sports. In school the child should sit in proper posi- 
tion at an appropriate desk. The narrow chair with 
straight back at right angles with its seat, having an ad- 
justable cross-piece to support the small of the back of the 
pupil, has been found most suitable. The pupil should 
not carry heavy books to and from school; as one-sided 
postures in standing, sitting, working, and playing all 
tend to produce lateral curvature of the spine. Nurse 
girls who carry a baby under one arm, or grocers’ boys 
laden down with provisions, often show marked deform- 
ity of the spine in consequence. 
The same remark applies to young persons in factories. 
At school frequent recesses give the pupils fresh air and 
change of position. Children should be made to stand 
with the head up, as if they were being measured and 
were trying to make themselves as tall as possible 
without actually standing on tiptoes (Goldthwait). 
This position throws the chest up and out and draws the 
shoulders back and the lower part of the belly in. The 
feet should be held straight, and toeing out must not be 
allowed. Weak feet, ankles, and legs will often cause a 
one-sided posture, as in this case one leg may be a little 
shorter than its fellow and lateral curvature of the spine 
will result. Astigmatism and deafness may cause the 
pupil to hold his head on one side (thus favoring lateral 
curvature) in trying to see and hear, and these must be 
corrected—astigmatism by glasses, and deafness often 
by removal of enlarged tonsils and adenoid growths. 
These diseases also greatly reduce the vitality and general 
health. Their surgical cure is, therefore, imperative. 402 
THE PREVENTION OF DISEASE 
Certain sports are particularly good in the prevention 
of deformities caused by round-back or lateral curva- 
ture. Thus, swimming with the breast-stroke (not side- 
stroke), riding astride, running and climbing, baseball, 
cricket, and football are desirable. Where there is a 
tendency to lateral curvature, side saddle riding, tennis, 
and golf may be inadvisable although I have known golf 
to cure lateral curvature by its effect in toning up the 
body through the invigorating outdoor exercise. 
The patient in this instance was a delicate, nervous girl, 
the more common type of patient with this deformity. 
Dress is most important in young children. Straps hold- 
ing up the clothing should always be made to bea,r on the 
shoulders next the neck, as do men’s suspenders, and not 
be placed so that they pass over the outer part of the 
shoulders. This position of the straps tends to cause the 
shoulders to droop and induces round shoulders 
(Goldthwait). 
Instruction in singing is much to be preferred to lessons 
in instrumental music where the positions are bad (as in 
playing the violin or piano). In singing the subject must 
stand erect and learn how to breathe properly and lift 
and fill the chest with air. 
Round-back is part and parcel of general weakness, as 
shown by weak ankles and turned out feet (see Figs. 17 
18), and increasing the vigor of the body by exercises, 
alternated with proper rest (the use of a low pillow at 
night or none), is more important than braces or back 
supports, although these have occasionally to be used. 
Consideration of the actual treatment of the deformities 
resulting from round-back or lateral curvature of the 
spine is out of our province, but it consists chiefly in 
well-directed exercises and occasionally (in lateral curva- 
ture) in the use of special apparatus and even plaster KNOCK-KNEES AND BOW-LEGS 
403 
casts. This treatment may best be undertaken by the 
orthopedic surgeon. 
KNOCK-KNEES AND BOW-LEGS 
Both these conditions (Figs. 15, 16) are due to general 
weakness or disease of the bones, particularly rickets. 
They are common deformities of young children. In 
knock-knees there is weakness of the knees owing to the 
Fig. 15.—Bow-legs (after Taylor). 
Fig. 16.—Knock-knees (after 
Taylor). 
stretching of the ligaments on the inside of the knees. 
Carrying heavy weights and standing too much may 
bring on knock-knee in older children. The feet are 
naturally weak and turned out (see page 405) unless 
they are purposely carried straight or turned in to 
counteract the weakness in the knees. The gait is 
awkward and the knees may knock together in walking. 
The deformity is due either to a bending of the lower part 
of the thigh bone or the upper end of the chief bone of 404 
THE PREVENTION OF DISEASE 
the leg, or both. Only one leg may be involved, but more 
often both legs. Occasionally one limb may have the 
bow-leg and the other the knock-knee deformity. In 
bow-legs the deformity commonly occurs below the knees 
in the chief leg bone (tibia), although the thigh bones 
may also be bent out of line. 
Prevention and Treatment.—Children with rickets 
should be under treatment for some months before they 
are permitted to stand. When the condition of knock- 
knees is not pronounced, so that the distance between 
the ankles in standing is not greater than 2 inches, the 
deformity may be corrected by making the inside of the 
sole of the shoe 34 inch thicker, so as to throw the weight 
on the outer side of the foot and take the strain off the 
inner border of the foot and the weak, inner side of the 
knees. In conspicuous cases of knock-knees or bow-legs 
braces should be applied by an orthopedic surgeon in the 
case of children under four who are walking. In severe 
cases operation is necessary in either knock-knees or 
bow-legs affecting children over four years of age. This 
consists in surgically breaking the deformed bones under 
an anesthetic and then setting the bones in proper 
position in a plaster-of-Paris cast. The operation is 
practically without danger. If the operation is done too 
early, as under four years, the deformity may recur. 
WEAK FOOT AND FLAT-FOOT 
These conditions are often seen in young children, as 
well as in adults who stand at their work, and should be 
corrected in their earlier stages before actual deformity 
occurs. 
In weak ankles there is usually a tendency to flat-feet. 
In standing, the characteristics of weak ankles are most 
apparent. These consist in prominence of the bones on WEAK FOOT AND FLAT-FOOT 
405 
the inside of the ankles, as seen in Fig. 17. Moreover, the 
subject stands with the feet held apart and the toes well 
turned out, as in Fig. 18. It was not so long ago that 
children were taught to turn their toes out in walking, 
and they were being continually corrected for failure to 
assume this position. 
