Columljia®mbers;itj> %. 
 mtl)eCitpofi^ett)|9orfe 
 
 COLLEGE OF PHYSICIANS"''*^ 
 
 AND SURGEONS 
 
 Reference Library 
 
 Given by 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/preventionofdise01buls 
 
THE PREVENTION OF DISEASE 
 
THE PREVENTION OF 
 DISEASE 
 
 TRANSLATED FROM THE GERMAN 
 
 WITH AN INTRODUCTION BY 
 
 H. TIMBRELL BULSTRODE, M.A. 
 M.D. Cantab. D.P.H. 
 
 Medical Department of H. M. I<ocal Government Board 
 
 I<ecturer on Public Health in the Medical School of Charing Cross Hospital 
 
 Honorary Secretary and Member of Council of the Epidemiological 
 
 Society of I,ondon, etc. 
 
 IN TWO VOLUMES 
 
 VOLUME I 
 
 FUNK & WAGNALLS COMPANY 
 
 30 i,afaye;tte pi<ace 
 
 NEW YORK 
 
 1903 
 
Preface to the English Translation. 
 
 It has been the endeavour of those concerned in the trans- 
 lation of this work to render the meaning of the original 
 into readable English. To effect this it has in many- 
 places been found necessary to break up into convenient 
 portions the lengthy sentences which are so frequently met 
 with in German scientific literature, but which are alien to 
 English ; and so far as possible the presentment of German 
 idioms in English words has been avoided. Great attention 
 has been paid to rendering the scientific terms and expres- 
 sions by their correct English equivalents. 
 
 Here and there slight omissions have been made, nearly 
 always for the purpose of abbreviation or condensation. It 
 has not however been deemed advisable to modify any of 
 the statements of the original, although there must neces- 
 sarily be numerous points on which there is room for two 
 opinions. 
 
 WILMOTT EVANS. 
 
Introduction 
 
 When Messrs. Archibald Constable & Co. told me of their 
 intention to publish the German treatise on individual pro- 
 phylaxis, of which this volume is a translation, and invited 
 me to introduce it to the profession of this country, I had 
 much pleasure, on ascertaining the scope of the work, in 
 complying with their request. 
 
 There are many who will, I think, agree that the term 
 " Preventive Medicine" is employed in this country in too 
 restricted a sense ; that its application to preventive action 
 in relation to certain infectious diseases alone is practically 
 a misuse of the expression. 
 
 For although Preventive Medicine might reasonably be 
 thought of as dealing with infectious diseases generally, it 
 must be accepted that its efforts have been in the past, and 
 are still, mainly directed to a few only of such diseases. 
 
 "When indeed we have made mention of smallpox, of 
 scarlet, typhus, and enteric fevers, of diphtheria, and of cer- 
 tain exotic diseases, such as plague, cholera, and yellow 
 fever, we have gone far to exhaust the group of maladies 
 with which Preventive Medicine is wont, as a matter of ac- 
 tual practice, to directly concern itself. 
 
 Although professedly, and in a small degree in practice, 
 diseases such as measles, chicken-pox, erysipelas, puerperal 
 fever, and infantile diarrhoea are regarded as within the 
 sphere of influence of Preventive Medicine, it cannot be 
 said that hitherto any very comprehensive attempts have 
 been made to curtail their operations ; and it is only quite 
 recently that pulmonary tuberculosis, which has now for 
 
 vii 
 
INTRODUCTION 
 
 manj^ years been regarded as communicable, has been added 
 to the diseases concerning which, many of our sanitary 
 authorities are now taking action. 
 
 With respect to certain other diseases, such as syphilis, 
 the communicability of which has long since been estab- 
 lished, which are responsible for much impaired health, 
 organic disease, and premature death, and one of which 
 maladies is but too easily transmitted from parent to off- 
 spring. Preventive Medicine in G-reat Britain is at present 
 silent. Possibly it is well, seeing the ethical and con- 
 troversial problems involved, that this passive attitude 
 towards the diseases here in question should not be 
 suddenly disturbed. The State cannot, perhaps, move in 
 a matter such as this, except in response to a decisively 
 expressed pubHc opinion ; and to overload the machinery of 
 public health administration with unpopular measures is, 
 as has been amply exemplified in the history of public 
 health, a futile and eminently unscientific proceeding. In 
 a word. State Medicine is as yet in its infancy, and the 
 near future has, in my opinion, enormous developments in 
 store. But pending any collective action by the State, 
 there is the more need and greater scope for the exercise 
 of prophylaxis on the part of the family physician ; indeed, 
 whatever attitude the State may in the immediate or 
 remote future adopt, there will, it seems to me, be a grow- 
 ing demand for the services, in a prophylactic sense, of the 
 medical practitioner ; and it is to the general medical prac- 
 titioner that this work is mainly addressed. 
 
 It has, of course, to be borne in mind that Preventive 
 Medicine, in its direct efforts to control the spread and to 
 promote the extinction of certain communicable diseases, 
 has exerted, and is exerting, an altogether remarkable effect 
 upon the health of the individual and of the community ; 
 that the eminently successful efforts of public hygiene to 
 provide a pure and plentiful supply of water ; adequate 
 air-space and light in and about dwellings ; safe and in- 
 offensive removal of sewage and refuse, and a better control 
 of our foods and drinks, is producing an effect which is felt 
 quite outside a limited group of infectious diseases. 
 
 viii 
 
INTRODUCTION 
 
 Moreover, the modern tenour of factory and worksliop 
 legislation, as also of measures, such as the Infants' Life 
 Protection Act, indicates that the State is beginning to 
 accept responsibilities, qiid the health of the individual, 
 over and above those which are embraced in the prevention 
 of infectious disease and of accidents. 
 
 Still, when all this has been conceded, it will prob- 
 ably be accepted that the Legislature as such, and the 
 sanitary authorities upon whom devolve the detailed 
 application of the Public Health Acts, have not hitherto 
 directly concerned themselves with the rearing of a healthy 
 citizen, save in so far as they have endeavoured to prevent 
 his illness from certain infectious diseases, and, in so doing, 
 have materially promoted his physical welfare. 
 
 Nor can it be said that outside the State there has been 
 any very serious or concerted attempt towards founding a 
 science of individual prophylaxis ; an omission for which 
 the public rather than the profession is responsible. 
 
 The medical adviser is called in to divert complications 
 and death where disease has already appeared ; he is 
 but rarely consulted as to the manner in which disease 
 itself may be prevented from crossing the threshold. 
 Whether or not it is true, as alleged, that the Chinaman 
 pays his physician only so long as he remains well, such 
 a custom does not obtain in Europe. And yet how many 
 are there who, having reached middle life, cannot appre- 
 ciate how much better their physical condition, and hence 
 their power for physical and mental endurance, might 
 have been, had they been looked to in a prophylactic sense 
 in their childhood and adolescence ? 
 
 Now the work which Messrs. Archibald Constable & Co. 
 are herewith publishing aims, in a measure, at supplying 
 this omission. Its object is the development of individual 
 prophylaxis. It is, as far as I am aware, the first attempt 
 which has been made to view human disease in its entirety, 
 whether communicable or not, from the standpoint of 
 Preventive Medicine, in the more comprehensive sense of 
 the term. 
 
 As with an architectural structure, so also with human 
 
 ix 
 
INTEODUCTION 
 
 diseases, we obtain different and fresh impressions, albeit tbe 
 structure is seen over and over again, according to the aspect 
 from "which we approach it ; and the sum total of the mul- 
 tiple impressions thus received makes us more familiar with 
 the edifice as a whole. 
 
 The human economy has been repeatedly approached, 
 with the result of an ever increasing knowledge, from the 
 medical, surgical, pathological, and psychological aspects, 
 but it has not, save in an altogether too restricted sense, 
 been approached from the view-point of the prevention of 
 deterioration and disease. 
 
 Professor Martins, who contributes to this volume an 
 admirable chapter on General Prophylaxis, attempts to 
 differentiate between Hygiene or Public" Health and Per- 
 sonal or Individual Prophylaxis, He even sees antagonism 
 of principle between these two when he says, " Indeed it 
 cannot be denied that here there is a great gulf, a dreadful 
 contradiction, between the aims of the hygiene of the in- 
 dividual and the hygiene of the race. By hygiene as 
 applied to an individual the physician strives to improve 
 the life even of the most wretched human being, and his 
 efforts are the greater the more feeble is the individual ; 
 but the hygiene of the race has for its ultimate aim 
 pitilessly to eliminate those of weakly constitution, and 
 thus improve the whole people." 
 
 But here Professor Martins is voicing a broader and more 
 evolutionary conception of Preventive Medicine than is 
 understood by the term in this country. 
 
 I have elsewhere^ stated that " the aim of Public Health 
 or Preventive Medicine is to curtail and, if possible, prevent 
 disease, to prolong existence and to render life happier by 
 means of improved physical conditions," and I fear that 
 even in this definition I may have gone further than some 
 of my colleagues in the Public Health Service would care 
 to go. 
 
 But Preventive Medicine, properly understood and ap- 
 plied, far from being the prerogative of a special branch of 
 
 ^ Quain's Dictionary of Medicine. Third Edition, 1902, edited by 
 H. Montague Murray, M.D., F.E.C.P. Longmans, Green & Co. 
 
 -X 
 
INTRODUCTION 
 
 the profession, must, it seems to me, guide our action in 
 every brancli, and perhaps be made use of by no one more 
 than by the medical practitioner or family physician. He 
 is in an exceptionally advantageous position to recognise 
 the earliest opportunity for the application of prophylactic 
 measures, either by himself or, through him, by those who 
 have devoted special attention to one or another organ or 
 system. 
 
 Preventive Medicine, as above set forth, strives to pro- 
 mote the quality as well as the quantity of human 
 existence. Its highest function is not merely to prolong 
 the expectation of life, but to enhance the sense of well- 
 being during life. 
 
 "We have not here in England concerned ourselves very 
 seriously with what is likely to be the effect, in an 
 evolutionary sense, of Preventive Medicine upon the future 
 of the race. 
 
 Whether or not the perpetuation, and consequent oppor- 
 tunity for propagation of the physically unfit is a wise 
 measure from an evolutionary standpoint is a question 
 which hardly calls for isolated consideration. Such per- 
 petuation is inextricably bound up with the improvement 
 alike of the relatively fit and of the unfit ; in a word, with 
 a general physical improvement of those now inhabiting 
 the planet. 
 
 Nature alone can determine, and that only in a post- 
 dated fashion, who are the fit and who the unfit. 
 
 Moreover, since physical evolution would appear, as far 
 as our knowledge of it goes, to be bound up, or to be at 
 the present time progressing along with, a moral evolution 
 which attaches more and more importance to human life 
 and well-being ; since, too, in the course of selective action 
 based solely upon physical qualities, man might by active 
 interference have kept back from existence some at least 
 of those who have enunciated and elaborated this very 
 evolutionary thesis, we may perhaps leave these remoter 
 issues to natural selection, and limit our horizon to the 
 present and immediate future. 
 
 We may do this with the more equanimity since this 
 
 xi 
 
INTRODUCTION 
 
 moral evolution of wHcli mention has been made would 
 seem to be tending at present to discourage marriage 
 unions between those having undesirable physical or 
 mental tendencies, such as might, through marriage, be- 
 come accentuated in the offspring. 
 
 In this country, however, we have not considered, even 
 ideally, other than the generations living or immediately 
 to follow, and there would seem therefore to be no anta- 
 gonism in principle between what we term Preventive 
 Medicine and what is spoken of, in this volume, as indi- 
 vidual prophylaxis. Each is an accessory to the other, 
 or, rather, the latter is a branch of the former ; and the 
 operation of both must inevitably promote the growth 
 of the science of Preventive Medicine, and enlarge its 
 sphere of general utility. 
 
 This individual medical prophylaxis is, again to quote 
 Professor Martins, " The sum total of medical counsel and 
 rules intended to protect the individual against disease. 
 In this .sense medical prophylaxis guides the individual 
 through the entire course of life, from the cradle to the 
 grave." 
 
 It is one of the functions of this branch of medicine to 
 ascertain as early as may be in the existence of the indi- 
 vidual, and with the aid which the life history of his 
 immediate progenitors can afford, what is the predisposition 
 of that individual towards any given " pathological re- 
 action " ; and, having ascertained such tendency, to prevent 
 its operation. Disease is not, as we are reminded by one 
 of the contributors to this volume, a " thing," but the 
 resultant of many factors, the working together of which 
 alone constitutes disease ; and one of the best uses to which 
 the public can put medical science is to seek its aid towards 
 preventing the co-operation of the several factors involved. 
 
 Dr. Rosen simply and aptly illustrates the goal of indi- 
 vidual prophylaxis when he remarks, " The physician 
 ought not to wait until he discovers an impaired note at 
 the apex of the lung, or hears rales, or till the discovery of 
 tubercle bacilli with the microscope makes the suspected 
 diagnosis of tuberculosis a certainty, before he begins to 
 
 xii 
 
INTRODUCTION 
 
 treat tlie patient hygienically and dietetically " ; and Profes- 
 sor Martins expresses the same idea in saying tliat '' To 
 bring np a weakly child who may be hereditarily tainted, 
 so that it does not succumb to the threatening danger of 
 tuberculous infection is individual medical prophylaxis," 
 
 So, too, Professor Mendelsohn, of Berlin, who contributes 
 to this treatise the section on the prevention of diseases of 
 the heart, will appeal to his readers when he insists that 
 " a truly scientific prophylaxis of heart disease can only 
 be carried out by the physician who makes a functional 
 diagnosis, not an anatomical one. It is not enough merely 
 to auscultate and percuss, and when nothing abnormal has 
 been detected by this procedure to conclude that special 
 prophylactic measures are unnecessary. Even when there 
 is no such organic abnormality present in the heart, its 
 condition and functional capacity should be determined in 
 every possible position of the body — when sitting, when 
 standing, when lying at rest and after different degrees of 
 bodily exertion." 
 
 This endeavour to found a science of general prophylaxis 
 may be regarded as an expression of the claim of the indivi- 
 dual to be studied, and treated, with a due consideration for 
 his tendencies, bents, or " idiosyncrasies," whether these are 
 due to hereditary transmission or not. He asks that he 
 may not, without due inquiry, be forced into the "average" 
 mould in the matter of drugs, education, or employment ; that 
 the " personal equation " may be made a note of as early in 
 life as possible, and that his anatomical and functional 
 capacity may be had regard to in the consideration of any 
 questions likely to involve his health or well-being. Clearly, 
 considerations of treatment cannot be altogether separated 
 from those of prevention. All treatment is in a certain 
 sense preventive in action, whether its aim be to avert 
 complications, further deterioration, or actual death ; and 
 what may be termed prophylactic therapeutics will be 
 found duly treated of in the present work. Although, as 
 Dr. "Windscheid has it, " against old age there is no pro- 
 phylaxis," we can, by well-regulated preventive action post- 
 pone the death which seems the inevitable penalty of birth. 
 
 xiii 
 
INTRODUCTION 
 
 It is impracticable in an introduction sncli as this to con- 
 vey an adequate idea of the precise scope of the present 
 ■work, which extends over nearly 1,000 pages, and a 
 brief indication of the ground it covers can alone be 
 attempted. The volume opens with a section by Dr. Grold- 
 schmidt, dealing with the principles of the prevention of 
 disease, and furnishing a short, and highly instructive, 
 survey of the prophylactic methods in vogue among the 
 Hindus and Chinese, the Israelites, Egyptians, Assyrians, 
 and others. This is followed by a historical sketch of 
 the growth of general preventive measures, such as the 
 provision of public water supplies, refuse disposal, etc. ; and 
 under this section there is an interesting account of the 
 gradual development of the prophylactic idea in respect of 
 the control and examination of meat, more particularly in 
 Grermany. It will be well that some of our lethargic local 
 sanitary authorities shall learn that in Augsburg, as early 
 as 1276, the slaughter of cattle was prohibited except in 
 slaughter houses, and that in 1716, in Hanover, it was 
 ordained that all cattle should be examined while still 
 alive, and that, if healthy, a mark should be branded upon 
 their horns. 
 
 After a historical account of the prevention of Epidemic 
 Diseases, we come to what has to be regarded as the special 
 feature of the work, which is prefaced by the highly in- 
 teresting article on " General Prophylaxis," by Professor 
 Martins, to which we have already referred. 
 
 Thereafter the several contributors treat systematically of 
 the separate organs, systems, or tissues of the body. 
 
 Throughout each section there is brought home to the 
 reader the scope which exists for preventive operations, and 
 he seems to realize the very contracted character of our 
 present day conceptions and practices in respect of pre- 
 ventive action. 
 
 Whether he reads the section on prophylaxis in surgery, 
 in midwifery, in the diseases of children, in those of the 
 eye, ear or teeth, or whether he surveys the field of pro- 
 phylaxis in diseases of the generative and urinary organs, 
 the results are the same. The need for greater and more 
 
 xiv 
 
INTRODUCTION 
 
 continuous medical supervision, a supervision which can, at 
 any rate in the first instance, be most usefully exercised by 
 the family physician, is unconsciously brought home to 
 him ; and the conclusion at which he arrives is that the 
 development of this prophylactic idea is calculated to pro- 
 mote the progress of public health and lead to a better 
 recognition by the public of medical advice and guidance. 
 If, indeed, advances were made even in the single direction 
 of appointing medical ofificers to schools who should periodi- 
 cally test the special senses of the school children, look to 
 their teeth, test their sight and hearing, detect existing 
 or threatening deformities, and rediice the hours of work 
 of the physically and mentally unfit, the harvest would 
 speedily be so abundant that further action in a similar 
 direction would naturally follow. 
 
 Obviously, in a work such as this, which is compiled by 
 many writers, there are some divergencies of opinion, more 
 particularly in relation to those diseases for which the world 
 is still striving for a prophylactic. There must necessarily 
 be views expressed with all of which no one writer can be 
 expected to entirely agree, and upon which no one writer is 
 capable of expressing an opinion. The work possesses an 
 additional interest in that it was written in the first in- 
 stance for the profession in Grermany. But the by no 
 means easy task of converting German into readable Eng- 
 lish has been successfully accomplished, and the method of 
 treatment throughout is original and exhaustive; indeed, 
 a perusal of it leaves the reader with a clearer conception 
 of the multitudinous bearings of diseased conditions, and 
 furnishes him with suggestions which, in application, 
 should be fraught with the saving of many lives and the 
 prevention of much disease and discomfort. 
 
 In conclusion, I venture to think that this new departure 
 will be cordially welcomed by the profession ; and the book 
 may, I trust, be instrumental in laying the foundation of a 
 systematic individual prophylaxis in this country. With 
 the rapid growth and diffusion of knowledge as to the pre- 
 vention of disease, the physician will be asked in an ever 
 increasing degree how the onset of certain pathological con- 
 
 XV 
 
INTEODUCTION 
 
 ditions may be prevented ; aud although he may not, at 
 present, always be in a position to indicate the lines which 
 should be followed, there can, I think, be little doubt that 
 the subject of individual prophylaxis will occupy an impor- 
 tant place in medicine in the near future. 
 
 H. TIMBEELL BULSTRODE. 
 
 XVI 
 
CONTENTS 
 
 Volume I 
 
 Introduction vii 
 
 The History of the Prevention of Disease, by Dr. S 
 
 Goldschmidt, of Bad Reichenhall . . . . i 
 
 General Prophylaxis, by Professor Martins, of Rostock 59 
 
 77 
 
 85 
 
 97 
 
 109 
 
 137 
 
 Internal Diseases ....... 
 
 Diseases of the Blood, by Dr. Rosen . 
 
 Diseases of Metabolism, by Dr. Rosen 
 
 Infe(5tious Diseases, by Dr. Richard Rosen . 
 
 Diseases of the Leungs, by Dr. Richard Rosen 
 
 Diseases of the Heart, by Professor Martin Mendel- 
 sohn, of Berlin . . . . . . -153 
 
 Diseases of the Digestive Organs, by Dr. Max Einhorn, 
 Professor in the New^ York Post-Oraduate Medical 
 School . . . . . . . . .189 
 
 Surgery, by Professor A. Hoffa, of Wiirzburg, and Dr. 
 
 A. Lilienfeld . . . . . . . .213 
 
 Diseases of Women, by Dr. O. Schaeffer, of the Uni- 
 versity of Heidelberg . . . . . -277 
 
 Midwifery, by Dr. O. Schaeffer, of the University of 
 
 Heidelberg ........ 337 
 
 Diseases of Children, by Dr. Rudolf Fischl, Lecfturer 
 on the Diseases of Children in the German Uni- 
 versity of Prague ....... 407 
 
V 
 
 '<\. 
 
 CONTENTS 
 
 Volume II 
 
 Disease of the Nervous System, by Dr. Windscheid, of 
 
 the University of Leipzig ..... 507 
 
 Mental Disease, by Dr. Walter Fuchs, of Emmendingen 565 
 
 Diseases of the Eye, by Professor Konigshofer, of 
 
 Stuttgart ........ 631 
 
 Disease of the Ear, by Dr. Albert Bing, of the Uni- 
 versity of Vienna . . . . . . . 737 
 
 Diseases of the Teeth and Mouth, by Dr. H. Christian 
 
 Greve, of Magdeburg ...... 767 
 
 Diseases of the Throat and Nose, by Dr. Theodor S. 
 
 Flatau, of Berlin ....... 799 
 
 Diseases of the Urinary Organs and of the Male Gen- 
 erative Organs, by Dr. Albrecht von Notthafft, of 
 the University of Munich, and Dr. Arthur Koll- 
 mann, of the University of Leipzig . . . 843 
 
 Venereal Disease and Disease of the Skin, by Dr. Max 
 
 Joseph, of Berlin . . . . -931 
 
 Index . . 987 
 
The History of the Prevention of Disease 
 
 BY 
 
 DR. S. GOLDSCHMIDT 
 
 OF BAD REIOHENHALL 
 
The History of the Prevention 
 of Disease 
 
 In tracing the history of the prevention of disease, we find 
 that the measures adopted for this purpose have always 
 followed certain lines, which often run parallel one with 
 another, though various races at different times have given 
 greater prominence to some one of these than to the rest. 
 With primitive man without any form of government 
 the prevention of disease differed but little from that which 
 we see among animals. He sought probably to protect 
 himself against changes of weather, against meteorological 
 events, against hunger, and against the attacks of wild 
 animals. Among nomadic tribes at the present day 
 prophylaxis takes the form of contests of strength, warlike 
 performances and gymnastic exercises. But they have 
 also their regulations with respect to food, cleanliness, and 
 magic rites which rest upon the ancient idea of the 
 demonological origin of disease. Among all these peoples 
 we find certain definite customs in connexion with family 
 events, such as marriage, the birth of a child and death. 
 The wearing of amulets and other magic charms has also 
 originated from the desire to guard against disease and 
 danger. 
 
