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 \ 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
increased by \ 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.
THE PREVENTION OF DISEASES OF CHILDREN 223
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^
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 219).
System in the bringing up of children is of as great im-
portance as in any other business of life. There is a proper
time for everything a time for nursing or feeding, 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 particu-
larly 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.
224 THE PREVENTION OF DISEASE
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 visit-
ing 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 de-
scribed their appearance and method of detection in an-
other place (see page 153).
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 leading
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 dis-
eased tonsil.
THE PREVENTION OF DISEASES OF CHILDREN 225
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 pos-
sibilities.
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 disease 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 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, necessary 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 neces-
sity 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 153).
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
15
226 THE PREVENTION OF DISEASE
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 im-
prove 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 pre-
vents the occurrence of a high, narrow palate which leads
to obstructed nasal breathing or, in other words, favors
mouth-breathing (see pages 20, 153).
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 77). Then the ques-
tion 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 193).
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 76).
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 weaken-
ing and serious malady (see page 107). Hookworm 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
THE PREVENTION OF DISEASES OF CHILDREN 227
be indicated for the offspring of tuberculous progenitors
(see page 247).
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 276).
Children should be taught from infancy the necessity of
individual handkerchiefs, soap, towels, wash-basins, cloth-
ing, 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 com-
mon. Even at home, eruptive diseases, colds, tonsillitis,
diphtheria, tuberculosis, etc., may be communicated by
the common use of these 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, 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 ar-
teries or, as it is called technically, arteriosclerosis.
ARTERIO SCLERO SIS
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 arterioscle-
rosis 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 thickening 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 rem-
edy by increasing their thickness. By strain of the arteries
is meant attempts at their overfilling, thus augmenting
228
ARTERIOSCLEROSIS 229
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 sub-
ject to nervous excitement 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 occur-
ring 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 ob-
struction of the artery which supplies the heart with blood,
when death is immediate. Both apoplexy and heart fail-
ure 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 reservoir,
and in their normal condition can hold all the blood in the
body if they are dilated. Overeating of meat is especially
230 THE PREVENTION OF DISEASE
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 effects 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 im-
portance. 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 stimulation 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
constant mental excitement, expectation, hope deferred,
anxiety and uncertainty dependent upon certain phases of
modern life, as the endeavor to keep one's place in the
world, or following a speculative business, or arduous pro-
fession, or indulging in too frequent sexual excitement
(see page 187) or in other dissipations.
ARTERIOSCLEROSIS 231
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 thickening
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 ca-
lamitous 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 require-
ments 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 any other cause. Certain chemical sub-
stances favor the production of arteriosclerosis. The abuse
of alcohol (the cause of 25 per cent, of cases of arterioscle-
rosis 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 arteriosclerosis 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 hard-
ening of the arteries through poisons resulting from the
232 THE PREVENTION OF DISEASE
stagnation of the intestinal contents and their putrefac-
tion. 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 con-
sists in total avoidance of meat, fish, and fowl and the sub-
stitution 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 overcome.
High enemata once in five days are useful. If any form of
local inflammation is present, as chronic appendicitis or
gall-bladder trouble, it must be cured, as it affords a local
nest for the breeding of the colon bacilli. Chronic intes-
tinal putrefaction is of great importance, since the absorp-
tion of the poisons generated by the colon germs may lead
not only to high blood-pressure, hardening 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."
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
ARTERIOSCLEROSIS 233
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 dis-
ease 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 practically 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, 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 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 thick-
ening 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
234
THE PREVENTION OF DISEASE
itself diseased, or the heart being strained by pumping
blood through the thickened vessels. But thickening of
the vessels is not always accompanied by high blood-press-
Fig. 6. Technic of sphygmomanometry with the Stanton in-
strument. Blood-pressure apparatus attached to arm. On squeez-
ing the smaller bulb the cuff about the arm is inflated and air-
pressure in chamber above mercury is increased, forcing" the mer-
cury 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.
ure, unless disease of the abdominal vessels is present (see
above) or the kidney or heart becomes involved.
In high blood-pressure we look, therefore, for arterial,
heart, or kidney disease, alone or in combination. There
ARTERIOSCLEROSIS
235
are many cases, however, in which no disease of either of
these organs can be detected in patients with high blood-
pressure, 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
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
accurate (Morrow).
artery, while the older method of guessing by feeling the
pulse has been shown most ridiculously unreliable. In 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.
236 THE PREVENTION OF DISEASE
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 repre-
senting 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
these 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.
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 tonsils
(see page 145). The fourth cause of heart disease is
syphilis, the heart trouble occurring more usually in middle-