Fig. 17. 
Fig. 18. 
The feet should be held in a straight line, neither 
toeing out or in while walking, although the slightly 
toeing in position is better than toeing out. 
Both weak ankles and flat-foot are caused by weakness 
of the ligaments and muscles of the foot. In weak ankles 
the weight tends to fall on the inside of the foot, as in 
Fig. 19, so that the arch of the foot gives way on the 
inner side and the entire sole of the foot rests on the floor. 
This is called flat-foot. Ordinarily only the outer half of 
the foot touches the floor in walking (Fig. 20). To deter- 406 
THE PREVENTION OF DISEASE 
mine the presence of flat-foot the soles of the feet may be 
smeared with vaselin, and then the patient may stand 
upon blotting paper to leave the impression of the feet; or, 
the soles of the feet may be brushed over with charcoal 
and the subject may stand upon white paper. In Fig. 
20 is seen the impression of a normal foot, while in Fig. 
21 is shown an impression of a very marked case of 
Fig. 19.—Foot seen 
from behind. 
Fig. 20. 
Fig. 21. 
flat-foot. In adults who develop flat-feet because their 
occupation requires them to be on their feet continually, 
as in the case of nurses, policemen, etc., there is often 
great discomfort or pain. This condition is commonly 
thought to be rheumatism. There may be pain and 
tenderness under the sole of the feet, about the ankles, 
under the heel, or under the outer ankle bone, and even 
in the calves of the legs, knees, thighs, hips, or back. 
Persons who stand much and have flat-feet and pain in 
the knees, hips, or back are often treated for rheumatism, WEAK FOOT AND FLAT-FOOT 
407 
or, if women, for womb trouble. On looking at the shoes 
of persons with weak ankles and flat-feet it will be seen 
that there is unusual wear on the inner edge of the soles, 
owing to the weight bearing chiefly on the inside of 
the feet (see Fig. 19). As we are dealing in prevention, 
it is not within our province to consider treatment of 
chronic and bad cases of flat-feet which 
often need forcible correction of the 
deformity by a surgeon and rest in bed 
with the feet in a plaster cast. Even 
marked cases of flat-feet, which requires 
plates to hold up the inner side of the 
soles of the feet, should go to the ortho- 
pedic surgeon for the fitting of plates 
rather than consult the shoe man, who 
will supply the ready-made article so 
commonly worn. To prevent flat-foot 
in the case of weak ankles and feet in 
children and adults who stand at their 
work the following advice may be 
given: 
In the first place the proper shoe 
should be worn. Such a shoe as is shown 
in Fig. 22 is of service and is often 
sold under the name of anatomic or orthopedic shoe. 
The sole forms a straight line on the inside of the shoe, so 
that the patient may have more bearing on the part 
where the greater weight comes, and the heel of the shoe 
is extended forward and inward for the same reason. 
This feature in the heel is a counterpart of the great toe in 
the barefoot savage which spreads out, or really in—that 
is, away from the outside of the foot—and prevents the 
foot and ankle from giving away as in weak ankle. 
Straight-foot walking and standing should then be 
Fig. 22. 408 
THE PREVENTION OF DISEASE 
practiced. The raising of the inner side of the sole of 
the shoe throws the weight of the body more on the outer 
side of the foot, and this is sometimes accomplished by an 
added sole piece about %6 inch thick (see Fig. 22), 
or by making the whole sole this much thicker along its 
inner border. 
Exercises in bare or stockinged feet are also' essential. 
The following are recommended : 
(1) Walk about the room three to five minutes with the 
toes pointing inward and the heels slightly raised from the 
ground (on tiptoes). 
(2) With the toes turned in walk on the outer border of 
the feet three to five minutes. 
(3) Stand with the toes turned in, quickly raise the 
heels, and slowly come down on the outer borders of the 
feet (three to five minutes). 
(4) While standing, rise on the toes, turn the heels 
outward; lower the heels slowly to the floor. 
The trained masseuse will also be of much service to 
children in manipulating the feet. Children should have 
times for rest and should practice walking straight-footed 
and on the outer borders of their feet with their shoes on. 
Bathing the feet with hot and cold water alternately 
for five minutes, followed by vigorous rubbing, will 
strenghten the muscles. 
If the general tone is low the improvement in the gen- 
eral condition will have a correspondingly beneficial 
effect upon the condition of the feet. CHAPTER XIX 
PREVENTION OF INFECTION AND BLEEDING IN 
WOUNDS 
Sterilization with Iodin, Inflammation, Sterilization by Washing. 
To Prevent Lockjaw. Special Wounds. Bullet Wounds. To 
Stop Bleeding. 
There are two methods in vogue to prevent the occur- 
rence of inflammation or infection in wounds. The first 
is most recent and simple. 
Sterilization of Wounds with lodin.—This is applic- 
able in wounds and cuts of all kinds where there is not so 
much bleeding as to demand its immediate arrest. 
Apply to the wound itself and to the skin immediately 
surrounding it the pure tincture of iodin by means of a 
small piece of absorbent cotton wound about the end of a 
stick, match, or tooth pick. The iodin should be freely 
applied so as to cover every part of the raw tissue. Wait 
a few minutes until the iodin is dry on the skin and then 
apply an absolutely clean or sterile dressing and bandage. 
If sterile gauze is not at hand, one may use cotton cloth 
which has first been boiled in water for five minutes. A 
dry dressing is better, however. In placing .the sterile 
gauze or cotton over the wound one should not allow one’s 
fingers to touch the part of the dressing that will come in 
contact with the wound. In small cuts compound tinc- 
ture of benzoin (p. 411) is ideal for treatment. 