 We shall see that highly civilized peoples, clinging to 
 the conception of a demonological or theological causation 
 of disease and of danger, seek to protect themselves against 
 these just as uncivilized races do, because at all times and 
 among all races there exists in addition to the scientific 
 view of the true cause of disease, also the opinion that dis- 
 ease may be traced to supernatural causes. Religious rites 
 
 3 
 
THE PREVENTION OE DISEASE 
 
 whicli have been handed down and are still practised 
 among us today have not a symbolical meaning only. In 
 the opinion of the people, religious ceremonies are concrete 
 means for the prevention or for the cure of disease. If 
 we look at one of the oldest of civilized peoples, the 
 Hindus, we shall find the conception of the demon ological 
 causation of disease so greatly developed and so conspicu- 
 ously permeating the whole life of this unequally gifted 
 but most interesting people, that the history of prophylaxis 
 would be incomplete without mention of their customs. 
 
 The strengthening of the body and cleanliness, to which 
 even nomadic tribes give some attention, are found to be 
 considered of even greater importance by races who have 
 settled down in any locality. The Grreeks and Romans 
 practised gymnastics regularly. Among the Greeks these 
 found their highest expression in the Olympian games, 
 and gymnastic exercises were resorted to not only for the 
 strengthening of the body for war but also probably for 
 its aesthetic development. For not only do we find the 
 m.en exercising their bodies in order to be able effectively 
 to resist an enemy, but the women also developed their 
 muscles by gymnastics though with no idea of taking up 
 arms against an enemy. The bathing and anointing of 
 the skin and washing of the feet after journeys were 
 customs among all ancient races. The Egyptians regarded 
 cleanliness in the light of a divine commandment. The 
 ruins which can still today be seen of magnificent baths 
 for the Greeks and Romans testify to lavish expenditure, 
 both municipal and private, for making bodily cleanliness 
 j)Ossible for all the citizens. Amongst the Hindus, 
 Hebrews and Mohammedans religion requires frequent 
 ablutions and baths. It is clear that all these hygienic 
 rules as well as the command to put on new garments on 
 certain occasions have also a symbolical meaning. Among 
 those nations whose religious customs are closely allied 
 with hygienic and dietetic regulations, it is difficult to 
 determine which was the primary motive. On the other 
 hand, as a contrast to these hygienic regulations, we find 
 numerous religious ordinances which are quite opposed to 
 
 4 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 the principles of health. Such for example are the rules 
 about penance, fasting and mortifying the body : in a 
 word the absurd regulations of asceticism, which sprang up 
 upon the fertile soil of the East as a means for preventing 
 to some extent a too joyous conception of life. Unfortu- 
 nately these ascetic practices have crept into the civilization 
 of the West as the results of atavism. 
 
 Among all races it was customary to anoint the body 
 after the bath. The anointing was often associated with a 
 kneading of the body which had a beneficial and tonic 
 effect, and which has recently been revived as a thera- 
 peutic agent under the name of " massage." 
 
 Further evidence of prophylactic regulations is to be 
 seen in the provision made for the water supply of many 
 ancient towns. Remains of aqueducts and conduits have 
 been found in Egypt, Assyria, Greece and Rome, the latter 
 in such a good state of preservation that it has recently 
 been possible to make use of them again. The knowledge 
 that many diseases may be caused by drinking impure 
 water seems therefore to date back very far. Hippocrates, 
 the father of medicine, urgently recommends physicians to 
 test drinking water carefully, and expressly warns them 
 against water from marshes as especially dangerous to 
 health. It is obvious therefore that the ancients were not 
 indifferent about the water for drinking purposes, and 
 their regulations about diet show an even more strenuous 
 endeavour to prevent disease which may be caused by food. 
 Among the Egyptians and the Jews we find clear regula- 
 tions about food, the supervision of which was entrusted to 
 the priest ; this will again be referred to in greater detail 
 in a special section relating to the Israelites. The disposal 
 of the excretions of the body and of other impurities also 
 occupied the minds of ancient civilized nations. The 
 Cloaca Maxima of Rome is the most impressive of these 
 drainage works and can still be seen today in action. 
 Remnants of food which would become a source of danger 
 through decomposition were destroyed by burning, while 
 the excreta of human beings and of animals generally were 
 drained into the rivers. Rules for the disposal of the dead, 
 
 5 
 
THE PREVENTION OF DISEASE 
 
 whether by cremation, as among the Hindus, Greeks and 
 Romans, or by burial, as among the Israelites, show that 
 the object was to remove from dwellings these sources of 
 disease as quickly as possible. 
 
 Thirdly, there was the protection against epidemic dis- 
 eases. No civilized people failed to recognize the difference 
 between infectious diseases and the other groups of mala- 
 dies. At different periods of history we find sometimes one 
 infectious disease sometimes another most prevalent. 
 Smallpox must have been known in very ancient times, 
 because in all histories of medicine we find mention of 
 inoculation against smallpox among the Hindus and 
 Chinese several centuries before the introduction of inocu- 
 lation into Europe. But both in antiquity and in the middle 
 ages no disease attracted so much attention as bubonic 
 plague which, known sometimes by that name, sometimes 
 as the " Black Death," decimated the towns of the civilized 
 world. Since the first thirty years of the nineteenth 
 century plague has only reached the confines of civilized 
 countries but has not penetrated within them. Asiatic 
 cholera then appeared in history and its ravages were not 
 less than those of plague. Besides such pestilences, which 
 fortunately appear only sporadically, we find records of 
 leprosy among the ancients as a contagious disease which 
 spread far and wide at the time of the Crusades, in 
 Germany, England, Italy and France, and as we shall see 
 later gave rise to very valuable institutions. Towards the 
 end of the middle ages, at about the beginning of the 
 Reformation, syphilis seems to have been more prevalent 
 than either before or since. We must consider historically 
 each of these epidemics in turn and find out how the people 
 tried to guard against them. Our plan will be first to 
 consider the prophylactic measures adopted by the various 
 great races of men. Then we shall take a retrospect of the 
 various general preventive measures and of personal 
 prophylaxis, and lastly trace out the historical development 
 of the prevention of the different epidemic diseases. 
 
PART I 
 
 PEOPHYLAXIS AMONG THE HINDUS 
 
 We have already referred to their practice of inoculation 
 against smallpox. There was also a sensible regulation 
 which forbade any one going out in the rain unprotected. 
 These and the rules about washing are however the only 
 ones of any scientific medical interest which we find among 
 the Hindus, all others are the outgrowth of fantastic 
 demonology and superstition. Disease is not so much 
 regarded as a punishment sent by God but as merely the 
 work of unfriendly demons which must be counteracted by 
 antidotes such as incantations, strange ceremonies and 
 exorcism. Though this kind of prophylaxis can lay claim 
 to no medical value, yet its historical significance is un- 
 mistakable, and even today among Europeans we find 
 superstitious ideas about disease and its prevention which 
 have come to us from the Hindus. In this sketch we 
 shall make use of the descriptions given by Biihler in 
 his very thorough work Grundriss indo-arischer Philologie 
 und Altertumskunde^ Strasburg, 1897. Unfortunately the 
 medical part of this work is not yet completed, but the 
 third volume contains sufficient material to serve our pur- 
 pose. 
 
 The child begins to be cared for even before he is born, 
 in fact during the very first month of intra-uterine life. 
 By prayers and sacrifices the sex of the coming child is 
 decided. For the fourth month a ceremony is prescribed 
 to prevent miscarriage. The woman moistens her right 
 hand and passes it across her abdomen above the navel 
 three times while repeating certain phrases. This cere- 
 
 7 
 
THE PREVENTION OE DISEASE 
 
 mony is followed by the garbharaksana, for the preserva- 
 tion of the embryo. A fruit (sthalipaka) is boiled, is 
 offered as a sacrifice by her six times, and afterwards the 
 mother's abdomen is anointed with butter while certain 
 words are recited. 
 
 Preparation is made for delivery (josantihoma) by select- 
 ing a room in which it is to take place. This is then 
 anointed or fumigated as a defence against evil spirits 
 (raksas). As soon as labour pains set in three experienced 
 women are called in. The father lights a fire, scatters it 
 about, offers sacrifices on it, and then besprinkles the woman 
 in labour with the consecrated elements. In other castes 
 he pours water into a vessel which has not been used before 
 and besprinkles the woman with it, he places a turymti 
 plant at her feet and touches the head or body of the 
 woman with it. The latter is moreover often stroked in a 
 downward direction. Four blades of munja, with their 
 points towards the east, and four reeds with their points 
 towards the west are put upon her head and form a kind 
 of oracle, since if they break down it forebodes danger 
 to her life. The woman is washed with warm water from 
 the right side of her head downwards over the whole body. 
 To ensure a normal third stage of labour the mother is 
 sprinkled with consecrated water after the birth of the 
 child. If the child dies directly after birth certain special 
 ceremonies are performed, but these are not of any interest 
 in connexion with our subject. 
 
 To ensure a safe puerperium another fire is immediately 
 lighted in the house after the delivery of the woman and is 
 kept alight for twelve days. The newborn child is held 
 over the fire while herbs are burnt in it for fumigation. 
 All domestic work is carried out by the light from this 
 hearth. Grains of mustard seed and of rice are used for 
 this fumigation. Curses against demons are uttered 
 several times a day before the fire. Every time after 
 offering sacrifice the father washes his hands and recites 
 a poem. Twelve days after delivery the fire is put out, 
 mother and child are washed, dressed in new clothes, and 
 both are permitted to leave the lying-in room. 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 We pass by the consecration ceremonies performed when 
 the hair is cut, the ears pierced, the beard shaved, and the 
 child goes to school —ceremonies intended to frustrate the 
 malignity of impish spirits. The marriage ceremonies 
 claim our attention. An important and sensible rule is, 
 that the woman, although obliged to be of the same caste 
 as the man, must not be related to him. Certain bodily 
 marks debar from marriage, but little is known about 
 the subject, and they seem to be decided by oracle rather 
 than by any examination. 
 
 Before the Hindu builds a house he must thoroughly 
 examine the site. The ground must not contain salt and 
 must have upon it no plant which is thorny or contains 
 milky fluid. Certain plants must be found only in certain 
 aspects. Thus towards the east there must be no as- 
 vattha, as it brings danger of fire to the house ; towards 
 the south no paksa, because it brings illness and early 
 death ; towards the west no nyagradha, because it brings 
 with it fighting ; towards the north no udumbarha, 
 because it brings disease of the eyes. 
 
 When illness arises the patient should dwell in the east, 
 north, or north-west of the house and he will then re- 
 cover. 
 
 We shall omit the complicated customs at death and 
 merely mention that children who have died under two 
 years of age are buried, but all other dead bodies are burnt. 
 But previously they are exposed to view for a long time. 
 Those who have taken part in a funeral procession must 
 not enter their houses again till they have fulfilled the 
 strict regulations for purification. But these are regula- 
 tions which have to do with mourning rather than the 
 prevention of disease. The house in which any one has 
 died may not be re-entered for three to fourteen days, 
 according to the nature of the fatal illness. To prevent 
 hereditary disease the grave must be kept well watered. 
 
 As there are certain customs and ceremonies for the 
 prevention of disease, so there are others again by means 
 of which the disease may be transferred from one person 
 to another. 
 
 9 
 
THE PREVENTION OF DISEASE 
 
 This superstition survives in tlie *' jettatore " and " maloc- 
 chio " of Italians. 
 
 The regulations which we have described were not only 
 in force in ancient India but are still largely practised even 
 at the present day by this highly gifted but apathetic 
 people who have found in Buddhism the most powerful 
 expression of a melancholy conception of the world. It is 
 not surprising that Hindus, holding these views about 
 medicine and taiking no active preventive measures, cannot 
 rid themselves of the many diseases which starting thence 
 often spread over the whole world, and are always endemic 
 in India. As they do not even know how to guard against 
 poisonous reptiles and beasts of prey, to whom about 40,000 
 human beings fall victim every year, so they do not try 
 to protect themselves by rational methods against the still 
 greater dangers of infective disease. The reports of travel- 
 lers that the Indian jugglers know how to make themselves 
 immune to the bites of poisonous snakes still require con- 
 firmation. 
 
 PKOPHYLAXIS AMONG THE CHINESE » 
 
 The Chinese have no native religion, and no priesthood 
 and no church except those which have been imported 
 from other nations. Nevertheless it is only natural that 
 superstitious beliefs about diseases, their treatment and 
 prevention, should have crept into this nation with its 
 enormous numbers of ignorant people. Yet prophylaxis 
 among the Chinese is more of the nature of pedantic rules 
 which have sprung from absurd conceptions of the universe 
 rather than from demonology. The Chinese are thoroughly 
 imbued with a sense of loyalty. They know nothing of 
 the exclusive caste system of the Hindus, but they bow 
 down before the idea of rank with its degrees, and see in 
 their poor mythological conceptions the degrees of rank 
 which are obvious to them in the State. Their deities are 
 the sun, the moon, the stars, and other impressive pheno- 
 
 ^ The information here given has been taken from Path's work 
 Religion und Kultur der Chinesen, Munich, 1862. 
 
 10 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 mena of the sky and the earth. There is a spirit of 
 drought, a spirit which injures horses, a spirit which 
 permits poisonous animals to exist, and they appease all 
 these spirits by many kinds of sacrifices of little value. 
 According to the severity of any disease it is referred to . 
 some higher or lower deity. Occasionally true Shamanism 
 is met with. At each season of the year (and the Chinese 
 have five seasons) there appears an inspector of the districts, 
 fung-siung-shi, who drives away the diseases peculiar to 
 that season ; his function seems however to be exercised 
 more in regard to the diseases of plants and of animals 
 than those of men. He appears clad in the skins of young 
 bears, has four eyes of yellow metal on his dress, carries 
 a lance and shield, and is accompanied by 100 followers 
 in red and black dresses. In the spring the exorcist 
 (Wa) addresses the spirits to prevent epidemics. But the 
 real prayer against disease is always said by women — pray- 
 ing women (niutscho). There is no real priesthood among 
 the Chinese. Proj^hesying, for which the tortoise shell 
 and the tsie plant are used as an oracle, is practised by 
 certain men. 
 
 The market regulations introduced by Confucius form a 
 collection of advice rather than of any real sanitary rules. 
 They contain warnings against the produce of the field 
 when not in season, against fruit which is not ripe, against 
 birds, game, fish, which have not been killed according to 
 direction. Further, raw food material alone must be offered 
 for sale, but no prepared food or beverage. Lastly, they 
 exclude from the market all animals and wine which have 
 been offered in sacrifice. 
 
 A better understanding of hygiene is shown in their 
 teaching that food must be according to the individual's 
 age, and that an old man may take many foods which are 
 forbidden to the young man. But this instruction is so 
 arbitrary that it loses much of its value for prophylaxis. 
 The Chinese are not given to taking alcohol. Cultivation 
 of the vine was introduced late into China, and grapes are 
 always eaten as fresh fruit. The Chinese make an intoxi- 
 cating drink from rice. The injurious effects of alcohol 
 
 11 
 
THE PREVENTION OF DISEASE 
 
 seem long ago to have been known and it is only permitted 
 to be used upon special occasions. But in order that drink- 
 ing might be reduced to the most moderate quantities, the 
 ancient emperors ordered this beverage to be drunk only 
 from very small glasses, and that 100 obeisances should be 
 made before drinking another such portion. Thus a small 
 quantity of alcohol takes a long time to consume. The 
 following regulations about food are for the most part com- 
 pletely incomprehensible. It is forbidden to eat young 
 fowls and turtle, wolves from which the intestines are 
 missing, dogs without their kidneys, foxes with the back- 
 bone missing or without a head ; rabbits and hares which 
 have been deprived of the lower portion of the backbone ; 
 sucking pigs in which the brain is missing ; fish without 
 bones ; turtles which have lost one shell. 
 
 The skin and sinews of slaughtered animals are to be 
 thrown away. Fish should be inspected to see whether it 
 is fresh or tainted. Dates must be fresh, chestnuts without 
 maggots. The down on peaches should be rubbed off; pears 
 and apples should be bored when offered for sale. 
 
 These market regulations are some of them sensible, 
 others absurd. Still more strange are the following warn- 
 ings : — Oxen which low at night have stinking flesh ; sheep 
 with thin long wool smell rank ; dogs with red thighs 
 have rancid fat ; birds with fine voice and shimmering 
 (white) feathers have putrid flesh ; pigs which do not see 
 well and whose eyelids stick together have fatty tumours ; 
 horses with black back and fore-legs have stinking flesh. 
 The following preventive regulations sound a little more 
 sensible. The tail of chickens when narrow and full should 
 not be eaten, nor the flesh near the tail of the wild goose. 
 The meat on the ribs of swans and owls is not safe, neither 
 is the liver of the fowl nor the stomach of the wild goose 
 and stag. Meat to be eaten should be tender. From this 
 list of food we see that the Chinese in general are not par- 
 ticular in their diet. If we add to this that the modern 
 Chinese despise neither rats nor moles nor snakes as food, 
 the above laws may seem absurd but are nevertheless in- 
 tended to restrict him in his appetite. 
 
 12 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 The mode of thought of the Chinese in reference to 
 spiritual matters affects their laws about food, different 
 kinds of which are special to certain seasons. The Chinese 
 recognize five elements (wood, fire, earth, metal and water), 
 and with these they associate five fundamental colours and 
 also five varieties of food, one for each season. Further, they 
 distinguish between five different kinds of taste ; and the 
 element, the season, the colour and the taste must always 
 agree. In the spring, which corresponds with the element 
 wood and with the colour green, bitters should be 
 eaten. In the summer, the season of fire and of red, sweet 
 foods are eaten. The season between summer and autumn 
 corresponds with earth and the colour yellow, and things 
 pungent should be eaten. Autumn is the time for the 
 colour white and for metals, therefore acid things should be 
 eaten. Winter is the season of water and of black, and 
 then salt food should be eaten. 
 
 We must not omit the hygienic regulations about dwell- 
 ings and cleanliness, though here too there are no obvious 
 intelligible reasons for them. 
 
 The doors of the house should always be open. The head 
 should lie towards the east. If an inmate becomes ill or is 
 overtaken by a storm he should change his position. He 
 gets up even if it be night, dresses and puts on his hat. 
 The body must be washed five times a day, each part of the 
 body with a different water ; the head and face should be 
 washed with millet water. After a bath, different dry 
 towels are to be used for the upper and for the lower parts 
 of the body. Moreover after a bath the Chinese have to 
 lie upon a mat on the grass and drink water. Every fifth 
 day children are admonished to take warm water to their 
 parents and ask to be bathed, and every third day to have 
 the head washed. If the face is very dirty rice water 
 may be used, but for soiled feet hot water only should be 
 used. 
 
 It is curious that the Chinese who do not, like the 
 inhabitants of India, burn corpses but cover them with 
 a little earth and then erect a mound over them, do not 
 have any common burial-ground. Each chooses for his 
 
 13 
 
THE PREVENTION OF DISEASE 
 
 relatives some favourite spot outside the town, and on fes- 
 tival days all the members of the family go to the mound 
 to deck it with flowers and possibly pray to the deceased. 
 It is characteristic that the Chinaman according to his rank 
 addresses a special deity, and it would be a punishable 
 offence against etiquette if an ordinary citizen were to ad- 
 dress his prayers to the highest deities, the sun and moon ; 
 the ruler however must address these deities alone. 
 
 From the above it is evident that this very intelligent 
 but unimaginative people have not contributed to the ad- 
 vancement of prophylaxis and of medicine any more than 
 have the inhabitants of India. And thus, though China is 
 less exposed to the ravages of epidemics than the neigh- 
 bouring people, yet it stands powerless against certain 
 results which follow from its culture, and knows no method 
 to adopt against its increasing over-population except in- 
 fanticide, artificial abortion and extensive emigration. 
 
 PEOPHYLAXIS AMONG THE ISEAELITES 
 
 The statement frequently made that the Jews are a 
 " priestly people " means distinctly that some of the laws 
 which were intended only for the priesthood in Egypt, were 
 proclaimed as valid for all the people by Moses, the pupil of 
 Egyptian priests. It is remarkable how severely any breach 
 of hygienic regulations is dealt with. The severity which 
 threatens with death the breaking of what often appears 
 to us some trivial dietetic regulation will only become in- 
 telligible if we look at the historical events of the period 
 when these laws were promulgated. 
 
