mations 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 145).

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



PREVENTION OF ACUTE AND CHRONIC RHEUMATISM 209

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.

Muscular Rheumatism. This is a condition 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 agonizing 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 42). The avoidance of exposure to cold and
damp and of sitting in drafts when warm are most
essential.

There is no connection between muscular rheumatism
and rheumatic fever or the various forms of joint inflam-
mation we have considered above, which masquerade
under the generic cloak of ignorance known as chronic
rheumatism. To prevent severe forms of muscular rheu-
matism one should at once resort to rest and heat on the

14



210 THE PREVENTION OF DISEASE

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 com-
pound 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 breath-
ing 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, and sKould 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 probably 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, towel, etc. Therefore



ACUTE TONSILLITIS 211

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 the kidneys, inflamed joints, etc. (see page 145).
For this reason one cannot teach the public too often or
emphatically that it is to be avoided by all means. Be-
cause patients apparently more often escape the dangers is




Fig. 5. Acute follicular tonsillitis (Gleason).

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
148). There is the most peculiar danger in tonsillitis and
sore throat in dairy employees, as the causative germ grows
and multiplies most favorably 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 204).

The dairy employee with sore throat should be im-
mediately removed from work and the local health au-



212 THE PREVENTION OF DISEASE

thority notified, to protect both the employer (from dam-
ages) and the public.

The most useful measure to avoid acute tonsillitis con-
sists 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 conse-
quences of this condition are both dangerous and far reach-
ing (see page 153). To avert these, and recurrences of
acute attacks, the total removal of the tonsils is com-
monly 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 remark-
able. The infant mortality has had most to do with statis-
tics 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 computing 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 mor-
bus, 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.

213



214 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 government-
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 excellence 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 215

as a routine measure? There is not the slightest doubt
that it would be for the best interest of every male infant
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-
Jiole 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 193)
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 artificial
feeding and to the generally inferior physique of found-
lings.

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 Washington 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
leadership once more with 1.66 deaths, and these increase



216 THE PREVENTION OF DISEASE

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 districts.
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 diseases, 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 German 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 ten years ago, the mortality of babies under one year
of age per 1000 births was very nearly 120, as compared 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 present 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 infant mortality by one-half in a
decade may be attributed chiefly to the improvement in
the milk-supply alone, as the climate has naturally re-



THE PREVENTION OF DISEASES OF CHILDREN 217

mained 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 284) . 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 diluting a
rich cow's milk with water we may obtain the right per-
centage of fat and at the same time reduce the normal
quantity of casein, so that it will coincide with 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 endeavoring
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 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,



218 THE PREVENTION OF DISEASE

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 if
ounces (4 tablespoonfuls) ; from a quart of milk containing
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 which 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 r 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. Each feeding consists of 2\ 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.

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-



THE PREVENTION OF DISEASES OF CHILDREN 219

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
287. Boiling the milk makes it more digestible by pre-
venting the formation of tough curds in the child's stom-
ach. 1

This method of feeding babies from birth with boiled
sk'mmed 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 ex-
clusively, 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 modifica-
tions 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 differ-
ent 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 dis-
agrees and gives rise to apparent curds (in reality, soap) in
the bowel discharges. 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
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.

1 Two teaspoonfuls of freshly prepared orange juice should be
given the baby twice a day about an hour before the milk feeding
(see pages 220, 221, 303).



220 THE PREVENTION OF DISEASE

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 malassimilation
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 which carried off the babies to the ex-
tent 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 mal-
nutrition 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
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



THE PREVENTION OF DISEASES OF CHILDREN 221

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 204).

The food should be adapted to each individual child by
an expert and his advice should be sought whenever pos-
sible.

Perhaps the method of feeding infants best adapted for
universal 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 ingredients
of human milk. Also because cows' milk contains more
than double the percentage of proteins found in human
milk. Sugar is added because it is a normal ingredient 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.

l "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.



222 THE PREVENTION OF DISEASE

Ordinary sugar agrees with some infants, but accustoms
them to an overs weet 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 1 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