No water should be applied to a wound before using 
iodin, because then the iodin will not penetrate into the 
tissues and kill germs. When the skin is very dirty or 
greasy about the wound it is well to wipe it off . with 
409 410 
THE PREVENTION OF DISEASE 
alcohol or gasoline, while protecting the wound by cover- 
ing it with a bit of sterile absorbent cotton or sterile gauze 
before applying the iodin. Then when the skin is dry 
apply the iodin to the wound and surrounding skin. 
If there are pieces of clothing, hair, splinters, or glass, 
etc., in the wound, these should first be picked out 
with forceps or hatpin before applying the iodin. 
Tincture of iodin is the most valuable first-aid treat- 
ment for all wounds and should be kept on hand wher- 
ever surgical accidents are likely to occur. Some 
smarting is produced by the application of iodin to fresh 
wounds, but this is temporary and not severe. In a 
recent book by the Medical Inspector General, Delorme, 
of the French Army the author states in italics, 
“Tincture of iodin is at present the best and safest 
disinfectant to make use of in the practice of war surgery, 
both in the fighting line and in the rear.” It is sometimes 
inconvenient for individuals to carry about on their 
persons a liquid like the tincture of iodin, so that oint- 
ments and powders may be substituted for the prevention 
and treatment of wound infections. 
Recent experiments in this country indicate that an 
ointment containing 10 per cent, each of tricresol and 
thymol may be safely used to the extent of a dram (or 
teaspoonful) on a wound, and will prove as effective as 
tincture of iodin in preventing infection. The bulk or 
base of the ointment consists of castor oil, 70 per cent.; 
white wax, 20 per cent.; and spermaceti, 10 per cent. 
Clean wounds, like cuts made by a surgeon, will heal at 
once without the formation of pus or inflammation, pro- 
viding cut surfaces are brought together and the wound is 
not too much torn or bruised. A single dressing is all 
that is required in such cases, and it is always advisable 
for the layman to leave the first dressing untouched until STERILIZATION OF WOUNDS WITH IODIN 
411 
the wound may be seen by a surgeon, even if a week or 
more elapse, if there is no fever, great pain, or certain 
signs of inflammation. 
In place of stitches the layman can more easily use 
surgeon’s adhesive plaster to close wounds. Strips of 
plaster inch wide and long enough to obtain a good 
hold on the skin (perhaps 2 inches on each side of the 
wound) should be laid at intervals of inch across the 
wound. The ends are firmly pressed down on one side of 
the wound, and while the edges of the wound are pinched 
together the free ends of the plaster are drawn tightly 
across the wound and pressed firmly down on the skin 
beyond. Strips of plaster should never completely 
encircle a limb or the circulation will be impeded. 
Large wounds should only be closed in part, leaving an 
inch or so for drainage. Small punctured wounds should 
not be closed at all, but after swabbing them deeply with 
iodin, a strip of sterile gauze or boiled cotton cloth should 
be pushed to the very bottom (by a boiled hairpin) to 
secure drainage before covering the wound with dressing. 
Since the tincture of iodin has become popular much 
damage has been done by its repeated application to 
wounds. A word of caution is therefore indicated here. 
A single application for a first sterilization of wounds is 
desirable but repeated applications do much harm in 
causing irritation. 
Also if tincture of iodin is applied over a sensitive 
skin area which is bandaged blistering may ensue. Apply 
the tincture to the wound and only a small area of skin 
surrounding it. For ordinary cuts on the hands, face or 
elsewhere which are not large enough to require stitching, 
and for abrasions where the skin is rubbed off, the applica- 
tion several times daily of compound tincture of benzoin 
on absorbent cotton, wound on the end of a toothpick or 412 
THE PREVENTION OF DISEASE 
match, is decidedly the best antiseptic treatment. The 
benzoin forms a protective coating over the wound or cut 
and requires no bandaging or covering of any sort. 
Tincture of iodine may be first applied lightly and only 
once to such small wounds and benzoin used several 
times daily till they heal. It is also the best treatment 
for cracks in the skin. 
Inflammation.—When there is much redness, swelling, 
pain, and heat about a wound it is best to apply a moist 
dressing until inflammation subsides. Soak sterile gauze 
(or boiled cheese-cloth) in boiling water containing as 
much boric acid as will dissolve. When sufficiently cool 
wring the water out of the gauze slightly with the clean 
hands, being careful not to touch the part of the gauze 
which will come in contact with the wound. Cover the 
wound over a large area with the dressing an inch thick, 
and then on this lay a piece of oiled silk or rubber cloth 
and enclose the whole with a bandage. Such a dressing is 
an absolutely harmless antiseptic poultice and will remain 
moist for twenty-four hours, when it may be replaced. 
Sterilization of Wounds by Washing.—The older 
method consists in washing wounds for fifteen minutes or 
so until all dirt and germs are removed. This is an 
efficient treatment, but requires some knowledge and 
skill to perform properly. Antiseptic solutions are often 
used, but water to which salt is added (1 level teaspoonful 
to the pint) and that has been boiled five minutes and 
allowed to cool sufficiently, is just about as efficacious. 
Pouring the water warm from a clean pitcher in a small 
stream upon the wound is one of the best methods, as one 
does not convey any germs to the wound with the hands. 
If there is much bleeding, water should be used as hot 
as can be borne. If the skin is very dirty surrounding the 
wound cover the wound first with a piece of sterile SPECIAL WOUNDS 
413 
gauze or boiled cotton cloth to protect it, and then wash 
the skin thoroughly with soap and water, and finally with 
alcohol diluted one-third with water. If there is much 
hair about the wound, as on the head, this must also be 
cut or shaved off for about an inch around the wound. 