 The Jews were a rustic people and very few in numbers. 
 Moreover this small nation had not only to till a very 
 unfruitful soil but also to be prepared for constant struggles 
 with neighbouring tribes. Under these circumstances the 
 preservation of each individual life was of the utmost eco- 
 nomic importance. It was urgently necessary to keep up 
 the working capacity of every man ; whoever therefore did 
 anything which would injure his own health would be 
 committing a crime against the general welfare, against 
 
 14 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 the power of defence and the power of work of the whole 
 nation. This affords a striking contrast to the inhabitants 
 of India and the Chinese, among whom over-popnlation had 
 given rise to carelessness in regard to prophylaxis. To break 
 the rules of health was not regarded from the standpoint of 
 demonology but was looked upon as falling away from God, 
 as a sin the direct consequence of which was punishment 
 by God. The theological conception seems somewhat strange 
 to our modern ideas, but compared with the demonological 
 conceptions of the inhabitants of India and of the Chinese 
 it marks a very great advance. The Bible recognizes no 
 demons, and we find in it no suggestion of the belief in a 
 devil. Man himself is responsible for his deeds, and though 
 the hard law " Thy sins shall be visited unto the third and 
 fourth generations " does not conform to our sense of justice, 
 nevertheless it expresses what careful observation at all 
 events shows to hold good for medical sins. The fact that 
 the Jewish race still exists, though no longer a nation, 
 though their national life lasted scarcely 500 years, and 
 though they have been persecuted and hated by the nations 
 among whom they have been scattered, is owing in no small 
 degree to the scrupulous way in which they have carried 
 out the biblical laws of hygiene. The best known of these 
 hygienic laws refer to their food. Here too correct obser- 
 vation is mixed up with superstitious ideas, though the 
 latter have in course of time assumed a commonsense mean- 
 ing. The law that the blood of slaughtered animals shall 
 be drained away rests upon the superstitious idea that life 
 has its origin in the blood, or that the spirit dwells in the 
 blood. Thence has arisen the dislike which the orthodox 
 Jew even at the present day feels to the blood of animals. 
 No part of the body may be used for food till all the blood 
 has been removed by salt and water. Yet in spite of the 
 superstitious origin of the custom, it is nevertheless a 
 valuable preventive regulation in hot countries. Salt is 
 very good for the preservation of the meat, and meat de- 
 prived of its blood is far less apt to decompose than meat 
 which still contains blood. The law that the flesh of a 
 slaughtered animal should be eaten not later than the third 
 
 15 
 
THE PREVENTION OF DISEASE 
 
 day, and if not eaten then mnst be burnt, seems a very sen- 
 sible regulation in countries where putrefaction sets in 
 extremely rapidly. The Mosaic law forbids the eating of 
 the flesh of certain animals as being unclean. We have 
 seen that other races too have prejudices against eating 
 certain animals. These national idiosyncrasies are not 
 always intelligible. Yet it is striking that there is no race 
 which does not exclude certain animals from use as food, 
 while these same animals are eaten by other nations. There 
 are American nomadic tribes who eat no fish ; others again 
 who have a prejudice against game. Even the Chinese, who 
 eat such a variety of food, have, as we have seen, laws for- 
 bidding the use of some foods. Certain Indian castes touch 
 no animal food, living exclusively upon a vegetarian diet. 
 
 The Mosaic Law especially forbids the eating of those 
 animals which experience has taught may cause disease : 
 such as the flesh of swine, of cats, and of certain rodents, 
 which Luther translates " rabbits,"' but which probably are 
 " rats.'' Recent research has shown that these animals are 
 apt to harbour trichinae, and Yirchow justly pronounces 
 Moses one of the greatest of physicians of all time. Animals 
 leading a free life such as wild animals and beasts of prey 
 may not be used for food, partly to discourage the love of 
 hunting which the Bible regards as a cruel sport, partly 
 because it is not possible to control the food of such animals, 
 and they sometimes eat food which is bad and which might 
 be harmful to men. Humane feelings for animals is a 
 reason why certain animals' flesh is forbidden to be eaten. 
 Thus only can we understand why it is forbidden to eat 
 the flesh of horses, asses, mules and camels, which have been 
 fed by man. These animals are so useful to man that to 
 use them for food is opposed to the tender feelings of the 
 biblical lawgiver. But we should be going very wide of 
 the mark if we thought there was a reason, sanitary or 
 humane, for every such law. For example it is quite 
 incomprehensible why the loins should not be fit for food 
 till the iliac vein has been removed. The biblical writer 
 has made a law of that which was a tradition long before 
 the Mosaic period. 
 
 16 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 Ritual circumcision is a very vexed question. This 
 custom was observed by many ancient races, and it is 
 known that Mohammedans practised the rite long before 
 the time of Mohammed. Recent historical investigation 
 shows that it arose out of a heathen worship, the worship 
 of Moloch. Still I believe we ought not to underrate the 
 sanitary value of this operation. The removal of the prepuce 
 prevents the collection of dirt, and the uncovered glans 
 loses much of its vulnerability in course of time. But 
 systematic data to prove the value of the rite are hitherto 
 wanting. Moreover the raising of this operation into a 
 religious act was certainly not of Mosaic origin. It is much 
 more probable that Moses, who was opposed to all such 
 heathen barbarous customs, had nothing to do with intro- 
 ducing this rite. He did not submit his own son to circum- 
 cision ; but the boy was circumcised, without the father's 
 knowledge, by the mother when the boy was ill in the 
 desert. And the mother was the daughter of the heathen 
 priest Jethro. Besides these hygienic laws stated above, 
 the biblical lawgiver issued other regulations which cannot 
 be improved upon even at the present day. He gives orders 
 about the position of privies : these are to be outside the 
 encampment, and the refuse is to be covered with earth. 
 Most exemplary regulations are laid down about the life 
 and intercourse between husband and wife, and about rest 
 on the Sabbath. 
 
 For leprosy modern prophylaxis can add nothing to the 
 biblical regulations. A leper must live outside the camp 
 and must not frequent public places. If any one is sus- 
 pected of having leprosy, he is isolated for seven days from 
 the members of the community, and then must appear 
 before the priest who examines him. If no suspicious signs 
 have developed, the patient is to be kept another seven 
 days outside the camp. "When then seen for the third time 
 by the priest, and there are no signs, the man is allowed to 
 rejoin the community, but his clothes are burned outside 
 the camp. 
 
 Space forbids us to say more ; neither is it necessary, 
 because the hygiene of food and the prophylaxis in the 
 
 17 c 
 
THE PREVENTION OF DISEASE 
 
 Bible have already been described at length by many 
 writers (Baginsky, Rabinowicz). 
 
 Later the Talmud concerned itself with preventive regu- 
 lations for the Jews. In this we find sensible and foolish laws 
 blended together. The rules about slaughtering animals 
 must be pronounced excellent from the hygienic point of 
 view, and we shall give the most important of them. For 
 this unavoidable and cruel act the slaughterman must take 
 care to use a very sharp knife without any notches in it, 
 and should kill the animal with one cut, and this cut 
 should pass through the neck as far as the vertebral column. 
 This fulfils too the hygienic requisite of letting the blood 
 flow out quickly, because this cut will sever the largest 
 vessels which convey blood to and from the head. The 
 subsequent washing with salt and water is also thereby 
 made easier. After the animal is killed it must be in- 
 spected. And then the signs of disease are described so 
 well that this description of the signs must have had a 
 wonderful result at a time when there was practically no 
 veterinary knowledge. For example we select the rule 
 which states that animals in which the pleura is found to 
 be adherent are unfit for food. Modern veterinary know- 
 ledge has shown that pleuritic adhesions are an important 
 sign of pulmonary disease in animals. There are rules 
 about the inspection of the spleen and intestines. And 
 here again many valuable signs of disease in animals are 
 mentioned. Side by side with these important and sensible 
 laws there are absurd rules which can only be due to 
 caprice : for example the law forbidding milk and meat 
 to be eaten together, and this has been further elaborated 
 by certain rabbis who do not permit milk, butter, or 
 cheese to be eaten after meat until four hours have 
 elapsed. 
 
 Modern science has adopted many of these sensible 
 prophylactic measures. The regular inspection of animals 
 by experienced men has added to the list several other 
 signs of disease, and on the other hand has enabled us to 
 remove certain injurious conditions. On the whole the 
 endeavour in the Talmud to lay down the natural principles 
 
 18 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 of health, demands the greatest admiration of scientific 
 men. 
 
 PROPHYLAXIS AMONG THE EGYPTIANS, ASSYRIANS 
 AND OTHER ANCIENT RACES 
 
 We know little about the prevention of disease among 
 these races. They probably had baths and anointed the 
 body, and observed certain rules about foods. It is known 
 that the Egyptians endeavoured to exclude epidemic disease 
 by quarantine, but the data available are so meagre as 
 to be of little use for our purpose. The nations of classical 
 antiquity, the Grreeks and Romans, have also done little in 
 prophylaxis. These two nations will be remembered for 
 their arrangements for the supply of water, for drainage 
 and for baths. I will merely give a few historical facts 
 which show a partial and temporary attempt at prophylaxis. 
 
 It is known that Lycurgus ordered simple food for his 
 Spartans, and his rules are regarded as correct when judged 
 by the physiology and chemistry of today. The Spartan 
 broth is celebrated. The laws of Lycurgus were intended 
 to train up a strong warlike people, and the simplicity of 
 the food was to accustom citizens even in times of peace to 
 all kinds of hardships, "Whether the custom of killing 
 weakly children soon after birth was practised for any 
 length of time is not recorded in history. Though cruel it 
 appears at all events to be an invaluable prophylactic. In 
 Athens we find a well organized market police supervised 
 by certain special officials, the ayopavo/xoi. The flesh of 
 unborn lambs was excluded from the market as being unfit 
 for food. Pliny tells us that a severe pestilence which 
 broke out among the soldiers of Alexander the Great on 
 the march to India was caused by eating bad fish. In 
 consequence of this, fish was prohibited as food for the 
 soldiers. 
 
 In Rome from the year 388 aediles supervised the cattle 
 markets, shops and eating houses. They determined the 
 price of meat and its fitness for human consumption. Goat 
 fiesh was not forbidden, but was considered less valuable 
 than other flesh. We can quickly pass over the classic 
 
 19 
 
THE PREVENTION OF DISEASE 
 
 races, because we shall later have to refer in another part 
 to the services they rendered in prophylaxis. 
 
 PART II 
 
 AN HISTOEICAL SKETCH OF VARIOUS PEOPHYLACTIC 
 MEASURES 
 
 Aftee the disruption of the Western Roman Empire the 
 political relations of the civilized world were rearranged 
 upon an entirely new basis. The Roman centralization 
 was lost. Yet in spite of the division of the empire into 
 separate territories, some large, some small, with different 
 languages, we find Roman civilization influenced all of 
 them. There is no reason therefore for us to follow the 
 fate of these countries and races separately, since the 
 development was much the same in all these territories, 
 and they were united by a common culture and later by 
 a common religion. "We shall therefore discontinue the plan 
 hitherto followed, and instead of tracing the progress of 
 prophylaxis in each separate nation we shall now describe 
 the various prophylactic measures, pointing out so far as 
 possible the advances in prophylaxis made by the various 
 nations. Repetition will be avoided wherever possible, 
 though we shall have to refer again to pre-Roman arrange- 
 ments to make the subject complete. 
 
 I. SUPPLY OF WATER 
 
 Not only for prophylactic reasons but also to satisfy an 
 urgent natural craving, man has always been compelled to 
 have a supply of water. "When nature provided water 
 which was disagreeable, man was compelled to find a 
 source of water which was more to his taste ; because, as 
 Pettenkofer rightly points out, we drink water not only as 
 a food but also for enjoyment. So in "West Asia we find 
 numerous wells and cisterns. In North Africa there are 
 
 20 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 wells three or four metres wide, not far from the Nile, 
 which were used for drinking and for agricultural purposes, 
 and are still worked today with waterwheels. These are 
 in the opinion of some historians (Eyth) as ancient as the 
 hieroglyphics. The Greek author Olympiodor wrote : " The 
 oasis of Thebes is perforated by cisterns like a sieve." A 
 number of these water reservoirs were put in order again 
 in the sixth decade of the nineteenth century. In China 
 too we meet with many round wells of very ancient date. 
 Arrangements for supplying water were, as already men- 
 tioned, made use of by the Egyptians and the Romans. 
 Some remains of aqueducts found in Egypt are of Roman 
 origin, and similar ones are found also in Asia Minor. 
 
 In the sixth century B.C. Polycrates had built an aque- 
 duct for Samos which consisted of a tunnel 1,000 metres 
 long. 
 
 It was the constant care of the Roman emperors to 
 supply the Eternal City with sufficient good water ; for 
 not only was much water required for the numerous in- 
 habitants, but also because the baths and numerous fish- 
 ponds of various rich Romans had to be supplied with 
 water. Thus gradually magnificent waterworks were 
 built, the oldest of which, the Appia Claudia, was opened 
 in 313 B.C. A second large aqueduct, Anio vetus, was 
 made in 273 b.c. ; and more than a century later, 144 B.C. 
 a third aqueduct, Aquamarva, was completed. Other 
 aqueducts were subsequently built by succeeding emperors. 
 Four of the old aqueducts are still worked (Aquavergini, 
 Aquamarica, Aqua felice. Aqua Paolo). 
 
 In the provinces too of the old Roman empire there are 
 numerous aqueducts : at Aries, Avignon, Arneuil, Con- 
 stantinople, Lyons, Mayence, Nimes, Paris, and Treves. 
 Several of the provincial ones have in modern times been 
 put in order and are again in use, as at Bologna, Metz, 
 Segovia and Spoleto. 
 
 It is to be regretted that the long period which we term 
 the middle ages allowed these splendid works to fall to 
 ruins. In recent years attempts have been made in part 
 to restore these and to supply towns with water of the best 
 
 21 
 
THE PEEVENTION OF DISEASE 
 
 quality in a way formerly undreamed of. What has been 
 done in this matter during the latter third of the nine- 
 teenth centurj'- is so recent that it is unnecessary to give 
 an account here. 
 
 II. BATHS 
 
 As in Rome we find waterworks, so also do we find baths. 
 It sounds almost incredible when we are told that imperial 
 Rome had 800 public baths. It is necessary to describe 
 the arrangements in a Roman bath, and then we shall 
 understand the very imposing ruins of these sanitary insti- 
 tutions (Baths of Caracalla). 
 
 Before bathing the Roman took a little exercise. The 
 room in which he undressed was heated, and there after 
 undressing he was anointed with oil. Then came the 
 application of the strigil, and after this he went into a 
 hot room or a hot bath to promote perspiration. Then 
 followed a cold douche and a cold plunge. After these 
 elaborate processes the body was again anointed. These 
 baths formed to a certain extent a centre for the business 
 and social life of the Romans. Here the events of the day 
 were discussed, while some went through gymnastic exer- 
 cises. The luxury of these baths seems not long to have 
 survived the fall of the Roman empire. Not till the time 
 of the Crusades do we see a revival of this institution in 
 Europe. The Crusaders, returning from the East, tried to 
 reintroduce the baths which were so common in the East. 
 Only in Spain, where the Moors ruled for a long time, were 
 luxurious baths established for the sake of the religious 
 rites of Islam which required believers to bathe frequently. 
 The manner of bathing was somewhat different from that 
 practised at Rome. The bather, after undressing, wrapped 
 round him a woollen cloak, put on sandals, and walked to 
 the hot bath. After the bath he rubbed the hard parts of 
 the skin, the heel and sole with pumice stone, and then 
 came anointing and sprinkling with odorous essences. 
 
 When the Moors had been driven out of Spain one of 
 the first acts of the pious populace was to raze to the 
 ground these remnants of heathendom. 
 
 22 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 The baths which were established in Germany, France 
 and England through the initiative of the Knights of the 
 Cross soon met with great approval. It became a custom 
 to take a bath before ceremonies such as marriage or 
 knighting. So too on the eve of a festival every one went 
 to his bath. Then the various reigning princes claimed the 
 income from baths ; they formed part of the so-called royal 
 prerogatives. By transfer or by lease these were made over 
 to the towns, and a special guild superintended and man- 
 aged the baths. These were regarded in the light of cura- 
 tive agents, and it is evident that the founders of these 
 institutions attached to them an hygienic value. It is 
 worthy of note that every Saturday the artisans were called 
 to their bath by a trained band of youths who carried 
 drums. Vapour baths were introduced in the twelfth 
 century. 
 
 Besides the public baths every rich citizen had a bath- 
 room fitted up in his own house, a room which served also 
 for entertaining his friends. Here the friends of the house 
 assembled for feasts and banquets, but each guest first took 
 a bath. 
 
 But in addition to these admirable baths the Knights of the 
 Cross brought something less welcome with them from the 
 East, namely leprosy, and many baths were doubtlessly estab- 
 lished because of this terrible disease. At least it has been 
 shown that so-called " soul-baths " were founded especially 
 for the poor by benevolent persons both to prevent and to 
 cure leprosy. It was a well meant but dangerous kind of 
 benevolence, for it soon became evident that this method 
 of trying to prevent leprosy was the very way in which 
 to spread it. And so it could not but happen that many 
 physicians became determined opponents of baths. Another 
 circumstance too tended to discredit these baths. In the 
 middle ages, that remarkable period which is characterized 
 by religious fanaticism and indulgence in excesses, these 
 baths were often used for the wildest orgies and shameless 
 licentiousness. The clergy, physicians and statesmen then 
 opposed these public bathing institutions and the good was 
 thrown away with the bad, for owing to this opposition on 
 
 23 
 
THE PREVENTION OF DISEASE 
 
 all sides and to the danger to health caused by these badly 
 managed baths, most towns gave up their public baths. 
 
 It should be mentioned that at the commencement of 
 the seventeenth century a number of cases of syphilis 
 which occurred in Brlinn were traced without any doubt to 
 an infection at a bath. To understand this we must re- 
 member that it was the custom in many places to cup the 
 bather directly after the bath, and the cupping instrument 
 was not always carefully cleaned after each time of being 
 used. 
 
 Instead of these public baths, which were being closed 
 nearly everywhere in Germany, the custom arose of going 
 to some bathing resort. Places which were pleasantly situ- 
 ated and especially which had water with curative proper- 
 ties were frequented in the summer by rich people. One of 
 the oldest of these bathing resorts is Baden in Aargau, if we 
 omit Aix-la-Chapelle which was much frequented even in 
 the time of Charlemagne. 
 
 Vapour baths were introduced into France rather earlier 
 than into Germany. They were called " etuves." As in 
 Germany, a guild of bathers was established, called the 
 " etuveurs." Cold baths and sea baths were first known in 
 England, and this English custom was brought to Germany 
 in the eighteenth century by physicians who had been to 
 England (Hufeland and Halm). The cold water institutions 
 on the continent date from the nineteenth century. 
 
 The value of the bath as a prophylactic and curative agent 
 is thoroughly accepted. The perspiring which is produced 
 by vapour baths has certainly helped to get rid of the 
 toxins of certain diseases, and the use of cold water after a 
 hot bath or to rub down the body fortifies the body and is 
 valuable in enabling it to resist atmospheric influences as 
 has been fully recognized in all ages. 
 
 III.— THE EEMOVAL OF EEFUSE AND THE DISPOSAL 
 OF THE DEAD 
 
 Old historical records and ruins of buildings connected 
 with the removal of refuse from towns are much more 
 scanty than those connected with the supply of water. 
 
 24 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 Probably this refuse which, would be injurious to health 
 was removed in the simplest way and used to manure the 
 land. But there appears certainly to have been the opinion 
 that removal of the refuse by drains was only practicable 
 with a simultaneous flushing. 
 
 The following are some of the facts as to drainage which 
 have come down to us. Babylon, Carthage and Egypt 
 are said to have had systems of drainage, and Jerusalem 
 in the Herod ian period is reputed to have such a system 
 to carry away the waste water into special reservoirs. 
 Here the impurities were allowed to settle to the bottom 
 as in settling tanks, the water in the reservoir was 
 then allowed to run off and the sediment was used as 
 manure. 
 
 Up to the present day, as mentioned above, the Cloaca 
 Maxima in Rome laid out by Tarquinius Prisons is still in 
 use. It was built not so much for the purpose of removing 
 refuse but to drain the town and marshy places. Later, all 
 polluted water was also drained into it. It emptied itself into 
 the Tiber below Rome. But even in Augustus' time it was 
 noticed that the fluctuating stream caused a backward 
 flow of the debris which led to serious results. The 
 emperor in consequence of this ordered that the drains 
 should be regularly flushed. 
 
 During the middle ages very little was done to keep the 
 towns systematically clean. The oldest structure which 
 exists in Germany for drainage of a town is that of the old 
 pottery town of Bunzlau which was regularly flushed by 
 means of a system of drainpipes as early as 1559. A 
 similar arrangement was started in Prague in the seven- 
 teenth century. The oldest drains in modern Europe are in 
 England. Almost every large town was provided with a 
 system of drains, regularly flushed, and many date back 
 to the sixteenth century. But even in England the 
 polluted water was conveyed into the nearest stream. It is 
 only since 1859 that attempts have been made to do away 
 with this evil. London took the lead. By means of an 
 intercepting sewer the sewage was conveyed to an outfall 
 below London where it was allowed to escape only on the 
 
 25 
 
THE PREVENTION OF DISEASE 
 
 ebbing tide into the Thames. But when this measure was 
 also found inadequate, the sewage was previously submitted 
 to a process of precipitation with the view of purifying the 
 eiEuent. 
 
 Hamburg, following England's example, commenced to 
 build drains in the fifties of the nineteenth century. Dant- 
 zig was the first town in Germany to have at the same 
 time a drainage system, a water supply system and irriga- 
 tion. Berlin, too, since 1875 has built a similar system 
 which ranks amongst the greatest installations for drainage 
 of the century. Almost all large communities nowadays 
 have followed the excellent example of these towns. 
 
 The methods employed for the disposal of the dead do not 
 show any very clear idea of prophylaxis. In Grreece and 
 heathen Rome the dead were burnt. The Israelites buried 
 the dead in the earth at a depth prescribed by their laws. 
 The European nations which sprang up out of the former 
 Roman empire seem not to have had any strict regulations 
 about burial till very much later. Not even coffins were in 
 general use, and there were no regulations as to the depth 
 of graves. 
 
 The churchyard was to only the slightest extent the 
 property of the community, but rather belonged to the 
 church authorities, and was always chosen so as to be near 
 the church. Hence the name churchyard, which is still 
 at the present day used to designate the place of burial. 
 In South Grermany, especially in Bavaria, the word Friedhof 
 (cemetery) is general. But the expression Friedhof (place of 
 peace) does not mean that those who rest there have found 
 peace, but that the spot is separated and fenced around. 
 
 IV. EULES CONCERNING MEAT. 
 All historical records about this subject show that all 
 settled peoples who did not themselves rear animals for 
 food supplies, but were obliged to buy meat from markets, 
 were protected by certain laws against fraud and against 
 articles of inferior value. These laws have already been 
 referred to so far as they concern the ancient races. 
 