The more thorough or, in other words, the longer the 
washing is conducted (from ten to twenty minutes), the 
better will be the result. In case it is necessary to 
remove some dirt or clots that cannot be washed off, one 
may boil some pieces of absorbent cotton or old cotton 
cloth for five minutes, and after washing one’s hands for 
the same length of time one may bathe the wound and rub 
off the dirt or clots with these as sponges. Then the 
wound should be covered with dry sterile gauze or, lack- 
ing this, wet cotton cloth after boiling it for five minutes. 
The part of the sterile gauze, or boiled cotton cloth, 
which will touch the wound should not first come in 
contact with the fingers. 
To Prevent Lockjaw.—Punctured wounds of the hands 
or feet soiled with street or stable dirt are especially liable 
to lockjaw unless properly handled. Any wounds much 
bruised or torn are also more subject to this infection. 
The reader is referred to page 129 for means of absolutely 
preventing this fearful complication. 
Special Wounds.—In deeply cut wounds of the hands 
it is not sufficient that the wound be closed by stitches, 
but nerves and tendons must be properly united or some 
of the fingers may be useless. This is work for an able 
surgeon and the general practitioner not infrequently fails 
to secure good results in these cass. Ragged, bruised 
wounds should be swabbed with iodin and left open to a 
considerable extent for drainage. 
Punctured wounds made by nails, splinters, knives, 
and teeth of animals are among the most difficult for the 414 
THE PREVENTION OF DISEASE 
layman to treat properly, even in the way of a first 
dressing. Unless made by a small, very clean body, as a 
needle, such wounds must be swabbed to the bottom with 
iodin and kept open by stuffing in strands of string or 
cotton cloth which have been boiled five minutes. Iodin 
may be applied by means of a little absorbent cotton 
wound on a toothpick. The toothpick should be wet 
before twisting the cotton about it to keep the cotton 
from coming off in the wound. 
Punctured wounds so small that one cannot swab them 
out with iodin, as from nails or bullets, are those which 
especially demand immediate surgical attention because 
germs become sealed in the wound and inflammation and 
lockjaw may result (see page 129). The moist, antisep- 
tic dressing, described under Inflammation, is often best 
for punctured wounds. Scalp wounds frequently bleed 
freely. The bleeding may be stopped by pouring water 
as hot as can be borne over the wound and by covering 
the wound with a pad of sterile gauze or boiled cotton 
cloth and holding it very tightly by a bandage about the 
head. Iodin is the best agent to apply when bleeding has 
stopped. The hair should be cut off for 2 inches about 
the wound, which may be closed by adhesive plaster 
(see above) and covered with dry sterile gauze and 
bandage. 
Bullet Wounds.—Clothing should be cut away about 
the wound and the wound and skin (for 2 inches around 
the wound) should be painted with tincture of iodin. As 
soon as the iodin is dry a pad of at least an inch in thick- 
ness should be bandaged snugly over the wound. The 
pad had best consist of sterile gauze, but in its absence, 
old cotton cloth which has boiled five minutes or sterile 
absorbent cotton may be used. The patient should 
be kept absolutely quiet in bed, as shock is common. TO STOP BLEEDING 
415 
If a limb is wounded it is well to apply some sort of a 
splint made of thin board, padded with folded sheets, to 
keep the wound at absolute rest. 
Shock is shown by pallor, cold hands and feet, and 
weak, rapid pulse. The patient should be given 4 table- 
spoonfuls of whisky in an equal amount of hot water 
and be surrounded by hot-water bags. 
Probing for bullets should never be undertaken by the 
layman and is usually undesirable on account of the 
danger of pushing germs into the wound. The a>ray is 
employed to locate bullets. Bullets are sterilized to 
some extent by the scraping they get and the heat gener- 
ated in the weapon, but if they carry any clothing into 
the wound inflammation is almost sure to result. 
Where a bullet passes through the body the wound of 
exit is usually larger and more ragged than the wound of 
entrance. If a person is hit by a charge of shot from a 
shot-gun at close range a dreadful wound is produced. 
Bleeding must be stopped (see below), the cavity thor- 
oughly swabbed with iodine, and packed loosely with 
sterile gauze or boiled cotton cloth, and covered with a 
thick pad of the same and bandage. Bullet wounds of 
the head, chest and abdomen are naturally the most 
serious and demand instant surgical attendance. 
To Stop Bleeding.—Keep cool. An adult may lose 1 
to 2 pints of blood without danger. 
When Bright Red Blood is Flowing in Spurts.—Place 
the patient on his back and make firm presure with both 
thumbs into the flesh just above the wound, that is, 
nearest the body. An assistant should then tie a tight 
bandage about the limb between the wound and the body 
—an elastic pair of suspenders or (best) a piece of rubber 
tubing. Or a rope or strap may be fastened tightly over 
a folded towel, to prevent injury of the skin. A folded 416 
THE PREVENTION OF DISEASE 
towel or handkerchief may be twisted tightly about the 
limb with a stick. A pad of sterile gauze, rounded stone, 
or cork, over clean gauze or cotton and directly upon 
the wound, held in place by bandaging, may help 
to plug the opening. A tight bandage (or tourniquet) 
may be kept on a limb for an hour without doing serious 
damage to the tissues. A bleeding arm or leg should 
always be held well up in the air resting upon some 
extemporized support. Spurting blood comes from an 
artery. 
To Stop Steady Flow of Dark Blood.—Make firm pres- 
sure with a pad of sterile gauze, or absorbent cotton, or 
clean handkerchief wet with alcohol, directly over the 
wound. This may be held in place with a tight bandage. 
Raise the limb on a support. If the flow of blood is large 
tie a tight bandage about the limb below the wound, that 
is, farthest from the body. This may be removed in half 
an hour. Steady flow of dark blood comes from a vein 
bringing blood toward the body and heart. Spurts of 
bright red blood come from an artery bringing blood 
away from the body and heart. 
To Stop Constant Oozing of Blood.—This means that 
small vessels are cut, and bleeding may be expected to 
stop through clotting of blood and contraction of the cut 
ends of the vessels. If it persists pouring water as hot as 
can be borne upon the wound may stop the bleeding, or 
constant pressure made on a pad of sterile gauze, absorb- 
ent cotton, or folded handkerchief wet in alcohol will ar- 
rest it. 
Ice-water at hand may be used in place of hot water, 
although the latter is preferable. The bleeding limb 
should be elevated. INDEX 
Abscess of teeth, 196, 211 
Acne, 90 
Adenoids and tonsils, diseased, 
cause of, 205 
how to detect, 205 
remote effects of, 164,175 
195, 196, 205, 210 
removal of, 206 
Alcohol, action of, 23 
on circulation, 25, 26 
on mental efficiency, 24 
on muscular system, 25 
on nervous system, 23 
on stomach, 27 
on temperature of body, 26 
as a food, 27 
as a poison, 27 
as a stimulant, 25 
bad effects of, 28 
composition of various 
drinks, 21, 22, 23 
summary of action, 28 
Allergy, 387 
Amebic dysentery, 113 
Anaphylaxis, 387 
Ankles, rheumatism of, 406 
weak, 404, 203, 332. See also 
Weak ankles. 
Ankylostomiasis, 392 
Appendicitis, cause of, 203, 332 
Armpits, perspiring, 80 
Arteriosclerosis, 285 
blood-pressure in, 290 
Arteriosclerosis, blood- pres- 
sure, estimation of, 292 
high, 292 
causes of, 285, 293 
constipation in, 319 
diet in, 297 
drinking in, 299 
examination for, annual, 295 
exercise in, 300 
obesity in, 288 
prevention of, 295 
work in, 301 
Asiatic cholera, 109 
carriers of, 109 
how communicated, 109 
means of preventing, 109 
vaccination against, 109 
Asthma, 385 
causes, 386, 389 
diagnosis, 388 
prevention, 389 
symptoms, 385 
treatment, 390 
Bacillary dysentery, 111 
Baldness, 91 
Barber, diseases acquired from, 
93 
Baths, 81 
cabinet, 87 
cold, 81 
hot, 86 
hot-air, 87 
417 418 
INDEX 
Baths, lukewarm, 85 
outdoor, 83 
dangers of, 84 
sea, 83 
Turkish, 87 
warm, 86 
Beriberi, 360 
cause of, 360 
symptoms of, 363 
vitamins in, 360 
Bleeding, to stop, 415 
Blood-pressure, 290 
estimation of, 292 
high, 292 
significance of, 292 
Botulism, 354 
Bow-legs, 403 
causes of, 403 
prevention of, 404 
treatment of, 404 
Breakbone fever (See Dengue). 
Breath, foul, 208 
Bright’s disease of kidney, 290, 
292, 294, 296 
causes of, 290 
prevention of, 295 
Bubonic plague, 143. See also 
Plague. 
Bullet wounds, 414 
Caffein, 17, 20 
Calories, 66 
Cancer, classes of, 212 
cures possible, 215, 216, 219 
early signs in, 212 
frequency of, 217 
heredity in, 230 
immunity in, 229 
injury as cause of, 221 
mortality in, 217, 232 
of appendix, 226 
Cancer of bone, 213 
of breast, 212, 221 
of colon, 214 
of face, 227 
of gall-bladder, 226 
of lip, 215, 226 
of mouth, 212 
of rectum, 214 
of skin, 212, 226 
of stomach, 214, 223 
of thyroid, 213 
of tongue, 212, 226 
of womb, 213, 225 
precancerous stage of, 215 
Canned food, poisoning from, 
353 
Carbohydrates, 58 
Cereals, 57 
Cerebrospinal meningitis, 185 
carriers in, 187 
prevention of, 187 
serum cure of, 186 
symptoms of, 186 
vaccination in, 189 
Chest, rheumatism of, 266 
Chicken pox, 101 
Children, adenoids in, 205, 280 
circumcision in, 270 
colds in, 174, 281 
constipation in, 328 
diseases of, 269 
feeding of, 271-279 
fevers in, 280 
indigestion in, 279, 336 
malaria, 151 
mortality in, 269, 271 
nervous, 304, 305 
sexual hygiene of, 248 
sickness of, 280 
teeth in, 37, 282 
tonsils in, 205, 224, 280 INDEX 
419 
Children, vaccination against 
smallpox, 94, 282 
typhoid, 102 
Chocolate, action and uses, 19 
composition of, 19 
Cholera, Asiatic, 109 
carriers of, 109 
how communicated, 109 
means of preventing, 109 
vaccination against, 109 
Chorea, 262 
Circumcision, 270 
Clothing for hot weather, 81 
for women, 79 
in winter, 58, 81 
of cotton, 80 
of linen, 80 
of silk, 80 
of wool, 80 
underclothing, 79 
Cocain habit, 35 
Coffee, action of, 20 
bad effects of, 20 
caffein in, 17 
composition of, 18 
excessive use of, 20 
habitual use of, 20 
susceptibility to, 19 
Cold in head, 173 
avoidance of, 174 
causes of, 174 
prevention of, 174, 175 
remedies in, 176 
treatment of, 176, 178 
vaccination in, 175 
Colds, 173 
Complexion, 89 
endangered by barber, 93 
eruptions on, 90 
Conception, when likely to 
occur, 256 
Constipation, 319 
causes of, 321 
definition of, 320 
diet in, 321, 323 
drugs in, 324 
exercise in, 326 
in children, 328 
injections in, 327 
massage in, 327 
mineral waters in, 324 
prevention of, 321 
symptoms of, 319, 328 
with colic, 328 
Consumption, 160. See also 
Tuberculosis. 