 We shall now consider the regulations which were pro- 
 
 26 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 mulgated after the decline of the Western Roman Empire. 
 These laws are mostly of municipal origin. Every com- 
 munity had its own police regulations about food. The 
 government and the ecclesiastical authorities rarely inter- 
 fered in the matter. 
 
 It requires mention that the German apostle Winfried 
 Bonif acius forbade the use of horseflesh which was so much 
 eaten in Germany, because he attributed to its use impurity 
 of the blood and leprosy. But if we examine a little more 
 closely into the reason of it we shall probably come to the 
 conclusion that it was dictated by a religious rather than 
 a sanitary motive, for it is well known that horseflesh was 
 eaten by the old Germanians at their religious festivals at 
 the solstice, so that the order struck at heathen ceremonies 
 in which the horse was a symbol. This may also have 
 been the reason why the eating of horseflesh was forbidden 
 by the Council of Celeia in 787. On the other hand Pope 
 Zacharias seems to have forbidden the eating of pork and 
 of bacon from purely sanitary motives. In the time of 
 Charlemagne the question was often discussed whether the 
 flesh or blood of an animal which had died or had been 
 killed by other animals might be eaten. 
 
 Towards the end of the eleventh and commencement of 
 the twelfth century a guild of butchers was established in 
 most towns of Germany. In free cities these were super- 
 vised by masters of the guild specially chosen for the work ; 
 in other towns sometimes by overseers, burgraves and other 
 imperial offlcials. The oldest known charter which contains 
 regulations about meat is probably that of the town 
 Freiburg in Breisgau in the year 1120. These data have 
 been taken from the very thorough treatise written by 
 Ernst Graber, to which all interested in the subject are 
 referred. We reproduce here only a few selections from 
 this book. 
 
 It is interesting to learn from an old deed of the town of 
 Augsburg of the year 1276, that slaughtering was forbidden 
 except in slaughter houses. Slaughter houses must have 
 already been in existence therefore at this period. In many 
 documents warnings are given against measly flesh, in 
 
 27 
 
THE PREVENTION OF DISEASE 
 
 others against leprous flesh, mangy sheep and the flesh of 
 calves which were too young. In many documents is a law 
 ordering that inferior meat must be sold separately from 
 good meat. 
 
 The conditions under the Holy Roman Empire were most 
 unfavourable for the carrying out of sanitary measures. 
 There is hardly any sign of any central initiative authority ; 
 not only did every sovereign make laws for his small 
 territory, but every community in it had its own special 
 laws. Only towards the end of the fifteenth century do we 
 find an endeavour to supplant these separate powers by a 
 strong central authority. Charles V, whose misfortune it 
 was that he did not understand the age, and regarded the 
 mightiest movements in human history as a mere revolt 
 by unruly men and discontented priests, nevertheless 
 endeavoured to strengthen the imperial power and to 
 extend it. He was helped on the one hand by the natural 
 decay of the feudal system, on the other hand by the new 
 development of science which began to stir again during 
 his reign after a pause of several centuries. The voices of 
 physicians too began to be heard. And thus during the 
 reign of this emperor an imperial sanitary police was 
 established in the year 1530. They adopted special mea- 
 sures for beer, wine, bread and meat, and fixed the price of 
 these. At the famous Imperial Diet held at Augsburg in 
 the year 1648 these laws were brought again to the notice 
 of all authorities with penal regulations. 
 
 Under this emperor experts upon hygienic and prophy- 
 lactic questions were for the first time in Grermany drawn 
 from the ranks of the physicians. At that time too a few 
 scientific works dealing with the preservation of health 
 were written, as Von Striippen's Nutzliche Reformation zu 
 guter Gesundheit und Christliche Ordnung and a German 
 edition of Fortunus Fidelis (Nissus sive medicinae patro- 
 cmium, Panorma, 1698). In 1559 official inspection of 
 slaughtered animals in Vienna was ordered by the State. 
 In 1582 an order was issued by the government of the 
 palatinate that all meat exposed for sale in the butchers' 
 shops must be labelled. Measly meat was to be sold at a 
 
THE HISTOKY OF THE PREVENTION OF DISEASE 
 
 special place, and flesh which was very measly was not to 
 be sold at all. 
 
 The disgusting custom of blowing up meat was practised 
 in earlier times even more than at the present day. Lich- 
 tenberg issued a rescript in 1587 which described this 
 process as disgusting, deceptive and dangerous to health 
 (" because many butchers have an unwholesome and dis- 
 agreeable breath "). 
 
 During that sanguinary time when a tedious war damaged 
 the prosperity of Grermany for centuries, it is scarcely 
 possible to speak of an imperial authority. The power of 
 the various princes which Charles V attempted in vain to 
 suppress was a sovereign power equal to that of the 
 emperor himself. The most powerful prince of that age, 
 the Elector Friedrich Wilhelm of Prussia, in those stormy 
 days raised the condition of his country with marvellous 
 energy in spite of the dangers of war and its distresses. 
 Prussia already possessed sanitary regulations, and these 
 were consolidated by the edict of 1685, while for the 
 regulation of medicine a central institution was established 
 for Prussia, the "Collegium Medicum" consisting of physi- 
 cians. After that uniform market regulations were drawn 
 up for the whole country. In the year 1769 a second 
 college was established, the "Collegium Sanitatis." The 
 object of founding this second college was " under the 
 Divine grace and care to protect our province and lands 
 from the pestilential plague and other contagious diseases 
 and to prevent the cattle from dying, so far as this is pos- 
 sible." Meantime a provincial medical college had been 
 established in every province, and in 1786 the " Collegium 
 Sanitatis " was instructed to combine with these and to 
 take over " the supervision of all institutions against 
 epidemic disease, pestilence among cattle and -of all that 
 concerns the maintenance of health and the removal of 
 causes of disease among men and cattle." In 1799 these 
 two colleges, " Collegium Sanitatis " and " Medicum," were 
 united and were provided with more extensive duties. 
 They were to occupy themselves with and examine into 
 everything which might be injurious to health, to look out 
 
 29 
 
THE PEEVENTION OF DISEASE 
 
 for any abuses and to remove them by suitable sanitary 
 rules and precautions ; they were also to see that the food 
 was wholesome. 
 
 In other countries too similar rules were made about this 
 time : for example in 1712 in Hanover. In 1716 it was 
 ordered in Hanover that all cattle should be examined 
 while still alive. If considered healthy a mark was 
 branded upon the horn of the animal. It was kept three 
 days, then again examined, and allowed to be slaughtered 
 if this second inspection showed the animal to be healthy. 
 A few unconscientious dealers imported smoked and salted 
 meat from abroad which came from diseased animals, and 
 a law was consequently passed forbidding the importation 
 of smoked and salted meat. In 1732 an order was issued in 
 Hanover that calves which had been suckled by diseased 
 kine should not be slaughtered till they had been taken 
 away from the diseased mother and had been fed upon 
 healthy milk for at least eight days. In the meantime 
 they were to be carefully examined, and especially the 
 tongue was to be examined for any ulcers. If not healthy 
 such calves were to be slaughtered by an ofhcial, but not in 
 the slaughter house, and were to be buried with their skin 
 and hair at a depth of four ells. 
 
 Since 1803 regulations have existed in Prussia to prevent 
 pestilence among cattle. But the greatest reform in this 
 matter was the establishment of veterinary schools, the first 
 of which was instituted in 1824 at Stuttgart. Unfortu- 
 nately these measures to ensure the meat being sound were 
 not carried out continuously. It is especially noticeable 
 that the regulations about slaughter houses were gradually 
 disregarded, so that in 1842 there was no longer any public 
 slaughter house in Berlin, although a short time previously 
 there had been three. It is remarkable that this condition 
 of things was possible under the strict Prussian rule. Then 
 Kiichenmeister's epoch-making discovery about intestinal 
 worms exposed the danger to the public of meat derived 
 from private slaughter houses which were not under super- 
 vision. A still more lasting impression was produced by 
 the great epidemics of trichiniasis which broke out in 
 
 30 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 Germany in 1864. As a result of this the Medical Society 
 in Berlin appointed a committee to inquire into the sub- 
 ject of trichiniasis and the prevention of this dangerous 
 disease, and the outcome of this inquiry was a unanimous 
 recommendation by this learned society that supervised 
 slaughter houses should be established in at any rate all 
 the larger towns of the kingdom. The recommendation 
 was not made in vain. And soon there was no large com- 
 munity in Germany which did not possess its slaughter 
 house, or at least was preparing to have one. 
 
 The crown to this sanitary work is the establishment in 
 our own day of the Imperial Board of Health. Still it 
 should be mentioned that even before this imperial institute 
 was founded various districts of Germany, such as Bavaria, 
 Saxony and Wiirtemburg, had excellent regulations of their 
 own about slaughtering and market police. 
 
 V. RULES FOR PERSONAL PROPHYLAXIS 
 
 In addition to these police regulations, to which the pre- 
 vious section has been devoted, there were also personal 
 prophylactic measures which can be traced back some of 
 them to old prejudices and customs, while others rested 
 upon an apparently scientific basis, and others again upon 
 the custom of taking certain foods and drugs which were 
 renowned, sometimes rightly and sometimes wrongly, for 
 their efficacy against disease. 
 
 1. Far into the period of the middle ages the mistletoe 
 bough was regarded in Germany and in England as a 
 preventive of disease and evil spirits. The custom arose 
 out of German myths. Another plant which was used to 
 protect against disease is the mandrake root. It is how- 
 ever difficult to conceive how the foolish belief in this root 
 originated. Some authors maintained that it possessed a 
 slight resemblance to the distorted face of one who had 
 been hanged. It is certain that even in the sixteenth 
 century the mandrake root was considered a most valuable 
 remedy by the apothecaries of that day ; that it was kept 
 in special boxes called coffins, and only sold for very large 
 sums. According to Kiihn the custom is said to be con- 
 
 31 
 
THE PEEVENTION OF DISEASE 
 
 nected with fire worsliip in India and in Germany, and it 
 is often put for the ash (the tree of Odin), the mistletoe, 
 the hazel (magic wand) and the mullein. But if the 
 Hebrew word "dadaim" is correctly translated by "man- 
 drake root," it was already in the Bible regarded as a 
 means against sterility in women. It is mentioned as pos- 
 sessing this power in Grenesis chap. xxx. verse 14. This 
 would show that it was regarded as a prophylactic also by 
 races which were not of Indo-European origin, 
 
 Pliny, in his Natural History^ also records that the man- 
 dragora is valued as possessing many kinds of prophylactic 
 and curative properties. Calomella translates the Greek 
 name by semihominis, and perhaps to this name is owing 
 the tradition that the plant grows only below the gallows 
 of a man who has been hanged although he was innocent. 
 Charlatans tell all sorts of marvellous stories about the 
 danger incurred in getting the plant, and ask a correspond- 
 ingly high price for it. Sixty thalers gold and even more 
 have been paid for one mandrake. " They may only be 
 gathered at full moon, and the plant is only efficacious 
 when pulled up with its root. At the moment when it is 
 thus pulled up, the plant utters such a terrible cry that he 
 who hears the cry dies of fright. Therefore it has to be 
 tied to the tail of a large strong black dog, and the dog is 
 enticed by a piece of meat placed some little distance away. 
 As the dog snaps at the meat the plant is torn out with 
 its root, and the dog of course pays the penalty of losing 
 his life." 
 
 A doll was carved out of the root in the form of a human 
 being, was dressed in grand clothes, concealed in a valuable 
 box called a " coffin " in some secret corner of the house ; 
 it was washed every month with wine and water and 
 dressed in new garments. The possession of such a man- 
 drake root protected against all kinds of dangers, removed 
 sterility, made childbirth easier, lessened the labour pains, 
 and guaranteed a good lying-in period. However in 
 ancient times other plants were used for the same pur- 
 pose, as aglaophotis and the peony. 
 
 Mistletoe is even up to the present time regarded as a 
 
 32 
 
THE HISTORY OF THE PEEYENTIOX OF DISEASE 
 
 valuable prophylactic. Its fame rests upon the G-erman 
 myth of Baldur's death. Among the ancient Grermans, a 
 priest in a white garment had to cut it from the tree with 
 a gold sickle and catch it in a white vessel. In Sweden it 
 is still today regarded as a tree which protects against 
 disease (especially epilepsy) and against burning. In Eng- 
 land it is the tree of love. A drink prepared from it 
 removes sterility, protects against every poison, and heals 
 every disease. Epileptics should always carry a piece of 
 mistletoe with them, because it prevents epileptic attacks. 
 In Germany huntsmen prize it because it brings luck in 
 hunting, and because any injury sustained while hunting 
 will quickly heal. 
 
 The juice of the ash protects against the bites of venomous 
 snakes. In Scotland the sap of the mountain ash is given 
 to newborn infants instead of honey to protect them from 
 cramp and diseases of the eye — " Infante nato obstetrix 
 Scotiae montaneae viridis fraxini ramusculum igni immittit, 
 succum inde imanentem ista deinde ori infundit infantis, 
 ut primum ejus nutrimentum" (Finn Magnussen"). In 
 Grermany chaplets of mistletoe and coral were valued as 
 protective. 
 
 Lastly we must mention aU those things which are 
 renowned as prophylactics. Some of these are connected 
 with the Christian religion, others are inherited, and others 
 again are found by accident. 
 
 Baptismal water protects against cramp and inflamma- 
 tion of the eyes of children (East Friesland and Thiiringen). 
 Consecrated water, especially when hailstones have chanced 
 to fall into it, protects men and animals against disease of 
 all forms (Thiiringen). A consecrated wafer will protect 
 man and animal from cramps ; so too will sacramental wine 
 (Lauenburg). Whoever drinks this wine on the day of 
 consecration will be protected the whole year against poison, 
 witchcraft and lightning (Bavaria). Wax candles which 
 are consecrated on Candlemas Day are fastened around the 
 wrist of women in labour. This will give an easy delivery 
 and a good lying-in period. The candle is most efficacious 
 when Candlemas faUs upon a Sunday. 
 
 33 D 
 
THE PREVENTION OF DISEASE 
 
 A little metal scraped off a church, bell and taken, is 
 specially valuable in protecting cattle from all forms of 
 illness, and it is also useful for man. The bellrope has a 
 similar effect ; and so too the fat with which the axle of 
 the bell is greased. The buds on plants consecrated on Palm 
 Sunday protect against swelling in the throat and fevers, 
 especially in children. Candles, cloths, ribbons, aprons and 
 pots which have been used for church ceremonies, have a 
 great reputation as prophylactics. So too consecrated nose- 
 gays of nine different kinds of flowers ; also the wedding 
 ring, bridal dress and bridal wreath. 
 
 Among things inherited old Bibles rank high as pro- 
 tectives (especially the Apocalypse). ItaHans carried on a 
 large trade in these at the commencement of last century. 
 These were often placed in the infant's cradle to protect it 
 from cramp. Old hymnbooks served the same purpose. 
 
 Among articles found the horse's hoof is famous even at 
 the present day. Its prophylactic value is great against 
 all infectious disease. 
 
 In all these things there was always some religious idea 
 or some feeling of compassion ; but another custom, which 
 we can trace back into the distant past, was more brutal, 
 and had to be performed by the blood of one who had been 
 executed, though innocent. Indeed prophylactic value was 
 ascribed to everything connected with an execution or 
 murder or death. 
 
 As late as the year 1861 the foolish populace of Hanau 
 rushed on to the scaffold on which a thidf was executed 
 for murder, in order to get a few drops of the blood while 
 still warm ; and in 1864 at Berlin the executioner after 
 executing two thieves who had committed murder, dipped 
 a quantity of linen into the blood which flowed out and 
 quickly sold the linen for two thalers a piece. This blood 
 protects against epilepsy and cures it. The nail to which 
 was fastened the rope by which a man was put to death 
 was made into gout-rings — that is, rings which protect 
 against gout. The gladiators at E-ome used to drink the 
 blood of those who had been hanged, and so protected them- 
 selves from epilepsy ; and bread which contained some of 
 
 34 
 
THE HISTORY OF THE PREVENTION OE DISEASE 
 
 this blood protected against gout. The bones and the cord 
 with which the victim was hanged answered the same 
 purpose. 
 
 In France at the present day the fat of criminals is 
 asked for at druggists', as a protection against consumption. 
 In the fifties a murderer in Switzerland confessed that he 
 had slain an innocent victim, that he might have the blood 
 and so protect himself against madness. "Whether now and 
 again some of the many inexplicable murders the motive 
 for which is so difficult to discover (such as " Jack the 
 Ripper") may not be connected with this superstitious 
 belief is at least worthy of discussion. The old unfortunate 
 superstition still exists among prostitutes, that they can be 
 protected against the contagious diseases to which their 
 dishonourable trade exposes them if they first have inter- 
 course with an innocent youth. 
 
 2. Among methods which have come down to us from 
 earliest antiquity, and to which still today great prophy- 
 lactic value is ascribed, are blood letting, cures by purgation 
 and cures by sweating. The three were very frequently 
 combined. 
 
 In the foregoing pages it has been possible to separate 
 the prophylactic measures from therapeutic ones, but 
 this is not possible for the above mentioned practices. 
 Probably the idea of these cures first suggested itself to 
 the mind at the bedside ; they were then used for patients, 
 and later came to be used as preventives of the diseases in 
 which they had proved efficacious. Venesection was prob- 
 ably the most unfortunate of these. 
 
 Pliny, in his Natural History^ calls the hippopotamus the 
 introducer of blood letting, and relates that when this 
 animal feels plethoric it goes to the stubble in the field and 
 opens a vessel of the thigh with the sharp points of the 
 stubble. It then closes the wound with mud. This absurd 
 story of Pliny's rests upon a correct observation that the 
 sweat given ofi* by the hippopotamus is bloodstained. 
 Stephanus Byzantius, a writer of the fifth century, says 
 that venesection was introduced by Pataleios, a son of 
 Aesculapius. He is said to have been stranded upon a 
 
 35 
 
THE PREVENTION OE DISEA8E 
 
 distant island wlien a yontli, and to have opened a blood 
 vessel and so saved tlie life of a maiden who had become 
 unconscious after a fall. The maiden, daughter of a shep- 
 herd on the island, was afterwards married by the successful 
 physician. The ojieration later was much practised by the 
 followers of Aesculapius in their temples. 
 
 In the Coan Prognostics it is taught that venesection 
 should be performed for threatened haemorrhage in impor- 
 tant organs. Hippocrates recommends venesection for 
 febrile diseases, for pain in the breast when commencing, 
 for difficult micturition, threatening apoplexy and loss of 
 speech. This shows that he employed venesection not 
 only in illness but also when a patient seemed likely to 
 become ill. 
 
 Ohrisippus of Cnidus, a Pythagorean, condemns venesec- 
 tion for mystic religious reasons (Gralen, de Venaesectione)^ 
 because the Pythagoreans, like the Israelites and several 
 other ancient races, believed that the soul was located in 
 the blood and venesection would lead to a reduction of the 
 soul's function. His renowned pupil, Erasistratus, one of 
 the founders of the Alexandrian school, is also no friend of 
 venesection. As a substitute for it another Alexandrian 
 Appollonius recommended cupping. The Empirics allowed 
 a wider field for venesection. Yet a contemporary of 
 Trajan, Menodatus of Nicomedia, would limit it to cases 
 in which important organs are threatened with congestion. 
 Asclepiades, who introduced Greek medicine into Rome 
 and was also an empiric, recommends venesection for 
 threatening apoplexy, but gives the warning that in 
 other cases its use should depend upon the climate. In 
 temperate climates it should be performed less often than 
 in hot climates. 
 
 The Methodists ascribed to blood letting a depletive 
 effect, and recommended it for plethoric constitutions. 
 Galen, Oribasius and Aetius recommended venesection at 
 the commencement of every inflammation. 
 
 Trains was a great friend of venesection and, contrary 
 to the opinion of his predecessors, he thought it did not 
 matter which vein was opened. At that time the schools 
 
 36 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 taugM that sometimes the vessel to be opened should be 
 near the diseased organ, sometimes that it should be on the 
 side opposite to that upon which the disease was. 
 
 The Arabians, especially Ehazes, were upon the whole in 
 favour of venesection, but they too thought that climate 
 should modify its use. Avicenna, the most famous Arabian 
 physician, was much more careful than Rhazes in his 
 enumeration of indications for venesection. He considered 
 climate and season as valuable factors in deciding upon the 
 operation, and he also took into consideration astrological 
 data. In the sixteenth century, Brissot thought that 
 venesection should be specially recommended as a preven- 
 tive against epidemic diseases. 
 
 Batelli was an enthusiastic advocate of venesection (De 
 Sanguinis Missione, Leyden, 1660). It should be done for 
 plethora and when the blood was corrupt. Neither age, sex, 
 nor constitution was a contra-indication to blood letting ; 
 but one ought not to withdraw too little blood. Two to 
 three pounds should be withdrawn at one time, or at least 
 a sufficient quantity to produce fainting. This was done 
 both to protect against disease and to cure disease, and he 
 held that it was false to assume that blood letting dimin- 
 ished the quantity of blood. Just as the quantity of milk 
 in the breast is increased by suckling, so the removal of 
 blood by venesection leads to the formation of fresh blood. 
 The blood which was withdrawn was laden with waste 
 matters, and was replaced by good pure healthy blood. 
 The medical faculty of Paris opposed this cruel absurdity, 
 but in spite of this protest and in spite of the rule which 
 was made by this faculty forbidding venesection, yet the 
 custom spread and extended in France, Italy and Spain 
 unhindered until towards the end of the sixteenth century. 
 All the protests of the more careful physicians and learned 
 bodies did less to stop this barbarous practice than the 
 satire of the immortal poet Moliere in his MaJade 
 imaglnalre. One of his choruses in dog-Latin runs : 
 " Phlaebotomia, dolum medicorum, nee non pontum 
 asinorum quia ilia ordinando non requiritur magna 
 scientia." Le Sage also at a later day wrote a satirical 
 
 37 
 
THE PEEVENTION OF DISEASE 
 
 chapter in his Gil Bias against the still prevailing evil. 
 The witty Paracelsus, in Germany, ridiculed with no less 
 scorn the unhappy followers of Galen who thought every 
 one had too much blood. He does not condemn it alto- 
 gether, but brings forward some astrological reasons 
 against Galen's arbitrary practice. About this time 
 calendars and rules were drawn up by physicians, and were 
 used till the beginning of the nineteenth century. Besides 
 weather prognostications there were also rules by which 
 could be found the day on which blood letting should 
 specially be performed. The oldest book of the kind is one 
 by Franz Eapoldis, Magnum et perpetuum Almanack^ 
 Antsverp, 1551, but David Haarlich's book was more used 
 and more pcnular. 
 