Cooking, broiling, 46 
frying, 46 
influences digestion, 46 
roasting, 47 
stewing, 47 
Cows, tuberculosis in, 163, 345 
udder disease in, 346 
Curvature, lateral, of spine, 397 
Cuts, 409. See also Wounds. 
Dandruff, 91 
Dandy fever, 158 
Deafness, prevention of, 206, 
322, 401 
Deformities, prevention of, 396 
Dementia, precocious, 314 
senile, 316 
Dengue, 158 
cause of, 158 
prevalence of, 159 
prevention of, 159 
symptoms in, 159 
Diabetes, prevention of, 384 
Diet, 47. See also Food. 
calories required daily, 67 
of fruit, 59 420 
INDEX 
Diet of milk, 56 
salt essential in, 63 
vegetarian, 54, 61 
vs. meat, 54 
Digestion in intestines, 46 
in mouth, 42 
in stomach, 45 
influenced by cooking, 46 
by dress, 66 
by emotion, 45 
by mealtimes, 66 
by posture, 66 
Digestive diseases, 330 
functional, 330 
organic, 330 
reflex or secondary, 330 
Diphtheria, 115 
antitoxin in, 115 
as preventive, 116, 117 
dangers of, 117 
for treatment, 116 
carriers of, 118 
diagnosis of, 121 
from milk, 345 
how acquired, 118 
susceptibility, Schick’s test, 
119 
vaccination against, 121 
Dysentery, 111 
amebic, 113 
treatment of, 114 
bacillary, 111 
carriers of, 112 
how acquired, 112 
prevention of, 112 
symptoms of, 112 
vaccination against, 113 
Dyspepsia, 330 
nervous, 336 
Erysipelas, cause of, 204 
Examination, physical, 295 
Exercise by correspondence, 70 
college, 70 
dangers of, 77 
fatigue from 73, 74 
for constipation, 326 
for different ages, 69 
for elderly, 72 
for flat-feet, 408 
for general development, 79 
for home, 71 
for middle aged, 72 
for obesity, 382 
for'youth, 69 
influence on body, 72 
on breathing, 74 
on heart, 52, 74 
on nervous system, 72, 73 
school, 70 
Face, acne on, 67, 90 
eruptions on,from barber, 93 
pimples on, 90 
powders, 90 
Fatness, 373 
Feeding infants, orange juice in, 
27, 276, 367 
pasteurized milk for, 277, 
347 
simple formula) for, 273, 
279 
Feet, flat-, 404. See also Flat- 
feet. 
perspiring, 80 
rheumatism of, 406 
Finger-nails, care of, 93 
Fish poisoning, 355 
Flat-feet, 404 
diagnosis of, 406 
exercises for, 408 
massage in, 329, 408 INDEX 
421 
Flat-feet, prevention of, 407 
symptoms in, 406 
Flatulence, intestinal, 289 
Fleas as cause of bubonic 
plague, 144 
Food, absorption of, 47 
poisoning, 333 
symptoms of, 333, 350 
requirements, 47 
Freckles, 90 
Fruit poisoning, 356 
Gall-bladder inflammation, 
cause of, 197, 203, 209 
remote effects of, 209 
Gall-stones, 332 
Gastritis, 332 
Glands, enlarged, 201, 203 
tuberculous, 162 
treatment of, 172 
Goiter, adolescent, 372 
prevention of, 373 
Gonorrhea, chronic, detection 
of, 244 
period of development, 235 
prevention of, 240, 241 
remote effects of, 235, 236 
symptoms of, 235 
Gout, rheumatic, 262 
Grippe, 179 
Hair, care of, 91 
to prevent falling, 92 
Hardening of arteries, 285. 
See also Arteriosclerosis. 
Hayfever, 386 
causes, 386, 389 
diagnosis, 388 
prevention, 389 
seasonal, 386 
Heart disease, 293 
causes of, 197, 203, 204 
prevention of, 295, 303 
Hemorrhage, to stop, 415 
Hookworm disease, 392 
diagnosis, 394 
how acquired, 392 
prevention, 394 
symptoms, 392 
treatment, 395 
Humpback, 399 
Hydrophobia, diagnosis of, in 
dogs, 125 
frequency of, 122 
in man, 128 
period of development, 126 
symptoms in dogs, 123 
in man, 128 
treatment of dog bite, 127 
vaccination against, 127 
effects of, 128 
Ice, dangers of, 65 
in cooling water, 65 
to know when safe, 65 
Ice-cream poisoning, 348 
Indigestion, 330 
causes of, 441, 330, 336 
nervous, 336 
Infant feeding, formulae for, 
273, 279 
orange juice in, 276, 367 
pasteurized milk in, 277, 
347 
Infantile paralysis, 190 
carriers in, 190 
germ of, 190 
how conveyed to persons, 
191 
path of entrance to body, 
190 422 
INDEX 
Infantile paralysis, period of 
development of, 191 
prevention of, 192 
serum for, 193 
symptoms of, 191 
Infants, prevention of disease 
in, 269 
Infection in wounds, prevention 
of, 409, 412 
Inflammation in wounds, 412 
Influenza, 179 
causes of, 179 
contagiousness of, 181 
definition of, 179 
development period in, 180 
prevention of, 182 
symptoms, 180 
Insanity, 312 
causes of, 313 
alcohol, 313 
syphilis, 313 
heredity in, 313 
manic-depressive, 316 
prevention of, 304, 312 
treatment of, 316 
Intestinal flatulence, 289 
putrefaction, 289 
Iodin in wounds, 409 
Joints, inflamed, causes of, 210, 
258, 262 
Kidney, Bright’s disease of, 
290, 292, 294, 296 
causes of, 290 
prevention of, 295 
stone in, 332, 335 
Knees, knock-, 403. See also 
Knock-knees. 