 Harvey's wonderful discovery brought certain modifica- 
 tions into the practice of venesection, and the contention 
 as to which part of the body should be selected now ceased. 
 But it was Helmont and his great reputation which checked 
 this thirst for blood letting, both of the professional and 
 of the unprofessional vampires. 
 
 The members of the iatro-chemical school of the 
 seventeenth century, and among them Anton Fortius at 
 Rome, were enthusiastic opponents of blood letting. The 
 blood is free from pollution and blood letting cannot there- 
 fore improve it, and plethora does not exist because there 
 is too much blood in the body, but because the blood vessels 
 are weak. If the contents of the blood vessels is with- 
 drawn the weakness is increased and not diminished. Only 
 when rupture of some vessel in an important situation is 
 threatened is it permissible to withdraw blood. Suitable 
 diet and bodily exercise are of more value in plethora than 
 is blood letting. 
 
 In opposition to the iatro-chemists were the iatro- 
 physicists who favoured venesection, and this is readily 
 understood when we remember the theoretical idea about 
 the nature of disease held by this school. 
 
 In the beginning of the eighteenth century a great 
 contention arose between two equally well known and 
 renowned physicians, Philip Hecquet and Jean Baptiste 
 
 38 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 Silva. The former considered venesection one of the best 
 sedatives; the latter maintained that the sedative effect 
 could be obtained by far less dangerous remedies. 
 
 Sydenham does not speak in favour of this absurd 
 reckless and dangerous blood letting, but uses it as a 
 pro23hylactic when acute disease threatens. Yet in spite of 
 the authoritative utterance of this great man, the custom 
 of blood letting could not be put an end to ; and two 
 opponents in other matters, Friedrich Hoffmann and Stahl, 
 joined hands in energetically recommending venesection as 
 a preventive against many diseases. It is probably in part 
 due to the influence of these two men that in the eighteenth 
 century almost every human being had himself bled at 
 least twice every year, and that in addition to this every 
 pregnant woman was bled before she was delivered. 
 Venesection survived for a long time, and was fostered by 
 the theories of Brown in England and of Broussais. It 
 was homoeopathy and the moderate Vienna medical school 
 which succeeded at the beginning of the nineteenth century 
 in dealing a decisive blow at this harmful custom. 
 
 There is much less to be said about cures by purgation 
 and by sweating than about cures by blood letting. They 
 were generally combined with blood letting. Purgation 
 for the prevention of disease is a very old custom, both 
 recommended by physicians and also in general use among 
 the people. Hippocrates recommended asses' milk as a 
 mild cure of this kind. It is probably correct to assume 
 that these suggestions of Hippocrates did not undergo any 
 great change till the sixteenth century, although asses' 
 milk was sometimes replaced by one drug sometimes by 
 another. Paracelsus ridiculed these methods of treatment, 
 but the humours recommended by him are probably of no 
 greater value than the treatment which he ridiculed. 
 Helmont is also an opponent of purgatives. They can- 
 not reach the " archeus," which is the cause of the 
 corruption of the juices. On the contrary, they reduce the 
 strength of the body and make it incapable of resisting the 
 " archeus." 
 
 The iatro-chemical school indirectly advocated purgatives, 
 
 39 
 
THE PREVENTION OF DISEASE 
 
 although they uttered a protest against purgative treat- 
 ment. For fever, which they regarded as the expres- 
 sion of acidity, they ordered alkalies, and all of these 
 purge more or less, so that they were in reality practising 
 that treatment against which they protested. Even up to 
 the present day purgation in treatment plays a large and 
 important role. 
 
 Sweating cures have already been referred to in the 
 section upon water supply. To cut short the illness at its 
 beginning not only were baths given, but many hot 
 beverages to cause sweating were recommended, such as 
 hot lemonade. Vapour baths were employed for the same 
 purpose, and were intended to rid the body of impurities. 
 So too when there was a predisposition to rheumatic, 
 gouty, or catarrhal disease. For such purposes they are 
 still extensively used at the present day. 
 
 There are also many articles of diet and medicinal sub- 
 stances which are valued, not altogether without reason, 
 as protective against certain diseases. Probably every race 
 has some such traditional remedy in use, and it would be 
 impossible to mention them all. The following are the 
 most common among them. 
 
 We find the Roman writers ridiculing the populace 
 as " smelling of garlic." Garlic is said to protect against 
 malaria, and it is also said to protect against hydro- 
 phobia and the bites of poisonous insects, as well as 
 against intestinal worms. How far this popular opinion, 
 especially common amongst the southern peoples, rests 
 upon correct observation is difficult to say. 
 
 It is known that the people of South Russia who live in 
 malarial districts have from time immemorial prepared 
 bitter drinks from plants which grow in the country, to 
 which they ascribe virtue against malarial infection. 
 Saffron was regarded by the ancient races as a valuable 
 prophylactic. How old the custom of taking alcohol is it 
 is impossible to say. History seems to show that every 
 race makes use of some intoxicating drink or some intoxi- 
 cating substance. Alcohol especially is said to protect 
 against many kinds of disease, and this property has been 
 
 40 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 ascribed to it from time immemorial. Travellers in the 
 tropics say that it has always been renowned as a pro- 
 tective against yellow fever and dysentery. Tobacco is 
 said to be equally valuable, but has only been known in 
 the old world since the discovery of America. 
 
 Under Louis XIII tobacco came to be used as snuif. It 
 is said to have the property of protecting against several 
 diseases. It is claimed that it relieves the brain and 
 thus prevents all kinds of disease. 
 
 Smoking is reported to have been introduced among 
 Spanish navigators about the middle of the seventeenth cen- 
 tury. They said that it protected against various diseases at 
 sea and also in foreign countries. Smoking tobacco has 
 always been valued as a prophylactic, but whether this is 
 correct must be left undecided. Sailors still chew tobacco to 
 protect themselves against scurvy. It is well known, too, 
 that navigators, especially in the northern seas, look upon 
 acids, particularly citric acid, as possessing antiscorbutic 
 properties. 
 
 Among drugs which are still today much prized 
 as popular prophylactics are arsenic and quinine. The 
 latter since its introduction has been used by everyone 
 going to a malarious district, and for this purpose it appears 
 to have fully deserved its reputation, and at the present 
 time we know of no other drug which possesses such valu- 
 able properties as cinchona bark, or its alkaloid quinine. In 
 mountainous districts arsenic has from time immemorial 
 been used to prevent debility. The inhabitants of some 
 districts (Steirmark, Tyrol, Salzburg) give very small doses 
 of arsenic even to the children so as to accustom them to 
 the poison. The dose of the arsenic is then increased, and 
 they would not be able to give up its use without very 
 injurious results. It is said that arsenic increases the power 
 of work, makes climbing of mountains easier, and prevents 
 the formation of goitre. The custom of eating arsenic is a 
 very ancient one. History does not say who first introduced 
 it nor when it was introduced, but the reputation of arsenic 
 is not altogether without reason. 
 
 The value of bodily exercise in the prevention of disease 
 
 41 
 
THE PREVENTION OF DISEASE 
 
 has been known from ancient times up to the present clay. 
 We need only mention Haller and Vieth, whose works give 
 much information on this subject. Later, Rousseau and 
 Basedow, basing their opinions upon this, devised reform in 
 education. The new art of gymnastics was founded by 
 Simon and Guthsmuths. The latter wrote his Gymnastics 
 for the Young in 1793, and the modern exercises to keep 
 the body in health are the outcome of this. 
 
 PART III 
 
 HISTOEICAL ACCOUNT OF THE PEEVENTION OF EPIDEMIC 
 
 DISEASES 
 
 Diseases which spread from man to man and diseases 
 which cling to certain localities have always given rise to 
 public and private precautions. The means adopted to 
 prevent these diseases varied according to the conception 
 which was held as- to their nature. The idea that they 
 were of demonological origin led naturally to the adoption 
 of demonological means such as magic, amulets and 
 exorcism. The theological theory caused religious means 
 to be used. The scientific conception of diseases and of their 
 causes led us to adopt dietetic measures for prevention 
 based upon scientific facts. Long ago the distinction was 
 made between contagious diseases which to a certain extent 
 are indigenous (endemic), and those which only from time 
 to time visit a place as epidemics and then after a time 
 disappear again. The former have been and are still 
 regarded with some amount of indifference, while the out- 
 break of an epidemic always frightens and terrifies the 
 people. Until quite recently little was done against those 
 terrible endemic diseases scarlet fever and diphtheria. 
 Isolation of the patient and inoculation against diphtheria 
 are of very recent date, while long ago measures, clumsy 
 though they may have been, were nevertheless used against 
 leprosy, syphilis, cholera and plague. 
 
 42 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 I. SMALLPOX 
 
 As already stated, one of the oldest known preventive 
 methods was inoculation against smallpox. Inoculation to 
 protect against smallpox has been practised in China and 
 India from time immemorial. It became general in 
 Europe only a century ago. Still, even without con- 
 sidering the ancients, here and there preventive smallpox 
 inoculation had been practised by dijfferent peo^^les in Europe. 
 Thus for example, the inhabitants of the Caucasus tried to 
 guard their children against disfigurement by smallpox. In 
 Denmark, too, in various districts of France and in South 
 "Wales inoculation against smallpox appears to have been 
 known before Jenner's time. In South Wales the operation 
 was known as " buying the smallpox " in consequence of 
 the belief that unless the person furnishing the lymph 
 received some recompense, pecuniary or other, no result 
 would accrue. An English physician, Sulten, tried to 
 improve the method of inoculation by taking the lymph 
 from the pustules of patients suffering from mild smallpox 
 and conveying it to the arm of young children by the 
 lancet point. To Sulten is due the credit of having 
 exercised great care in inoculating so as to minimise the 
 danger of the operation. Of 17,000 children whom he had 
 inoculated up to the year 1767 only six or seven died from 
 the inoculation. This inoculation was carried out in some- 
 what of a business-like fashion by Sulten. Everywhere he 
 had agents who carried out his method with good results. 
 The results were so brilliant that some physicians believed 
 smallpox had altogether disappeared in England. Others 
 believed that it would be possible to prevent an outbreak by 
 giving various drugs. For this purpose Medicus recom- 
 mended quinine ; Vanderbock and Boerhaave recommended 
 antimony and mercury. These remedies were thought to 
 be more efficacious than prophylactic inoculation. Until 
 the eighties of the eighteenth century Junker and Faust 
 recommended isolation of the patient as the best means for 
 
 43 
 
THE PREVENTION OF DISEASE 
 
 checking smallj)Ox. Edward Jenner, a medical practitioner 
 residing at Berkeley in the vale of Gloucesterskire, was 
 led towards the discovery of vaccination by the casual 
 remark of a young countrywoman who told him that 
 milkmaids were immune to smallpox infection if they 
 had been accidentally inoculated with cowpox while 
 handling the udders of the cows in milking. This 
 statement appears to have made a profound impression 
 upon Jenner's mind, and after much inquiry and reflec- 
 tion he performed his first vaccination in May, 1796. The 
 subject was James Phipps, a boy aged eight, who was 
 vaccinated on his arms with matter from a vesicle on the 
 hand of a dairymaid who had been infected with cowpox 
 while milking. In the following July an unsuccessful 
 attempt was made to inoculate Phipps with variolous 
 matter. Two years later Jenner published his memor- 
 able Inquiry^ and although his thesis was stoutly 
 opposed, and some want of success attended his first 
 efforts, he was subsequently able to establish an institute 
 for vaccination in London. Soon afterwards a similar 
 institution was established in Berlin by the celebrated Heim. 
 Others were established in Vienna by Johann Carro, in 
 Geneva by Odier, in Hanover by Strohmeyer and Ball- 
 horn. It is surprising that the strong opposition to 
 vaccination which in later times appeared, and at the 
 present day still exists, was almost unknown when these 
 institutions were founded. Protective inoculation with 
 vaccine from arm to arm spread from land to land, and 
 later became compulsory in most civilized countries. A 
 poet wrote in 1802 — 
 
 So raffb fast in alien Zonen 
 Die Blatternpest mit wilder Hand 
 Die Mensclien bin zii Millionen, 
 Eh' die Vernunft ein Mittel fand, 
 Das uus, Avenu man so weislicli niit/t, 
 Vor diesem Erdeniibel schlitzt. 
 
 44 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 [In almost every zone smallpox struck clown men by the 
 million till a means was found wliicli, wisely used, protects 
 us against this evil.] 
 
 The experience of the Franco-German war showed that 
 although protective for some years vaccination loses its 
 protective effect after a certain lapse of time. And then in 
 Germany and in certain other countries re- vaccination in 
 the twelfth year of life was made compulsory. Unfortu- 
 nately we have no similar prophylactic measures against 
 other epidemic diseases. 
 
 Another disease against which prophylactic measures 
 have been usefully employed for many years is malaria. 
 The opinion that this serious disease is sometimes con- 
 tracted by merely breathing the air of malarial districts 
 is now known to be incorrect, as it as been shown by Koch 
 and others that malaria is conveyed largely, if not entirely 
 through the instrumentality of certain mosquitoes. Though 
 this was not known in earlier times, yet it was tolerably 
 certain that malaria was confined to marshy districts. And 
 many of the ancient civilized races endeavoured to drain 
 the marshy ground, and thus render it healthy. Some 
 historical documents show that such efforts to drain 
 districts were made in the remotest ages. Reliable in- 
 formation about this matter is first met with in history in 
 connection with the Pontine Marshes. A large plain thirty 
 to forty kilometres long and eight kilometres broad, lying 
 to the south-east of Rome, separated from the sea by a 
 tableland, was once one of the most flourishing districts. 
 It is said that thirty-three towns stood there under the 
 Volscians. Numerous canals drained the region, and fertile 
 gardens and fruitful fields are said to have covered it. In 
 the year 358 b. c. the Volscians were defeated by the 
 Romans after several sanguinary battles, carried away from 
 their homesteads and scattered. From that time the 
 drainage works were neglected. The houses of the towns 
 fell in, and the district became one of the worst in Europe. 
 In spite of its fertility no one ventured to settle down there, 
 for he would undoubtedly have fallen a victim to the 
 pestilence. The practical Romans did not fail to try and 
 restore this unhealthy region to its former flourishing con- 
 
 45 
 
THE PREVENTION OF DISEASE' 
 
 dition. It was thought that this wonlcl be possible by 
 draining the Pontine Marshes, and so in the year 312 an 
 attempt was made to provide the Via Appia with a system 
 of drainage. These works were carried on by the consul 
 Cornelius Cethegus, by Csesar Augustus, Nerva, Trajan and 
 Theodoric the Great, but were never completed. Eighteen 
 popes repeated the attempt, but always with insufficient 
 money and technical means. Finally Pius VI took the 
 work in hand with sufficient means. The Via Appia, 
 which in the meantime had completely fallen to pieces, was 
 restored at an outlay of 7,000,000 lire. He built a long- 
 canal to drain it, with many branch ditches. This great 
 effi^rt was indeed crowned by some measure of success. 
 Part of the devastated plain was restored to cultivation, 
 but the greater part of it lies still in ruins and decay. 
 Quite recently attempts have again been made by the 
 Italian Grovernment to improve the land by planting 
 eucalyptus trees. 
 
 II. LEPROSY 
 
 V^e have already seen that the older races, especially the 
 Jewish, sought to protect themselves from leprosy. The 
 Old Testament tells us that lepers were obliged to dwell 
 outside the camp, and that provision was made for them so 
 as to avoid as far as possible all intercourse with them. The 
 New Testament tells how the Saviour in His wanderings 
 outside the town and in the vicinity of graveyards came 
 across lepers who besought Him to help them. The Grreeks 
 appear not to have been familiar with the worst forms of 
 leprosy (elephantiasis) and the ulcerating scabbed form. 
 It would appear to have become more general at the time 
 of the Crusades. Leprosy was in the middle ages what 
 cholera has shown itself to be in our own time, "part of 
 that force " which " makes for ill but works good." Not 
 only the Crusades but other historical events too may have 
 assisted the spread of leprosy, possibly the inroad of the 
 Moors into Spain and the migration of nations. Although 
 the word leprosy occurs frequently in the records of the 
 
 46 
 
THE HISTOHY OP THE PREVENTION OP DISEASE 
 
 Arabians, it should be remembered that the expression is a 
 general term and seems to denote several very different 
 diseases, some of which are quite innocent. Among the 
 Lombards special hygienic precautions were taken against 
 leprosy during the reign of King Rotthard. The unfor- 
 tunate lepers dwelt in special places outside the town. They 
 were altogether excluded from social intercourse and to a 
 certain extent regarded as civilly dead. 
 
 Two facts about the way in which leprosy was regarded 
 show extremely well the character of the middle ages. 
 On the one hand the greatest disregard and cruelty were 
 shown to lepers ; on the other hand a romantic enthusiasm 
 was evinced for these lepers by those who saw in this 
 plague the special grace of God. Both views led to the 
 adoption of corresponding prophylactic measures. Sprengel 
 writes, " When any one was pronounced to have leprosy, 
 he was declared civilly dead with the most gruesome cere- 
 monies. Then he was led into the church by a priest, 
 exchanged his former dress for a black garment, and upon 
 his head and breast were placed two woollen bands which 
 were visible from afar. Then a requiem was said as at a 
 funeral. The priest then took the leper into a house which 
 stood alone, cautioned him never to appear in public in any 
 other dress, to go about bare footed, and to avoid wells, 
 churches and bakeries. Finally a shovel full of earth was 
 thrown over the bare feet of the leper. The leper was from 
 that moment regarded as civilly dead (just as are at the 
 present day those who are of unsound mind) and could not 
 sue at law or inherit or acquire property. He was only 
 permitted to touch with a stick anything he wanted to buy, 
 and as he went along he always made a noise with a rattle 
 to give warning that he was coming." 
 
 It is evident that these scandalous rules were prompted 
 by a desire to check the spread of the disease, but like all 
 acts of cruelty it did little to accomplish its end. On the 
 contrary, those so ignominiously treated were often em- 
 bittered and gave vent to their bitterness by rising against 
 their hardhearted oppressors and not seldom banded them- 
 selves together with other classes of persons, especially the 
 
 47 
 
THE PREVENTION OF DISEASE 
 
 Jews, who were driven to desperation by the injustice of 
 their fellow citizens. 
 
 But side by side with such cruelties other measures were 
 resorted to as the outcome of the romantic tendency of the 
 middle ages. We have already said that some believers 
 looked upon the lepers as people specially favoured by Grod. 
 And many orders were founded to undertake the care of 
 lepers, the oldest order being that of the Knights of St. 
 John, established in the seventh century by merchants in 
 Amalfi, A document dating back to 1311 is still in exist- 
 ence which gives information about the organization of this 
 order, which became so renowned later by its deeds in war, 
 and about its hospitals. This order tried to moderate the 
 severity of the civic laws against lepers. These patients 
 were permitted to make their homes within the borders of 
 the institution. They were permitted to marry and the 
 married couple were dowered by the order. Four physicians 
 looked after the physical welfare of the patients. The 
 respect felt for lepers became so great, that in time the 
 grand master was always selected from among them. 
 
 Thanks to the influence of this religious order, and 
 possibly also from fear of infection, the benevolence of the 
 public was aroused, and everywhere asylums for lepers 
 were established called leper houses. There were also 
 smaller huts for a few lepers, the so-called stellae and 
 cucurbitae. Out of these institutions have arisen a large 
 number of the hospitals and infirmaries of the present day. 
 Until a few years ago the general hospital in Salzburg bore 
 the inscription " Leper House." 
 
 III. VENEEEAL DISEASE 
 
 There is no certain information about syphilis until the 
 middle ages, when the disease was more common than ever 
 before or since. If it is permissible to form an opinion 
 about the spread of the disease from its names, this loath- 
 some disease seems to have been carried into France from 
 Italy (mal de Naples, souvenir de Milan), and from France 
 into Germany (French disease). Whether the English law 
 
 48 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 about brothels in 1126 and its revival in 1430, threatening 
 the brothel keepers with a fine if they take in diseased 
 women and ordering a regular visitation by physicians, 
 refers to syphilis is not clear. A similar order issued by 
 King John of Naples is regarded by some historians (Haeser) 
 as a forgery. 
 
 The prevention of syphilis, as carried out today in all 
 civilized countries except England, i.e. regular examination 
 of the women, does not date back further than the French 
 Revolution. Brothels have existed from the earliest days 
 and were under strict police control, but whether these 
 were established for sanitary or criminal reasons is not 
 evident. And of what use was an examination carried out 
 without a speculum, and this has not been in use a hundred 
 years ? History shows moreover that syphilis has been 
 commonest when prostitutes have been lodged in special 
 houses, so that this appears to be of no prophylactic value. 
 In the middle ages prostitution was sanctioned even by 
 the clergy, and alsa taxed. It is difHcult to say whether 
 this encouragement of vice by laity and clergy was based 
 upon any medicinal and prophylactic idea. 
 
 The renowned teacher of law, Rittershausen (who lived 
 1566-1613) says nothing about any such idea, but considers 
 the existence of such houses to be necessary for the sake of 
 morality. 
 
 Modern advocates of prophylaxis justify these degrading 
 examinations by similar reasons, to check the spread of 
 syphilis. The connection between syphilis and prostitu- 
 tion which is medically unregulated was recognized in 
 France, so that at the time of the French Revolution 
 regular inspection was instituted on the Continent in the 
 same way in which it was already being carried out in 
 England. But today England is probably the only 
 country where such inspection is no longer made, though 
 it is carried out more or less thoroughly everywhere else. 
 
 Permission to maintain houses for prostitution has some- 
 times been allowed and sometimes been refused, but always 
 with a view of checking syphilis. In Vienna a decree 
 forbidding such houses was issued under Maria Theresa, 
 
 49 E 
 
THE PREVENTION" OF DISEASE 
 
 and a similar law was made iu Berlin in 1848. Thus it is 
 difficult to decide wlietlier the true idea of prevention of 
 syphilis requires the closure of all such houses or not. 
 
 Regular inspection in the army and navy as regards 
 syphilis commenced in England and has been in force in 
 G-ermany for about a century. 
 
 IV. PLAG-UE 
 
 This terrible pestilence has in modern times only been 
 known in Europe in the first third of the nineteenth 
 century. It has again and again threatened to invade 
 civilized countries, and was one of the most terrible scourges 
 in past centuries. In the fourteenth century nearly 
 25,000,000 people were swept away by it in Europe. Many 
 towns were reduced to one quarter of their original number 
 of inhabitants. The oldest records show that this was one 
 of the most terrible of pestilences. Thucydides and Livy 
 give descriptions of it which are among the most terrible 
 pictures in the history of the world. And later Boccaccio 
 has also described it. In Thucydides the plague broke out 
 during the Peloponnesian war, decimated the Grrecian cities, 
 especially Athens, and reduced the fighting capacity of the 
 troops so gresitlj that it required all the eloquence of 
 Pericles to raise again the spirits of his countrymen. It 
 is remarkable that the historian makes no mention of any 
 prophylactic measures which were taken against the disease. 
 From other quarters it is reported that Empedocles adopted 
 extensive measures against the plague. When there was a 
 great epidemic he had large fires made at different places in 
 the towns to purify the air. He regarded the sirocco as the 
 means by which plague was spread, and therefore wanted 
 to close a cleft in the mountain by which this wind came. 
 
 Another suggestion made by the same physician seems 
 more sensible and practicable : he suggested that fresh water 
 should be carried into the river Hypsos at Selinos to remove 
 the miasmatic effiuvia ; but it is doubtful whether this was 
 directed against plague or against malaria. In the whole 
 Knass of Greek literature we read of no really valuable 
 attempt to combat plague epidemics. This attempt was 
 
 BO 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 made only quite recently, and to explain the measures which 
 were adopted we shall refer to the bubonic plague which 
 recently appeared in South Europe. 
 
 In 1812 it appeared in Constantinople, soon afterwards in 
 other towns in Turkey and Egypt. In one year some 
 12,000 people died of plague in Constantinople. It was 
 carried to Odessa by ships, and 3,000 out of a population of 
 28,000 in that city succumbed to the disease. At the same time 
 it spread from Constantinople to Bucharest, where a tenth 
 part of the total population of 80,000 fell victims to plague. 
 It also spread from Constantinoj)le by the sea to Malta and 
 some of the Grecian islands. In Malta it carried off 6,000 
 people. In 1815 the plague was still in Turkey, and was 
 conveyed thence to the east coast of the kingdom of Naples. 
 It broke out to the great alarm of "Western Europe in ISTaja, 
 a small seaport town of that kingdom, and in a short time 
 killed 792 people. 
 
 For the first time we find strict prophylactic rules. The 
 seaport town was strictly isolated, and moreover those ill 
 with plague were taken to well supervised quarantine 
 buildings. Ships from suspected seaports were not per- 
 mitted to enter, and goods already unloaded were disinfected 
 by exposure to superheated steam. These rules proved to 
 be most efficacious. The plague was not only stamped out 
 at Naja itself, but the whole of Italy and the greater part 
 of the west of Europe escaped the infliction. 
 
 Again, in 1820 the oriental plague appeared in the 
 Balearic Islands. Majorca alone lost 2,000 persons, Palma 
 8,000. The experience of Naja had not been in vain. 
 Quarantine regulations were adopted against the infected 
 islands and the plague stamped out. 
 
 In 1820 and 1829 cases of plague appeared again in 
 Moldau. They did not extend far. Here and there smaller 
 epidemics appeared : in 1872 in South Russia ("Wetljanka) ; 
 in 1899 in a laboratory in Vienna. But each time it was 
 possible by strict isolation and quarantine to master the 
 epidemic. 
 
 Epidemics of plague are of great historical interest 
 in civilization quite apart from medical considerations, 
 
 61 
 
THE PEEVENTION OE DISEASE 
 
 because they left behind them the utmost desolation in 
 the regions they attacked. Sometimes the phj^sicians were 
 sacrificed by the distracted populace ; sometimes the officials 
 were suspected of having poisoned the wells ; sometimes 
 the malice of the populace was directed against certain 
 classes of the people who had escaped the plague. Thus, in 
 the sixteenth century a rising against the Jews in Cologne 
 broke out as the result of the plague, because the Jewish 
 quarter had been little attacked by plague. In one day 
 many thousands of these unfortunate people fell victims to 
 the fanaticism of the populace, and the authorities were 
 powerless to stem the tide of revolt. In 1830 the Jews 
 were slaughtered in Cracow for the very opposite reason, 
 because in an epidemic of cholera the Jewish quarter of the 
 town suffered most. Such was the logic of the people and 
 of the Grod-fearing clergy. 
 
 From descriptions of the plague we see that it was known 
 in the nineteenth century to be spread by human inter- 
 course on sea or on land. We see further that this know- 
 ledge led to the adoption of very stringent but also very 
 successful measures. More recently other remarkable facts 
 concerning the spread of plague have come to light. Re- 
 search is now being made into the vital processes of the 
 plague bacillus, and it is to be hoped that the important 
 knowledge gained in the various laboratories will soon enable 
 preventive inoculation to be employed successfully in relation 
 to this disease. It is scarcely necessary to add that during 
 the middle ages, when plague was regarded as a punishment 
 from Heaven for the wickedness of men, attempts were made 
 to appease the wrath of the Lord by prayers, processions 
 and pilgrimages. Much greater interest is felt by us in 
 
 V. ASIATIC CHOLEEA 
 
 If ever a scourge of God has prompted mankind to good 
 deeds it is cholera. It is largely owing to this scourge that 
 towns are nowadays supplied with good drinking water and 
 with a regular system of drainage. The scientific work, 
 too, which has to record such brilliant results during the 
 last part of the nineteenth century, is also connected with 
 
 52 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 cholera. Halier's researches in bacillary diseases, Tiersch's 
 experiments in -which he inoculated white mice with 
 cholera excreta, are closely connected with the last epi- 
 demics of cholera. And though these attempts to fight 
 cholera have not been followed by any great result, yet 
 they proved a stimulus for similar work in other diseases 
 and have been valuable as introducing a new line along 
 which science, especially medical science, can travel. It 
 cannot be regarded as mere chance that the experiments 
 of Pasteur and of Lister followed directly upon the cholera 
 epidemic of 1866. Indeed if we look at the development of 
 science historically, the connexion between the last great 
 epidemic of cholera and the first translations of Charles 
 Darwin into German will not escape notice. But in this 
 place we shall not concern ourselves with the last cholera 
 epidemic, when opinions as to the spread of the disease were 
 already firmly established, but with the first which visited 
 Europe to any great extent. 
 
 At the beginning of the nineteenth century the world had 
 already fairly well advanced in science. Protection against 
 epidemics was no longer sought by spiritual and ecclesias- 
 tical measures. The knowledge that the course of a pesti- 
 lence could be influenced by customs and habits was already 
 widespread. Physicians and reformers tried to regulate and 
 improve the customs of the people, so as to make them more 
 in consonance with the principles of health. The State 
 recognized the necessity of employing physical methods to 
 combat physical sources of ill. Cholera was not altogether 
 unknown at its first appearance in Europe. Writers in 
 classical antiquity — Celsus, Aretaeus, Caelius — describe an 
 epidemic disease the symptoms of which agree very closely 
 with those of cholera. Cholera seems also to have been in 
 England from 1669-72 ; Sydenham and Willis mention it. 
 Owing to the extraordinary lack of intercourse of those days 
 epidemics spread very slowly and not very extensively. 
 
 In India cholera has been known since the remotest 
 ages, though it is limited to a certain district — the delta 
 of the Ganges. In 1817 a remarkable increase in the 
 mortality from this disease occurred in this region. The 
 
 53 
 
THE PREVENTION OF DISEASE 
 
 small town of Madia first attracted tlie notice of tlie English 
 Grovernment. Thence in 1817 cholera spread along the 
 Ganges from place to place, from town to town. In Jessore, 
 a somewhat larger town, it was alarmingly prevalent, yet 
 bnt little was done to prevent its spread. Not till it reached 
 Calcutta and carried away 200 persons every week (at 
 that time the population of Calcutta numbered 600,000) did 
 the English Grovernment, in consequence of the proximity 
 of one of its garrisons, begin to take active steps. Still 
 nothing very radical was attempted, although official reports 
 were drawn up. For two years cholera continued to be 
 epidemic in Calcutta, and thence spread to the neighbouring 
 Sundas, a garrison town with a large number of British 
 troops, of whom 9,000 died from the disease. Then the 
 Government ordered the removal of the garrison. They 
 were removed to the mountains, and this caused the dis- 
 appearance of the disease from the army. But from the 
 delta of the Ganges it spread, as it were along radii, to all 
 parts of India. Bombay, Madras, the Coromandel coast and 
 Ceylon, lying to the south were in turn invaded. The 
 epidemic on the island of Ceylon lasted from 1819-23. The 
 disease had already overspread India. Then it appeared 
 in Mauritius, which was 3,000 miles distant, and 6,000 per- 
 sons succumbed to it. 
 
 In 1820-1 it reached the African coast. It spread also 
 eastward from India to Sumatra, Java, Macao and China ; 
 and in 1821 it appeared at Pekin. From India it spread 
 also to Celebes and Manilla. Rapid intercourse with the 
 East quickly took it to the rest of India and Arabia. In 
 1821 it appeared at Bagdad, and spread thence along the 
 great caravan road to Alejopo and Syria. It spread also 
 from India north-west across Persia to Astrachan. For ten 
 years cholera existed unchecked in the countries outside 
 Europe, but except in Astrachan, where its progress had been 
 checked, Europe had till then escaped cholera. In 1830 it 
 broke out in Odessa. Two years later it had spread over 
 the whole of Europe. In 1832 it had invaded central 
 Germany, France, England, Holland, and thence spread to 
 the United States of America. 
 
 54 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 At that time the following points had been definitely 
 established in connexion with prophylaxis — 
 
 1. The ready transmissibility of cholera was viewed with 
 alarm and was known to be connected with human inter- 
 course. Whether it could be spread by goods was not 
 evident. Whether it became epidemic in every place to 
 which it was carried seemed at least doubtful. For some 
 inexplicable reason some towns in Europe remained free 
 from epidemic, though the disease had undeniably been 
 introduced into them. There was no time to pause for 
 reflection. The expensive method of quarantine was selected 
 as it seemed to promise the best results. What the result 
 was we shall now see. 
 
 When cholera broke out in 1830 in Eussia it appeared 
 outside Moscow. Strict quarantine of the residents was 
 immediately ordered, and as it seemed with success. Dur- 
 the whole of the quarantine period, extending over several 
 months, no case of cholera appeared in the town itself. But 
 this calm was but a deception, and soon there followed a 
 bitter disillusion. In spite of the long period of quarantine 
 the pestilence broke out in Moscow and thence spread along 
 the highway towards St. Petersburg. St. Petersburg was 
 then put in quarantine, and again apparently not without 
 success. But here too, as in the case of Moscow, cholera broke 
 out a few months after the quarantine regulations were 
 removed. The political conditions of Eussia at that time 
 were the most favourable which could have existed for the 
 spread of cholera. The last embittered revolutionary war 
 was being waged by the Poles, who were endeavouring to 
 throw off the yoke of Eussia, All the hardships and trials 
 which resulted from this war were so many favourable 
 factors for the spread of cholera. When the Eussian columns 
 crossed the Austrian boundary and entered Galicia this 
 pestilence followed. Galicia became a hotbed for cholera. 
 A senseless regulation was made too late, and quarantine 
 against Eussia was established long after the pestilence had 
 already broken out in Austria. Taking warning by Austria 
 Prussia established an extensive military cordon to cut off 
 communication with Eussia. But this did not prevent the 
 
 55 
 
THE PREVENTION OF DISEASE 
 
 cholera appearing in Dantzig on October 30, 1831. Isola- 
 tion of Dantzig also proved quite ineffectual. Cholera 
 spread thence without pause into the heart of Germany 
 through Staluponen and Posen to Breslau, and then to 
 Madgeburg, Halle and Berlin. France too made an unsuc- 
 cessful attempt to cut off communication with Germany. 
 And when, in spite of this precaution, cholera broke out 
 in Paris this costly and useless attempt was abandoned. 
 
 This, briefly, was the course taken by the first epidemic 
 of cholera in Europe, which extended over so long a period. 
 Quarantine and other regulations to isolated places had 
 proved to be almost valueless. Since that cholera has 
 often invaded Europe. War would seem to be the condi- 
 tion most favourable to spread cholera, as during the 
 sanguinary war between Austria and Prussia in 1866. 
 But the lessons in prophylaxis were not lost. This at least 
 is certain : that quarantine, which proved to be so effectual 
 against plague, has proved to be almost valueless in the 
 case of cholera. Pettenkofer has done us the great service 
 of showing what is necessary to check cholera. Witli 
 unwearied eloquence the great investigator drew attention 
 to the fact that the introduction of cholera into a place is 
 only dangerous when that place is under conditions which 
 are favourable to the development of cholera, and these 
 conditions are sometimes a pestilential soil and sometimes 
 polluted water. 
 
 Next we come to the present period in the history of 
 cholera, and with this ends what we have to say about 
 the history of the prophylaxis of this disease. We would 
 only add that the most recent researches in the laboratory 
 would seem to make it possible for each individual to pro- 
 tect himself, for a time at least, against cholera. 
 
 With these prophylactic regulations against the above 
 mentioned diseases our historical material is exhausted. 
 The measures adopted to prevent typhoid fever, typhus, 
 scarlet fever, diphtheria, measles, whooping cough and 
 influenza all belong to quite recent times. The prophy- 
 laxis of pneumonia and tuberculosis also dates back less 
 than twenty years, though Gerhard told us at the 
 
 66 
 
THE HISTORY OF THE PREVENTION OF DISEASE 
 
 International Tuberculosis Congress in Berlin that in the 
 eighteenth century regulations had been issued in Italy 
 and Portugal ordering the isolation of tuberculous patients, 
 forbidding things belonging to such patients being sold or 
 given away, and imposing heavy fines on physicians who 
 failed to notify the disease. 
 
 The prophylactic rules to prevent wound infection and 
 puerperal fever are of older date. In 1869 in the Leipzig 
 Clinic the first trial was made of Lister's antiseptic method. 
 This was a very elaborate procedure and by no means 
 applicable to all operations. Beneath the so-called protec- 
 tive, a piece of linen which had been previously dipped in 
 carbolic oil and which was held up over the operating 
 table by four assistants, the part of the body to be operated 
 on was first well washed and the operation then performed. 
 When the operation was over the protective was lowered 
 and placed over the wound. A piece of tinfoil was smeared 
 with putty containing one per cent, of carbolic acid, and 
 was placed over the wound after quickly removing the 
 protective. This tinfoil dressing was then secured by 
 adhesive plaster and bandages. This clumsy and awkward 
 method was gradually replaced by a better, and antiseptic 
 methods have become aseptic in the course of thirty years. 
 But all this is still within the memory of the present genera- 
 tion of medical men and need not be further detailed here. 
 
 In close connexion with the prophylactic treatment of 
 wounds is the rational method by which lying-in women 
 are protected against puerperal fever in lying-in institutions. 
 The absurd theories held as to the origin of puerperal fever 
 even in the sixties, and the opinion that this terrible disease 
 could be prevented by costly systems of ventilation in 
 lying-in hospitals, or by special nourishment during the 
 puerperium or even by purgatives, have all been overthrown 
 since the introduction of antiseptics. Although Semmel- 
 weiss had already in the fifties surmised the true aetiology 
 of puerperal fever, although Burow had introduced into his 
 clinic a kind of antiseptic method long before Lister, yet 
 the warnings and the results of these two men were un- 
 heeded. Semmelweiss' most useful life ended in insanity 
 
 57 
 
THE PREVENTION OF DISEASE 
 
 and suicide. And tliongli Burow's end was not a tragic 
 one, yet tlie value of his method was not appreciated. 
 These facts show us that right ideas and truths are not 
 accepted till their time has come. In the case of the anti- 
 septic method we had not long to wait, 
 
 KETROSPECT 
 
 The foregoing shows the part which prophylaxis has 
 played in the history of medicine. It has closely followed 
 the theoretical ideas held about disease. It forms not onlj'' 
 a part in the history of medicine but also in the history of 
 civilization. "We see that superstitious and religious ideas 
 as well as scientific ones are responsible for the teaching 
 about prevention of disease. Even at the present day, 
 when hygiene is doing so very much in all the conditions 
 of life, demonological and theological views as to the origin 
 of disease are still widely held. Just as certain proverbs, 
 sayings and fairy tales have come down to us from antiquity 
 and are still uttered by the lips of children, so too demopx)- 
 logical and theological precautions still enter into the 
 childish minds of the people in spite of scientific research. 
 But the Government measures against disease are no longer 
 based upon these old ideas. A well devised system of 
 prophylaxis based upon scientific knowledge will consist 
 of scientific methods. And now that prophylaxis has fol- 
 lowed the lead of science the results obtained have been 
 very important. Probably no one would contradict us if 
 we said, "Prophylaxis during the last half of the nineteenth 
 century has done more to prevent disease than all that it 
 did in previous centuries." Nevertheless the knowledge 
 gained in the past has not been in vain and useless for the 
 present. Just as a venerable tree yearly sheds its leaves, 
 and these fall over its roots protecting them from atmo- 
 spheric influences and providing nutriment for the plant by 
 their decomposition, so too is it with the tree of knowledge. 
 The wrong ideas, the errors, are like the leaves. They fall 
 from the branches but protect the vitality of the tree, so 
 that for many successive years it is able to adorn itself 
 again and again with new foliage 
 
 58 
 
General Prophylaxis 
 
 BY 
 
 PROFESSOR MARTINS 
 
 OF EOSTOCK 
 
 69 
 
General Prophylaxis 
 
 What is general propliylaxis ? Prophylaxis includes the 
 knowledge and the methods by means of which we prevent 
 or at least endeavour to prevent disease ; and the scope of 
 general prophylaxis is the scientific inquiry as to whether 
 this is on the whole possible, and in what way it may be 
 done. The aim of hygiene however is similar. What 
 then is the difference ? For unless there is a difference, in 
 spite of the similarity of their aim, we shall not be justified 
 in allowing that prophylaxis is a branch of science distinct 
 from hygiene. 
 
 In the first place, what is hygiene ? Hygiene, said 
 Reich, has for its object " the care of the whole physical 
 and moral wellbeing of man, both individually and collec- 
 tively, and the prevention of disease." Accordingly he 
 regards hygiene " as the philosophy, science and art of 
 normal life," and draws a sharp contrast between it and 
 " the modern public sanitary authorities, whose main object 
 seems to be the cleaning of cesspools and disinfection." 
 Unquestionably this work too is beneficial to mankind, and 
 prevents pestilences and much misery. But it is not 
 hygiene : it is not the bond which links together physicians, 
 statesmen, educationists and moralists ; it is on the one 
 side applied chemistry and physiology, and on the other a 
 matter of police administration. 
 
 In contrast to this " general Hygiene " endeavours to 
 advance the wellbeing of humanity in every direction : to 
 influence medicine, education and religion, to improve the 
 customs of the people and to give a wholesome impulse to 
 all the conditions of life. 
 
 If hygiene were that bond " which includes all who are 
 
 61 
 
THE PREVENTION OF DISEASE 
 
 working for the welfare of mankind and all who are 
 striving after knowledge," then the very vastness of its 
 aim and the vagneness of its task would frustrate its object. 
 To the moral reformer who believes that crime and vice 
 may be lessened by mastering the passions, the disinfection 
 of cesspools may certainly seem work of little value. 
 Modern hygiene as now promoted by the State, represented 
 in all universities and discussed at congresses, is entirely 
 free from all such Utopian aims. It is an applied science, 
 and as such is limited to the physical life of man, and has 
 for its object "inquiry into the causes of disturbances in 
 health and of disease, the prevention of these disturbances, 
 and if that is no longer possible, the removal of such dis- 
 turbances." The difficulties of the scientific conception of 
 hygiene arise from the fact that it is not always easy to 
 draw a sharp limiting line between it and allied subjects. 
 If the object of hygiene is the prevention of disease, this 
 presupposes the necessity of knowledge of the way in 
 which diseases arise. But the determination of the causes 
 of disease has been hitherto the domain of general and 
 experimental pathology. Is this now to be transferred to 
 hygiene? In part this has already been done. The 
 important courses of bacteriology are given in Germany 
 almost without exception in the department of hygiene 
 and not of pathology ; but this is explained by the historical 
 development of this youngest branch of experimental 
 pathology. 
 
 Hygiene is indeed and will remain an applied science, 
 without any methods which are peculiar to itself. Though 
 hygiene has a well defined area within which physics and 
 chemistry, physiology and pathology work, yet each of 
 these sciences has its own field of work and its own methods 
 of research. Hygiene has to do with all these fields of 
 science and accepts the methods of physical as well as of 
 chemical and of biological research. But it has not the 
 task of forming these methods. It makes use of all these 
 to serve its own purposes, that is it uses them exclusively 
 to promote health and prevent disease. Now that we know 
 that the health of the community may be improved by 
 
 62 
 
GENERAL PEOPHYLAXIS 
 
 good drainage and the scavenging of towns, the architect 
 and the administrative officer who carry these out have 
 become hygienists. In the prevention or removal of ai,y 
 pestilence by hygiene, not only is the physician needed to 
 show what is the nature of the infectious germ, but the 
 State and lawmakers must make regulations which shall 
 prevent a spread of the infection. And when it has been 
 shown that degeneration of the race may be prevented by 
 State supervision in the selection of individuals fit for 
 marriage, and when it has been shown that improvement 
 can thus be brought about, then there will necessarily arise 
 a demand, both social and hygienic, for new legal regula- 
 tions about marriage. 
 