Knock-knees, 403 
causes of, 403 
Knock-knees, prevention of, 
404 
treatment of, 404 
Lateral curvature of spine, 397 
Legs, bow-, 403. See also Bow- 
legs. 
rheumatism of, 406 
Lockjaw, 129 
antitoxin in, 129 
how made, 132 
how acquired, 129 
prevention of, 131, 132 
symptoms, 130 
wounds predisposing to, 129 
Locomotor ataxia, 237. 
Longevity and marriage, 257 
in various countries, 276 
Lumbago, 265 
Malaria, 147* 
cause of, 147 
how acquired, 147 
methods of preventing, 147 
quinin in, 150, 152 
where prevalent, 153 
Marriage and longevity, 257 ' 
sexual hygiene in, 252 
Masturbation, 248 
circumcision for, 248 
prevention of, 248 
remote effects of, 249, 250 
treatment of, 251 
Measles, 136 
contagious period of, 136 
development period in, 136 
isolation required, 137 
mortality in, 136 
prevention of, 137 
symptoms, 137 
Meat poisoning, 351 INDEX 
423 
Mental disease, prevention of, 
304, 312 
Milk, bacteria in, 344 
diarrhea (infantile) from, 344 
diphtheria from, 345 
dirt in, 345, 346 
food value of, 56 
for infant feeding, 273, 279 
pasteurization of, 277, 347 
Freeman’s home, 348 
home, 347 
poisoning, 333 
scarlet fever from, 345 
septic sore throat from, 346 
to aid digestion of, 56 
to fatten invalids, 56 
tonsillitis from, 346 
tuberculosis from, 345, 346 
typhoid fever from, 345 
Mortality rates, 269, 270 
from tuberculosis, 270 
in infants, 269, 270 
reduction in, 270 
Mosquitoes, dangers of, 147, 
153, 158 
Mouth breathing, 37 
infection, 43, 194 
significance of, 194 
pus germs in, 198 
Mumps, 138 
complications, 139 
contagious period, 138 
development period, 138 
duration of, 139 
symptoms, 138 
Muscular rheumatism, 265 
Mushroom poisoning, 357 
Nervous children, rearing of, 
306 
diseases, prevention of, 304 
Nervous dyspepsia, 336 
indigestion, 336 
build in, 336 
causes of, 336, 337 
diagnosis of, 333, 340 
heredity in, 336 
posture favoring, 336, 337 
symptoms of, 338 
surges in, 341 
treatment of, 339 
prostration, 304 
causes of, 304, 306 
prevention of, 304, 312 
symptoms of, 309 
Neurasthenia, 304 
Neuritis, causes of, 265 
Nose infections, 258 
significance of, 258 
Obesity, 373 
Bouchard’s cure, 379 
causes of, 374 
diseases in, 374 
Ebstein’s cure, 380 
effecting life, 373 
effects of, 373 
exercise in, 382 
glandular secretions in, 374, 
376 
Locke’s cure, 380 
milk cure in, 312 
Oertel cure in, 378 
reduction of, 377 
symptoms in, 376 
treatment, 377 
water in, 382 
Old age, dangers in, 285 
deferred, 285, 295. See 
also Arteriosclerosis, 285 424 
INDEX 
Opium habit, 35 
Orange juice in infant feeding, 
276, 367 
preventing scurvy, 367 
Paralysis, infantile, 190. See 
also Infantile paralysis. 
Paranoia, symptoms of, 315, 
316 
Paresis, 237, 255, 314 
Pasteurization of milk, 347, 348 
Freeman’s home method, 
348 
home, 348 
Pellagra, causes of, 370 
symptoms of, 370 
vitamins in, 370 
Perspiration of armpits, 81 
of feet, 80 
Physical examinations, 295 
Plague, 143 
contagion in, 144 
countries invaded, 143 
Haffkine’s vaccine in, 146 
how acquired, 144 
prevention of, 145 
symptoms of, 144 
Pneumonia, 183 
broncho, 183 
germs in mouth, 198, 203 
how communicated, 184 
lobar, 184 
prevention, 184, 185 
treatment, 185 
Poisoning by food, 344 
ptomain, 350 
Poliomyelitis, 190. See also 
Infantile paralysis. 
Potato poisoning, 357 
Poultice, antiseptic, 412 
Pregnancy, prevention of, 255, 
256 
Protein requirements, 50 
Ptomain poisoning, 350 
Putrefaction, intestinal, 289 
Pyorrhea, 40, 147, 158, 196, 210 
Rabies, 122 
diagnosis, 125 
dumb, 124 
symptoms of, 123 
Rachitis, 367. See also Rickets. 
Rheumatic gout, 262 
Rheumatism, acute, 258 
causes, 205, 258, 259 
prevention of, 258, 262 
symptoms, 258 
chronic, 262 
causes of, 262 
prevention, 263, 264 
muscular, 265 
of ankles, 406 
of back, 265 
of chest, 266 
of feet, 406 
of legs, 406 
Rickets, 367 
causes of, 367 
prevention of, 369 
symptoms of, 368 
Riggs’ disease of gums, 40, 197, 
210 
causes of, 40 
cure of, 41 
prevention of, 41 
remote effects of, 41 
Round shoulders, 397 
effects of, 397 
prevention of, 400 
symptoms of, 397 
treatment of, 322, 401 INDEX 
425 
Sausage poisoning, 354 
Scarlatina, 133. See also Scar- 
let fever. 
Scarlet fever, 133 
carriers of, 134 
development period, 134 
disinfection in, 135 
from milk, 345 
how acquired, 134 
isolation period, 135 
prevention, 135 
susceptibility to, 133 
Scurvy, 365 
cause of, 365 
cure of, 365 
in infants, 366 
prevention of, 367 
symptoms of, 366 
prevention of, 367 
symptoms, 366 
vitamins in, 366 
Self abuse, 248. See also Mas- 
t urbation. 