 Even if we abandon Reich's Utopian ideas of improving 
 the whole world in general by hygiene, and if we restrict 
 hygiene strictly and exclusively to the realm of natural 
 science, its scope will evidently still be very wide. As a 
 social science, evolved in response to a social need, it is 
 and must continue, as Hueppe says, to be social hygiene 
 or else not exist at all. It is of service in maintaining and 
 in improving the individual type, the race and the people ; 
 and its task is a far greater one than that implied by the 
 term hygienic when this is used to express merely the 
 medical art of preserving the lives of weakly or diseased 
 individuals. Indeed it cannot be denied that here there is 
 a great gulf, a dreadful contradiction, between the aims of 
 the hygiene of the individual and the hygiene of the race. 
 By hygiene as applied to an individual the physician strives 
 to improve the life even of the most wretched human being, 
 and his effi)rts are greater the more feeble is the individual ; 
 but the hygiene of the race has for its ultimate aim piti- 
 lessly to eliminate those of weakly constitution and thus 
 to improve the whole people. 
 
 The solution of this contradiction is the hygienic problem 
 of the future. If indeed the watchful care which is 
 taken to protect weakly individuals threatens directly the 
 soundness of the race, the question may arise whether, from 
 the standpoint of this higher social hygiene, the philan- 
 thropic movements for providing institutions for the weakly 
 
 63 
 
THE PREVENTION OF DISEASE 
 
 and crippled and so interfering with, racial selection are not 
 an evil. Our whole ethical sense is opposed to such a conclu- 
 sion. There must be some solution which will reconcile the 
 aims of the hygiene of the individual and the hygiene of 
 the race, and utilize them both in the service of humanity. 
 It is not our duty here to find this solution. It was only 
 necessary to point out the sharply marked difference 
 between the two. That which we term prophylaxis is 
 medicine applied to the improvement of the individual ; 
 this alone concerns us in this textbook. The far greater 
 and more extensive task of social hygiene — in which, in 
 addition to physicians, lawgivers, government officials and 
 engineers are engaged — lies beyond its scope. 
 
 In this limitation lies the scientific justification for a 
 general and a special prophylaxis. In his capacity as an 
 individual, as a citizen and a lawgiver, the physician 
 ought to make himself familiar with the great problems 
 of social hygiene. His purely medical duties are however 
 somewhat different. These only require him to help the 
 individual man who is ill and to guard against disease the 
 healthy man who is entrusted to his care. By adopting 
 these limits general hygiene and general prophylaxis do not 
 come into conflict. Tradition says, whether correctly or 
 incorrectly is not for me to determine, that the Chinaman 
 pays his physician only so long as he remains well. The 
 old and sensible custom, which nowadays is dying out, 
 of having a family physician was based upon a similar 
 idea, that an important if not the most important aim of 
 medical skill lay in individual prophylaxis. This is im- 
 possible when the physician is paid for each separate visit 
 to the family, and therefore goes only when expressly asked 
 to call, for experience shows that he is not generally called 
 till the mischief is done. 
 
 Individual prophylaxis should commence with the earliest 
 training of the child. The family physician, in the good 
 old sense of the word, knew thoroughly all the peculiarities 
 of the family — both the good and the bad. Faithfully and 
 preseveringly he studied the special disposition of each 
 child. Thus he could assist the parents by warning and 
 
 64 
 
GENERAL PROPHYLAXIS 
 
 advising them about the child, and so he was able to 
 nurture the delicate little human plant into a strong 
 weatherproof tree. 
 
 The more this useful work of the family physician is lost, 
 the more pressing becomes the need for some substitute. 
 In our time, with its socialistic tendencies, the State and the 
 community are undertaking more and more this duty. 
 "What the members of the family fail to do is done by the 
 State. And more than this. The supervision of the young, 
 the regulation of their mode of life and conditions of 
 development by the State and the community must more 
 and more become such that it will be permitted to inter- 
 fere with the freedom of the household arrangements when 
 they are proved to be unhygienic. For these reasons school 
 physicians will be necessary in the future. The duty of 
 the school physician will be to see that general hygienic 
 measures are carried out, that infection is prevented from 
 spreading by timely isolation of the patient, that the 
 schoolrooms are supplied with sufficient air and light, 
 that mental and physical exercises are suitably varied, and 
 so on ; and further if he will prove truly of value, he 
 will look after individual prophylaxis also, because one plan 
 is not applicable to all, and the amount of mental and 
 bodily exercise which may be regarded as a normal average 
 may be for some individuals a harmful excess. 
 
 Medical prophylaxis is accordingly a special branch of 
 hygiene. It is the sum total of medical counsel and rules 
 intended to protect the individual against disease. In this 
 sense medical prophylaxis guides the individual through 
 the entire course of life, from the cradle to the grave. Just 
 as there are diseases peculiar to the infant, to the school- 
 boy and to the old man, so too must there be prophy- 
 lactic measures suitable for the various periods of life. But 
 these too must be modified and graduated according to the 
 need of any individual, otherwise they may possibly do 
 harm instead of good. To give an example : it is true that 
 alcohol is nothing less than a poison in childhood, while 
 in old age it is a valuable tonic and preservative. Yet in 
 exceptional cases, in acute febrile debility, alcohol may be 
 
 65 F 
 
THE PREVENTION OF DISEASE 
 
 a useful medicine for tlie cliild, and on the otlier hand, when 
 there is arterio-sclerosis, and a tendency to apoplexy, it may 
 be a poison to the old man. In the prevention, as in the 
 question of production of disease, we must take into con- 
 sideration the personal factor. 
 
 Individual prophylaxis assumes complete knowledge of 
 the mode of origin of disease in the individual. The whole 
 history of medicine shows that it has always been believed 
 that, under precisely similar conditions, of two individuals 
 one may fall ill while the other will remain well. Hence 
 it follows that general pathology which is based essentially 
 upon an experimental foundation, and studies the laws of 
 the injurious effects produced by harmful agents upon all 
 members of the same class, is unable to explain the cause of 
 every case of disease. Disease may in some cases often be 
 produced by conditions which are not general, that is they 
 would not produce disease in every individual without 
 exception. This can only be explained by the existence of 
 some causal factor in that case which is not common to all 
 the members of the class. All such individual factors 
 which are inherent in the cells, tissues, or organs are 
 termed constitutional. Whether this constitutional causative 
 factor of disease be inherited or acquired, it must never be 
 omitted from our consideration of the production of disease, 
 unless we have to deal with an injury which is so severe 
 and dangerous that no life or organic structure could resist 
 it, such as traumatic destruction of the tissues, severe 
 poisons and very virulent infections. These general causes 
 of disease can only be prevented by one method of 
 individual prophylaxis — their avoidance. The man who 
 does not want to be wounded should do his best to avoid 
 going to a place where there is shooting. He who lives in 
 a district which is perfectly free from malaria and cholera 
 will not get these diseases. This is so clear and self-evident, 
 that it might seem as if the battle against external causes 
 of disease were alone worth waging and were the only 
 possible way in which disease could be prevented. 
 
 The history of vaccination has already shown that this is 
 a complete error. That terrible pestilence, smallpox, has 
 
 66 
 
GENERAL PROPHYLAXIS 
 
 almost completely disappeared from among us, not because 
 we have discovered and destroyed the exciting cause of 
 smallpox — which indeed is still unknown — and have thus 
 prevented its spread in the world, but solely because 
 we have succeeded in making every individual personally 
 proof against this pestilence.^ The application of this 
 principle to other infective diseases marks one of the 
 greatest advances in modern medicine. There are there- 
 fore two methods by which we may prevent or overcome 
 infectious disease. We can prevent such disease either 
 by destroying the exciting cause of the disease, by making 
 it innocuous, by keeping it from coming into contact with 
 individuals, or by a method which . will strengthen, fortify 
 and immunize those who are exposed to the disease. In 
 epidemics of diseases coming from abroad, such as cholera and 
 above all plague, we endeavour *to protect ourselves solely 
 or almost solely by restricting intercourse with infected 
 people. We try to prevent the exciting cause of the disease 
 from entering our country, and when in spite of all 
 precautions the disease has nevertheless made its 
 appearance, we isolate the individual affected and thus 
 prevent further spread. In endemic infective diseases, such 
 as tuberculosis, diphtheria, the acute exanthemata and 
 typhoid, this method by itself is insufficient. To close the 
 gate of the town is of no avail because the enemy is already 
 within the walls. In such a case we may yet succeed if we 
 remove the conditions necessary for the existence of the 
 enemy which has already entered. Munich, Dantzig and 
 Berlin, formerly hotbeds for typhoid fever, have been 
 almost completely freed from the disease by drainage. 
 Wherever the exciting causes of the disease are known to 
 exist adequate measures must be taken. The destruction of 
 tuberculous sputum by the patient himself is a social 
 duty which is owing to humanity, and the State will have 
 to consider how far it is justified in insisting upon the 
 isolation of patients with infectious disease without 
 unduly interfering with household arrangements. 
 
 1 This applies to Germany rather than to Great Britain. [Trans- 
 lator.] 
 
 67 
 
THE PREVENTION OF DISEASE 
 
 But all these measures belong to general or State 
 hygiene. What then is the work of individual medical 
 prophylaxis ? There remains for it a wide and most useful 
 field of work in strengthening and fortifying the individual 
 himself. Immunization, as is evident in connection with 
 smallpox, can be carried out by the State. But at the 
 present time smallpox is still the exception. To bring up 
 a weakly child who may also be hereditarily tainted, so 
 that it does not succumb to the threatening danger of 
 tuberculous infection, is individual medical prophylaxis. 
 
 This is the more true when we deal with diseases in 
 which the constitutional factor predominates, and the 
 exciting cause — the so-called " external cause " — is a 
 minor one. The large group of functional neuroses and 
 of diseases of metabolism belong to this class. The 
 greater the predisposition, the less the exciting cause 
 which suffices to produce the disease. The common 
 causative factors peculiar to any disease, that is those 
 which would cause disease in an individual of average 
 strength, do not exist in these cases. Tubercle bacilli 
 and alcohol are both causes of disease, and there is a 
 strong agitation against both. Yet it would be radically 
 wrong to estimate them alike, so far as concerns the 
 production of disease. Alcohol is a poison only when 
 taken in a given quantity, and this quantity is very 
 different for different individuals. One with a congenital 
 tendency to neurasthenia will not be able to take the 
 amou.nt of alcohol which for the healthy man is a 
 harmless and pleasant stimulant : and individual prophy- 
 laxis must take this into consideration. 
 
 And what is true of alcohol is also true for other 
 stimulants and pleasures : for tobacco, tea and coffee, and 
 for sports, sexual intercourse and mental exertion. The 
 duty of the physician is to estimate the relative amount 
 which in any particular individual would cause disease. 
 
 But how can this relative estimate of the specific 
 tendency to disease be made ? This is a weighty problem, 
 and upon the answer the possibility of individual pro- 
 phylaxis in a scientific sense will stand or fall. 
 
 68 
 
GENERAL PEOPHYLAXIS 
 
 Many pathologists whose work is concerned with 
 " external " causes which under all circumstances produce 
 pathological changes, only make use of the term predis- 
 position when they have nothing else upon which to 
 fall back. It must be confessed that the vague expres- 
 sions, a weak or a strong constitution, a lymphatic or 
 an arthritic diathesis, do not help us much ; because gene- 
 rally the diagnosis of such a condition in any individual 
 is only possible after the disease has shown itself. When 
 we say that one who suffers from liver disease has a 
 bilious constitution, or that one who has had an attack of 
 cerebral haemorrhage has an apoplectic tendency, the 
 statement is quite valueless. That is evident directly we 
 think at all about individual prophylaxis. The history of 
 medicine tells of many different attempts to put this 
 ancient vague idea of a constitutional tendency into some 
 definite exact terms. Mostly an anatomical basis was 
 chosen. Beneke worked it out into a system thirty years 
 ago from this standpoint. He determined the relative size 
 of organs in various constitutions by measuring and 
 weighing them after death, and looked upon these 
 measurements as exact expressions of those constitutions. 
 This laborious work of Beneke's has been quite useless, 
 and the reason of this is evident from a consideration of 
 the subject of individual prophylaxis. When a person's 
 constitution makes him especially liable to contract any 
 disease and we desire to protect him from this danger 
 by regulating his manner of life, and by keeping him away 
 from sources of specific infection, the measurement of the 
 length of his intestine and the width of his arteries 
 and the volume of his heart and lungs after death are 
 entirely useless. Moreover it is less a question of the 
 relative size of his organs than of their relative functional 
 capacity. And the individual variations in this can be 
 determined for most organs before the disease sets in, by 
 exact physical and chemical examination. This is the 
 method towards which clinical medicine now points. It 
 is purely clinical. The individual and the special ten- 
 dencies of^ his organs are themselves carefully studied and 
 
 69 
 
THE PREVENTION OF DISEASE 
 
 considered. It is most useful because it enables us to draw 
 up a scientific scheme of exact individual prophylaxis. 
 
 The physician for mental diseases is for the most part 
 accustomed to take into consideration great and definite 
 differences in the personal predisposition of his patients. 
 The brain is the most highly developed and therefore the 
 most highly differentiated organ in the human body. It is 
 a well established fact that this differentiation has its 
 material substratum. But this is scarcely perceptible 
 anatomically. Whether the attempt by Mobius to revive 
 Gall's phrenology will be of any use remains to be seen. 
 For the present we fall back upon determining the 
 functional capacity, and this can be done very exactly. 
 A well trained teacher — unfortunately they are not all 
 so — knows well the specific " tendencies " of his scholars 
 and takes them into consideration. Such specific ten- 
 dencies may also be negative. There may be con- 
 genital functional inferiority of will-power, of feeling, 
 or of intellect. Individual prophylaxis by physician and 
 by teacher is then called for. Unfortunately " individual- 
 ization " in this sense conveys to many no meaning. The 
 time will come when individual prophylaxis, founded upon 
 scientific observation and determination of functional 
 capacity, will play an important part in teaching. 
 Theoretically, at least, individualization would appear to 
 be taken into consideration in the treatment of patients, 
 if we can believe the prospectuses of the numerous 
 dietetic institutions and institutions for the cure of 
 nervous disease. But how is it really in practice ? How 
 oan such individualization be learned, while the pathology 
 and treatment taught at the universities are exclusively 
 general pathology and treatment — that is while students 
 are taught what is true only about the average human 
 being ? Take as an example the effect of drugs. Our 
 knowledge of them is their typical effect : that is their 
 effect on the average normal man. Individual deviations 
 from this type, and the by-effects systematically studied 
 by Lewin, are regarded by most physicians merely as 
 interesting curiosities, and are put down to "idiosyncrasies." 
 
 70 
 
GENERAL PROPHYLAXIS 
 
 Yet they are of immense scientific value in the study of the 
 production and prevention of disease in the individual. 
 Striking and great deviations from the typical action of 
 drugs met with in certain individuals, such as intolerance 
 of alcohol, morphine, antipyrin, or iron, show that there 
 is some abnormal nervous predisposition which the physician 
 should take into consideration, not only in the treatment 
 but also in the prevention of disease. The modern trained 
 physician for nervous diseases has long been accustomed to 
 be very cautious in prescribing the various so-called nervines 
 to his patients, and conversely the appearance of any 
 so-called idiosyncrasy in a patient would be to him a sign 
 of a special nervous diathesis. 
 
 The alcohol question, which is becoming more and more 
 urgent, can neither be understood nor solved apart from the 
 view of the production of disease. There are individuals 
 with badly developed nervous systems to whom alcohol is 
 an absolute poison, but to wish to deprive the large majority 
 of men of alcohol, though their nervous systems are strong 
 enough not to be injured by a moderate use of wine, a 
 harmless and therefore an excellent stimulant, would be 
 to throw away the good with the bad. Conversely he who 
 does not yet know how injurious even a moderate use of 
 alcohol is to children and to those with a tendency to 
 neurasthenia cannot claim to have any knowledge of 
 prophylaxis. 
 
 That favourite catchword, " individualization," is at the 
 present time even more meaningless when applied to weak 
 conditions of other organs than when used of functional 
 neuroses. Yet in most cases hereditary inefficiency of other 
 organs may generally be determined by a careful estimation 
 of their functional capacity even before it has given rise to 
 any real disease. A scientific prophylaxis is only possible 
 when we know what special organic weakness is present, 
 that is what individual predisposition to disease exists. A 
 great and far-reaching task is before us in this field of 
 clinical inquiry, in which, equipped with all the means of 
 modern scientific methods, we endeavour to determine from 
 what diseases an individual who is still healthy will be 
 
 71 
 
THE PREVENTION OF DISEASE 
 
 likely or liable to suffer. The proof that there is a con- 
 stitutional albuminuria or glycosuria may be taken as a 
 typical example. Those who desire further information 
 about this subject and about the problems still to be solved 
 are referred to the fourth chapter of my book, " The Pro- 
 duction of Internal Diseases " (Vienna, 1900). 
 
 One other question arises. Some causes of disease can be 
 got rid of and banished from the world. Is it possible also 
 to avoid predisposition to disease ? That is the question 
 and it is obviously quite different from the question pre- 
 viously put, namely how the outbreak of a disease may be 
 prevented for which there is an hereditary predisposition. 
 To answer the question we need to know whence came the 
 predisposition, how it arose, and what conditions and factors 
 caused its development. We distinguish between acquired 
 and inherited predispositions to disease. The former arise 
 through external causes which are also the causes of real 
 diseases. Measles and influenza " predispose " to tuber- 
 culosis, and so too does diabetes. Tabes dorsalis and 
 general paralysis of the insane develop in a syphilitic con- 
 stitution. Prophylaxis for the prevention of such acquired 
 predispositions coincides with prophylaxis of the predispos- 
 ing illness itself. Whatever opinion one may hold about 
 the connexion between syphilis and locomotor ataxia, it is 
 certain that an individual who has not had syphilis will be 
 far less likely to have tabes than one who has formerly had 
 syphilis. The direct prophylaxis of syphilis is also an in- 
 direct prophylaxis of tabes. But when the syphilitic consti- 
 tution is already present, and there is therefore an acquired 
 predisposition to tabes, special prophylaxis is required to 
 prevent locomotor ataxia. Syphilis greatly reduces the 
 resisting power of the peripheral sensory neurones against 
 external injuries such as colds and excessive strains. One 
 who has been infected with syphilis should therefore be- 
 ware of exposing himself to such injurious conditions, and 
 this may be a matter of considerable importance, for 
 instance in connexion with campaigns. A predisposition to 
 a disease will be much more serious when the predisposition 
 has not been acquired by the action of any external in- 
 
 72 
 
GENERAL PROPHYLAXIS 
 
 jnrious causes. It is then generally termed congenital or 
 hereditary. Many physicians regard the two, congenital and 
 hereditary, as identical, and this is much to be regretted as it 
 leads to want of clear clinical judgment. It is obvious that 
 anything which is congenital must in some way have been 
 inherited, that is it comes from the parents. The term 
 hereditary is however often not used in this general sense. 
 "We are accustomed to speak of hereditary disease only when 
 it can be shown that one or more ancestors have suffered 
 from the same disease. This want of precision leads on the 
 one hand to the denial of any predisposition to tuberculosis 
 in a tuberculous patient whose parents or grandparents 
 were free from tuberculous disease, and on the other hand 
 makes us speak of an epileptic tendency — say in an 
 epileptic — because an aunt only happened to be epileptic. 
 Both are unreliable statements. The first fact is not 
 sufficient to exclude a specific predisposition in that 
 individual, nor the second sufficient to establish such a 
 predisposition. The problem of heredity in pathology 
 suffers from a confusion of ideas which can here be only 
 briefly referred to and cannot be fully discussed. The 
 principal points to be considered in heredity are probably 
 as follows — A "disease" is never inherited. To hold such 
 a view would be an unscientific return to a theory of disease 
 which was abandoned long ago. Disease is not a " thing," 
 it is neither an object nor a property, but it is a process 
 which developes and progresses upon a given substratum. 
 Neither epilepsy nor phthisis can be demonstrated on the 
 dead subject or stained for the microscope, or grown as 
 a pure culture. "What we see is the organ which has been 
 attacked by the disease, the anatomical and histological 
 changes brought about in the organ ; and we can see the 
 external exciting cause of the process. If the child is 
 born with well marked anatomical changes, then we have a 
 case of disease of true intra-uterine development. A child 
 with congenital syphilis, which is born with evident signs 
 of syphilitic disease, has suffered intra-uterine infection. The 
 disease is congenital. But this process has nothing to do 
 with the problem of heredity. It is hardly different when 
 
 73 
 
THE PREVENTION OF DISEASE 
 
 a child is born apparently healthy — that is so far as we can 
 judge — or really healthy, then later it becomes ill without 
 any apparent external cause. In the case of microbic 
 diseases there is then the possibility that the exciting cause 
 of the disease (the tubercle bacillus or the unknown 
 microbe of syphilis) was born with the child, though it had 
 not yet become possible for it to cause any pathological 
 effects, and this possibility occurs only in extra-uterine life. 
 Such cases are rare but they do occur, for example in 
 tuberculosis. But this knowledge does not in any way aid 
 in solving the problem of heredity. In this instance also 
 it is obviously a case of intra-uterine infection. Indeed 
 these cases need not to be separated from the former where 
 intra-uterine infection had produced intra-uterine disease. 
 This fact needs to be emphasized in any discussion. That 
 the true problem of heredity is not touched by the question 
 as to whether and how far we are to accept the fact of an 
 intra-uterine infection, will be evident when we remember 
 that the chief hereditary diseases are not infective diseases. 
 What is it that is transmitted by heredity in mental and 
 nervous diseases, in diseases of metabolism, or in the so-called 
 constitutional diseases which are justly termed hereditary ? 
 It is merely a certain weakness of some organ or tissue, a 
 specific kind of vital inefficiency which renders that organ or 
 structure more susceptible to external injurious influences 
 than is a normal organ. That there is such a congenital 
 specific inferiority of various structures, organs or systems 
 in the body has been shown by clinical experience for 
 over a thousand years, and can also be proved in an 
 individual by careful examination of his functional 
 capacity. The question, to put it briefly, is whether 
 such predisposition to disease is and must be inherited, and 
 what are the conditions under which it is transmitted. 
 Such is the scientific problem of heredity, upon the 
 solution of which alone depends the possibility of 
 prophylaxis. 
 