Sexual diseases, 234 
prevention of, 240 
hygiene in children, 248 
in marriage, 252 
in youth, 248 
Shell-fish poisoning, 355 
Shoulders, round, 397. See 
also Round shoulders. 
stoop, 397 
Skin, eruptions of, 90 
to prevent, 91 
Smallpox, inoculation against, 
95 
prevention of, 94 
preventive measures, 96 
symptoms of, 100 
test for susceptibility, 97 
vaccination against, 94 
Soaps, 90 
Spine, curvature of, 397 
Stiff neck, 265 
Stomach, cancer of, 214, 233 
330 
ulcer of, 330 
Stoop shoulders, 397 
Stone in kidney, 272 
Stoutness, 373. See also Obe- 
sity. 
Strawberries, poisoning by, 358 
St. Vitus’ dance, 262 
cause of, 201 
Sunburn, 90 
Swimming pools, diseases from, 
85 
Syphilis, contagious period, 237 
in mothers, 237, 238 
hereditary, 237 
how acquired, 236 
locomotor ataxia in, 237 
marriage in, 244 
paresis in, 237 
period of development, 236 
prevalence of, 238, 239 
prevention of, 240, 246, 248 
stages in, 238 
Wassermann test in, 238, 240, 
244 
Tea, action of, 20 
bad effects of, 20 
caffein in, 17 
composition of, 18 
excessive use of, 20 
habitual use of, 20 
susceptibility to, 19 
tannin in, 18 
Teeth, abscess of, 196, 211 
adenoids affecting, 37 
brushing, 39 426 
INDEX 
Teeth, care of, 38, 39 
cause of serious diseases, 196, 
211 
dental floss in care of, 39 
irregular, 37 
protruding, 37 
Riggs’ disease of, 40, 197, 210 
straightening, 38 
toothpicks, 39 
Tetanus, 129. See also Lock- 
jaw. 
Them, 17 
Throat, infection of, 43, 194 
from milk, 345,346 
significance of, 194 
Tobacco, action of, 30 
composition of, 32 
effect in cigarettes, 33, 34 
in cigars, 33 
in pipes, 33 
on efficiency, 34 
ill effects of, 30 
psychic effects of smoking, 34 
Toe-nails, care of, 93 
Toilet powders and soaps, 89 
Tonsillitis, acute, 266 
from milk, 345,346 
prevention of, 267 
Tonsils and adenoids, diseased, 
cause of, 205 
how to detect, 205 
remote effects of, 164,175 
195, 196, 203, 205, 
210 
removal of, 206 
tuberculous, 203 
Tuberculosis, 160 
acute form, 166,167 
age when it begins, 161 
build susceptible to, 162 
care of patients, 170 
Tuberculosis, causes of, 164 
conditions favoring, 166 
contagion of, 165 
disinfection in, 172 
early symptoms of, 168 
from milk, 163, 346 
immunity to, 165 
in children, 162 
in cows, 163 
inheritance of, 161 
marriage in, 170 
mortality in, 160 
occupations favoring, 166 
of glands, 162 
paths of entrance of, 162 
percentage attacked, 161 
prevention of, 168, 170, 172 
treatment of tuberculous 
glands, 172 
Tuberculous glands, 162 
treatment of, 172 
Typhoid fever, 102 
carriers of, 107 
from milk, 345 
how acquired, 105 
means of contagion, 105, 
107 
vaccination against, 102 
period of protection 
by, 104 
Ulcer of stomach, 330 
and duodenum, cause of, 
199 
cancer following, 223, 330 
causes of, 199, 331 
medical cures in, 330 
surgical cures in, 330 
Uncinariasis, 392 
Underclothing, 80 INDEX 
427 
Vaccination against cerebro- 
spinal meningitis, 189 
against cholera, 109 
against colds, 175 
against diphtheria, 120 
against dysentery, 113 
against hydrophobia, 127 
against infantile paralysis, 
193 
against influenza, 182 
against lockjaw, 129 
against plague, 146 
against pneumonia, 185 
against smallpox, 94 
dangers of, 98 
origin of, 95 
period of protecting, 97 
proof of value, 98 
technic of, 98 
vaccine matter, 96 
against typhoid fever, 102 
against whooping-cough, 142 
against yellow fever, 157 
Vegetables, poisoning by, 356 
Vegetarian diet, 61 
Ventilation, 88 
Visceroptosis, 336 
Vitamins, 48 
absent in pasteurized milk, 
366 
in beriberi, 360 
in pellagra, 370 
in rickets, 367 
in scurvy, 365 
lack of, 362,363 
varieties of, 48, 49 
Wassermann test in syphilis, 
184, 189 
Water, dangers from, 63 
in daily diet, 63 
supply, 63 
from wells, 64 
purified by bleach, 65 
by boiling, 64 
by filtering, 66 
Weak ankles, 404 
exercises for, 408 
massage for, 408 
prevention of, 407 
symptoms of, 406 
Weight of body, normal, tables 
for height and age, 375 
Whooping-cough, 139 
development period, 140 
disinfection in, 143 
mortality in, 140 
prevention of, 141,142 
symptoms in, 140 
vaccination against, 142 
Wounds, bullet, 414 
dressing for, 409 
inflammation in, 412 
iodin in, 410 
lockjaw in, 129, 413 
stitching, 411 
to prevent infection of, 409, 
412 
treatment of, 409-415 
Yellow fever, 153 
cause of, 153 
how to avoid, 155 
prevention of, 155 
serum in, 157 
symptoms of, 156 
vaccine for, 157 
where prevalent, 156