 It is a matter of no importance whether such prophylaxis 
 takes the form of a general prophylaxis under the care of the 
 State or of an individual prophylaxis under the care of a 
 
 74 
 
GENERAL PROPHYLAXIS 
 
 physician. In both cases it will be necessary in the first place 
 to forbid certain individuals from marrying. The suggestion 
 recently made, apparently with all seriousness, of submitting 
 all degenerates to castration cannot for the present be 
 entertained. Therefore by the urgent advice of the family 
 physician, who however cannot compel its adoption, or by 
 laws enacted by the State, we should be justified in 
 forbidding marriage in certain cases, cases in which the 
 hereditary transmission of some specific tendency to 
 disease is certain or extremely probable. Which are 
 these? One need but put the question in practice and 
 difference of opinion at once begins. The single point 
 about which all are agreed is that those who have any 
 manifestations of syphilis should not marry. But here it 
 is not a question of true heredity but of intra-uterine 
 infection, and this must obviously be prevented. In 
 tuberculosis doubt at once begins. Intra-uterine infection 
 is known, but it is so rare that it is very questionable 
 whether we are justified in forbidding all phthisical 
 individuals to marry. And what is the probability of the 
 hereditary transmission of the tuberculous predisposition ? 
 How in any individual case is it possible to judge 
 whether such transmission is possible, probable, or even 
 certain ? 
 
 And now with regard to the true hereditary diseases. 
 There is no doubt that there are apoplectic families and 
 diabetic families, psychopathic and nervous families ; that 
 is families in which the special disease occurs frequentl3^ 
 But what is meant by " family " ? "What is included in 
 the term ? Those only who bear the same name ? This 
 would exclude the female side in heredity. The science of 
 genealogy — a special science having its own methods — 
 knows this and tries to avoid such cardinal mistakes. The 
 statements in many medical books and treatises about 
 inheritance of pathological conditions are neither more 
 nor less than a collection of anecdotes without any critical 
 inquiry. 
 
 Any really useful prophylaxis against hereditary disease 
 will only be possible when the heredity problem in its 
 
 75 
 
THE PREVENTION OF DISEASE 
 
 relation to the production of disease has been to some 
 extent cleared up. I must content myself with these 
 brief remarks to show that there is a scientific basis for 
 general prophylaxis. 
 
 The outcome of what has been said is that in addition 
 to the received general and special hygiene, there is also a 
 general and special prophylaxis, which deserves to be 
 worked out scientifically and practically. We understand 
 by it the sum of all purely and exclusively medical 
 knowledge and measures whose object is the prevention 
 of disease. These are in part general and in part 
 individual. The general prophylactic measures are those 
 directed against agents which are equally injurious for and 
 will produce disease in all individuals belonging to the 
 group. Individual prophylaxis presumes the existence of 
 some constitutional factor which will cause the development 
 of disease in some one individual. The one is a comple- 
 ment to the other and passes over into it without any sharp 
 line of demarcation. The more general the measure, the 
 more does it become a hygienic work in which not only 
 the physician but also the engineer, the legislature and 
 the educated classes take part. The special work of the 
 ph^j'sician, on the other hand, is the greater the more it is a 
 question of recognizing and removing the individual factors 
 of disease, that is to say predispositions to disease. The 
 last-named factor is a much more important cause of the 
 development of disease than is usually believed, and there 
 is no danger for the present that the physician will have to 
 give place to the sanitarian. On the contrary, individual 
 prophylaxis is one of the most important clinical tasks 
 for the future. 
 
 76 
 
The Prevention of Internal Diseases 
 
 77 
 
The Prevention of Internal Diseases 
 
 Owing to the varying nature of internal diseases, their 
 preventive treatment differs in certain particulars from 
 that required in other groups of disease. In surgery and 
 the allied branches of medicine, external injurious influ- 
 ences play a very large part in the aetiology of disease, 
 while the constitution of the individual himself is less often 
 a prominent factor. In such circumstances prophylaxis is 
 concerned with the prevention and removal of these inju- 
 rious influences which are external to the individual, rather 
 than with the individual himself. It is of course not 
 altogether a matter of indifference who the person is who 
 slips down and falls upon his outstretched hand, or who 
 it is that runs an infected pin into his fingers. The brittle 
 radius of an old man will be more likely to break than the 
 radius of a young man ; and the pin will only pass through 
 the thick outer horny layer of the skin of the labourer's hard 
 hand, while it will penetrate also the deeper layers of a more 
 delicate skin, and the poison will be deposited there and set 
 up an inflammatory reaction. In such cases prophylaxis 
 has not to make the bones more capable of offering resis- 
 tance or the skin thicker, but has merely to direct itself 
 against the harmful external cause. 
 
 It is otherwise with internal medicine. Here we can only 
 partially succeed in removing the exciting cause of the 
 disease or in discovering specific remedies. Our main 
 concern must be so to act upon the functions of one 
 or more of the bodily organs that the natural powers of 
 resistance of the body against the exciting cause of the 
 disease may be increased. Consequently in our preventive 
 treatment we have more and more to consider the indivi- 
 
 79 
 
THE PREVENTION OF DISEASE 
 
 dual himself and his bodily constitution with its acquired 
 and its inherited peculiarities, and its power of resisting 
 injurious influences. As a rule these internal diseases arise 
 because there is a disproportion between the functional 
 activity of an organ and the functional requirements. 
 Under normal conditions of the body these two correspond 
 exactly ; an increase in the functional demands is accom- 
 panied by an increase in functional activity ; a decrease in 
 the demands by a decrease in activity. The normal body 
 is able to adapt itself, in the sense in which Darwin used 
 the term, not only to its general surroundings — the climatic 
 conditions, the food and the other conditions of life — but also 
 to any special demands which are brought to bear upon it. 
 These influences may be mechanical in their nature, such 
 as powerful muscular efforts which it meets by increased 
 metabolism, increased circulation and deeper respiration ; or 
 they may be sudden changes of temperature to which the 
 skin is exposed and which are promptly compensated for by 
 contraction or dilatation of the cutaneous vessels ; or again 
 they may be bacteria which have got into the respiratory 
 passages or into the digestive tract, and are overcome by 
 the action of the epithelium or are expelled from the body 
 by a violent coughing effort in the one case or by increased 
 peristalsis in the other. 
 
 There is however a natural limit to the demands which 
 may be made upon the organism, and when this limit is 
 exceeded the organism suffers. The body, or generally 
 that part of the body which is attacked, then undergoes 
 a change which leads to further changes — functional or 
 anatomical. These changes are accompanied by a tempo- 
 rary or permanent weakening of the body, and the condi- 
 tion is then called morbid. This process of "pathological 
 reaction " is not essentially different from the above men- 
 tioned process of "physiological reaction." Often the one 
 passes imperceptibly into the other, so that the difference 
 is merely one of degree ; but the results brought about 
 by the two processes are very different, the physiological 
 reaction is quickly over, the pathological reaction lasts 
 more or less long and always weakens the organism. 
 
 80 
 
THE PREVENTION OF INTERNAL DISEASES 
 
 The exciting causes, the stimuli, are essentially the same 
 in both processes ; different organisms, and even the same 
 organism at different times, will react differently to the 
 same stimulus. A cold current of air in one case will call 
 forth adequate functional activity of the cutaneous vessels, 
 and the effect of the cold air upon the body will be exactly 
 balanced : this is physiological reaction. While in another 
 case the cold air produces hyperaemia and then bronchitis 
 or some other disease. This is pathological reaction. A 
 dish of " Sauerkraut " will cause a violent attack of gastro- 
 intestinal catarrh in one man, while another man will 
 thoroughly enjoy the same dish ! Thus the various known 
 exciting causes of disease — such as cold and other atmo- 
 spheric conditions, getting wet through, excess in eating and 
 drinking, strains, poisons, and the entry of bacteria into the 
 body — do not always cause disease, but only when they • 
 chance to reach a body which is prepared to react patho- 
 logically. The kind of reaction by which the body responds 
 to any stimulus depends upon peculiarities for which we 
 are seldom able to find an anatomical explanation, and 
 they are said to rest upon the general constitution. A 
 good constitution would be one which could adapt itself to 
 all influences of life, to which it would always " react 
 physiologically." In truth no such " good constitution " 
 exists, and we are content to describe a man as possessing 
 a good or healthy constitution when it suffers no ill effect 
 from the ordinary stimuli of daily life. The standard for 
 health is not the same for all men : one man can do hard 
 physical labour with ease, thanks to his strong muscular 
 system, but a sudden change in the weather or a chill 
 will often give him a cold ; and conversely, another man has 
 little power of doing hard physical work but never takes 
 cold. The body is not capable of meeting all demands upon 
 it equally. So long as there is nothing obviously wrong 
 in any organism and it is able to do its ordinary work 
 with comfort, it may be considered healthy. 
 
 A weak constitution does not necessarily give rise to 
 disease whenever it is exposed to injurious conditions. 
 One man with a weak constitution may continue in good 
 
 81 G 
 
THE PREVENTION OF DISEASE 
 
 health for many years and may not suffer from illness 
 brought on by his constitution until middle life ; we need 
 but mention gout and diabetes as examples. In other cases 
 again various symptoms may appear early though it can- 
 not be said that any disease is present ; medically these 
 symptoms indicate a definite kind of constitution, and the 
 disease appears later when called forth by some exciting 
 cause. These symptoms characteristic of a certain consti- 
 tution may however again disappear and no disease be de- 
 veloped ; the constitution of an individual is not fixed and in- 
 capable of modification, but may be altered by the different 
 conditions of daily life. The constitution depends, first upon 
 inherited predisposition, and next upon the acquired pecu- 
 liarities of the organism. An originally strong constitution 
 may under unfavourable conditions become a bad constitu- 
 tion, and conversely a weak constitution may be strengthened 
 by favourable circumstances and the disease peculiar to that 
 weak constitution never be developed. 
 
 In these cases the objects of prophylactic treatment are 
 self-evident. Firstly our duty is to prevent or remove all 
 injurious external conditions which experience has shown 
 will contribute to the development of disease ; secondly 
 our duty is to strengthen or improve the faulty constitution 
 and thus remove the predisposition to disease. It is essen- 
 tial that we should recognize early the existence of a 
 predisposition, and this is made possible by — 
 
 Firstly : a knowledge of the hereditary tendency of 
 certain diseases ; 
 
 Secondly : a knowledge of the definite signs and early 
 manifestations peculiar to a certain constitution, particularly 
 during the years of growth ; and 
 
 Thirdly : a knowledge of the changes in the constitution 
 and functions of the organism which often follow an illness, 
 which appear at certain epochs of life and which accompany 
 a complete change in the conditions of existence. 
 
 The prophylactic measures to improve the constitution 
 cannot be enumerated once for all, because they differ accord- 
 ing to the organ or symptom upon the defective nature of 
 which the faulty constitution rests. All diseases indeed 
 
 82 
 
THE PREVENTION OF INTERNAL DISEASES 
 
 are in a way constitutional. Whether the disease be one 
 affecting the heart, the lungs, or the processes of metabol- 
 ism, or whether it be a so-called infective disease, there is 
 a certain predisposition to it in the particular individual, 
 and when some external injurious factor is added the 
 disease developes. The differences between the various 
 diseases depend upon the part of the body affected, the 
 constitution and the external harmful influences which 
 have combined to produce the disease. In most so-called 
 infective diseases the last named factor — infection — pre- 
 dominates, and the constitution is of comparatively slight 
 importance : for example, malignant anthrax is a disease 
 which probably always developes when the bacillus 
 anthracis enters the body. The cholera vibrio however is 
 occasionally found in the evacuations of healthy people. In 
 tuberculosis constitutional predisposition is the most im- 
 portant factor. 
 
 And further, the course run by these diseases is not the 
 same in every individual. Not only may the final conse- 
 quences of any disease be different, but their whole clinical 
 course and sometimes even their pathological and 
 anatomical forms may be different in different individuals. 
 This is daily seen in tuberculosis by every doctor. In 
 epidemics too, where there cannot be very great differences 
 in the degree of virulence of the poison, we see neverthe- 
 less very great differences in the severity of the attack 
 depending upon the individual who is affected, that is 
 upon his constitution. The same is also true for all other 
 diseases : whatever be the external exciting cause, the con- 
 stitution nevertheless determines the course which the 
 disease runs. 
 
 Although it is now evident that almost all internal 
 diseases are to a certain extent constitutional, yet in 
 medicine we have long been accustomed to give the name 
 of " constitutional disease " to a certain number of diseases, 
 mostly diseases of the blood, such as anaemia, chlorosis, 
 leukaemia, haemophilia and scurvy. We generally also 
 include disorders of metabolism, such as gout, diabetes, 
 obesity, rickets and scrofula. These diseases do indeed 
 
 83 
 
THE PEEVENTION OF DISEASE 
 
 possess certain characteristics which distinguish them from 
 other groups of diseases. They run a chronic course and 
 from their very beginning affect the whole organism, and 
 though some external condition may help to cause the 
 disease, yet any very obvious and tangible exciting cause 
 is wanting. The constitution is essentially the determin- 
 ing cause, and the peculiarity of the constitution is generally 
 inherited. Nevertheless no really fundamental difference 
 separates these diseases from the rest, and there are inter- 
 mediate forms which connect these two groups. "We need 
 only mention tuberculosis as an example, for some writers 
 describe it under "the infectious diseases," others under 
 " constitutional affections," and others under diseases of the 
 lungs. From what has been said above about constitution 
 it is obvious that any classification of diseases into groups 
 must be artificial, but it is convenient for the study of 
 diseases. 
 
 Ebstein groups the diseases we have mentioned under 
 " diseases of the protoplasm," and Immermann under 
 " general disorders of nutrition." This would compel us 
 to include under the disorders of nutrition such a disease 
 as hereditary and constitutional syphilis, and those diseases 
 in which there is a chronic state of malnutrition as in the 
 cachexias of cancer and malaria. It seems best therefore 
 to consider the prevention of the diseases of the blood and 
 of the disorders of metabolism in the narrower sense, 
 separately from the rest. 
 
 84 
 
The Prevention of Diseases of the Blood 
 
 BY 
 
 DR. EOSEN 
 
 86 
 
The Prevention of Diseases of the Blood 
 
 Conditions of anaemia are so numerous and aetiologically ' 
 
 so different that they cannot be prevented by any single 
 method of prophylactic treatment : for instance anaemia 
 may arise suddenly from severe haemorrhage, or it may be 
 a sequela of some severe febrile disease, or it may be chronic 
 and secondary to some morbid condition ; for all these 
 varieties the prophylactic treatment cannot be the same. 
 The ordinary simple anaemia which is so common and gives 
 rise to no symptoms in itself, can scarcely be called a 
 disease, but it becomes a disease when diminished functional 
 activity and other general disturbances are associated with 
 the anaemia. It is met with mostly in women during the 
 second decade of life, and aetiologically has much in 
 common with chlorosis, and the prophylactic treatment of 
 the two is essentially the same. Premonitory signs of this 
 disease often appear during childhood ; these children are 
 pale, their muscles are flabby and their appetite bad, and 
 they take every possible ailment, and especially they readily 
 catch cold and are a great trouble to the family physician. 
 Their " delicate health " is partly the outcome of heredity, 
 partly the result of improper bringing-up. Moreover 
 during puberty young girls in civilized countries are so 
 much troubled with anaemia and chlorosis, that prophy- 
 lactic measures are suitable for nearly all of them. 
 
 The old medical textbooks recommend plenty of meat, 
 not only as a valuable remedy in anaemia and chlorosis but 
 also as a preventive. But our views about the supreme 
 value of a diet consisting largely of meat or of nitrogenous 
 food have been completely changed by the great advances 
 
 87 
 
THE PREVENTION OE DISEASE 
 
 made during tte last decade in the physiology of food, by 
 Voit, Pettenkofer and Eubner ; moreover anaemia and 
 chlorosis are not primarily disorders of nutrition, but primary 
 disorders of the formation of blood which are not dependent 
 upon the nutrition of the body. Naturally, insufficient 
 nourishing food for any length of time will reduce the 
 activity of the organs which form blood, as it does in the 
 case of all other organs. Conversely when the circulation 
 is defective the organs of absorption finally suffer too. In 
 the prophylactic treatment of anaemia and chlorosis there 
 is no indication to depart from ordinary diet. The diet 
 should include the three principal kinds of food in the 
 proportions which the principles of physiology have shown 
 to be necessary. Cereals should predominate in quantity, 
 and half a pound of meat daily on an average is sufficient. 
 The diet of women who work in the factories of large 
 towns is generally insufficient : it does not contain enough 
 nitrogenous food, because the foods rich in nitrogen, such 
 as meat and eggs, are too expensive for them. It may be 
 well here, in connexion with the diet of poor people, to 
 point out that the increase and extension of sea fisheries 
 have made fish very cheap, whether fresh, smoked or dried, 
 as cod, haddock and sturgeon. Recent attempts to make arti- 
 ficial nitrogenous preparations, such as " tropon" by Finkler, 
 deserve attention, but for the present need not be considered 
 as entering into the diet of the masses ; moreover tropon 
 is readily deposited in fine powder from its solutions, and 
 is not enjoyed when taken for any length of time. 
 
 In addition to a suitable diet the prophylactic treatment 
 of anaemia and chlorosis includes an hygienic mode of life 
 during growing youth. It is one of the difficult duties of 
 the family physician to arrange this. This subject however 
 belongs rather to general hygiene and cannot be described 
 here, though a few of the most important points may be 
 named. As to games : it is good that girls nowadays play 
 more at games and thereby get out more into the fresh air, 
 use their muscles and increase their metabolism. But we 
 must caution them against overdoing it, because over- 
 fatigue and over-exertion lead to anaemia and chlorosis. 
 
 88 
 
THE PREVENTION OF DISEASES OF THE BLOOD 
 
 Grirls who go out to service "where the work is hard often get 
 chlorosis though the surrounding external conditions are 
 good and healthy, and the chlorosis improves directly the 
 girls leave service for a few weeks' rest. Girls should there- 
 fore not be sent out to service too young, not before they are 
 seventeen or eighteen years of age, even though they may look 
 strong and well-developed. Among factory girls and shop girls 
 in large towns, who so very often suffer from anaemia and 
 chlorosis, generally combined with nervous debility and 
 other secondary ailments, over-strain by working beyond 
 their powers is a very important causative factor. They 
 leave their home, already feeling weak in muscle and nerve, 
 are occupied the whole day with their work, the monotonous 
 nature of which is in itself tiring, and in addition have 
 often to walk a long distance to get from their home on the 
 outskirts of the town to their work near the centre. 
 Experience shows that very few of them ride to their work : 
 they walk there and back in order to save the fares. 
 Imagine a weakly girl who gets up between five and six 
 o'clock in the morning, then has an hour or perhaps more 
 to walk to her work, works there till evening with a short 
 interval at midday, standing or walking about much, she 
 has an hour's walk or more home in the evening to her 
 supper when she is tired and done up ; and this meal is the 
 principal meal in the day. At midday these girls generally 
 eat in the factory a slice of bread and butter only which 
 they have brought with them from home. These girls on 
 reaching home at night are often so depressed that they 
 have no appetite for supper and go to bed overtired and 
 without having had sufficient food. And then anaemia 
 and chlorosis with nervous debility and other diseases do not 
 fail to appear. Medical treatment can often do much for 
 these girls by ordering them to ride home at night : in a 
 short time one generally hears that they have a better 
 appetite in the evening and feel refreshed and sleep better 
 at night. It is therefore most essential that the physician 
 should find out exactly how much work each girl does. In 
 many cases he will consider it necessary to curtail the work, 
 not by reducing the work actually done at the factory, 
 
 89 
 
THE PREVENTION OF DISEASE 
 
 but by cutting off other avoidable forms of work and 
 exercise. 
 
 The conditions are again different with people whose 
 occupation is almost entirely mental and who are obliged 
 to sit in their rooms all the day. In this connection we 
 must consider schools, especially high schools, whose methods 
 of education we are endeavouring at the present time to 
 reform. We need only mention here the great questions 
 of overstrain and the substitution of natural science for 
 some of the other studies and the use of object lessons, 
 Grymnastic exercises are receiving greater attention in 
 schools, but they are sometimes injudiciously given in the 
 early hours of the day instead of at the close of the morn- 
 ing or still better during the afternoon. When given in 
 the early hours the tiredness left after gymnastic exercises 
 prevents proper attention being given to the lessons which 
 follow. Harmonious development of body and mind is 
 wanted for the young ; unequal development injures both 
 body and mind, checks the natural cheerfulness of youth 
 and makes them pale-cheeked and peevish pessimists. 
 Unfortunately the parents often from lack of judgment and 
 from vanity spur on their weak children to exclusively 
 mental work, that they may take the first places at school 
 and bring home brilliant school reports, while their bodily 
 development remains far behind the average for their age. 
 To interfere in these cases will be one of the important 
 duties of school physicians ; long lasting severe anaemic 
 conditions often enough result from such forced mental 
 development and neglect of the body, and it is therefore 
 well to take these children away from school for half-a-year, 
 utilizing this period to rest the brain entirely and to 
 strengthen the weak body by suitable diet, moderate 
 exercise in the fresh air, cool baths and similar measures. 
 
 In adults too, the severe mental work of professional 
 life and of other callings which are sedentary often leads 
 to anaemia and its consequences, and what has been recom- 
 mended for school children is required for these cases also. 
 The patient should follow hygienic rules and get sufficient 
 bodily exercise out of doors by sports and by walking. 
 
 90 
 
THE PREVENTION OE DISEASES OF THE BLOOD 
 
 Unfortunately ball games in the open air for adults are 
 not yet the custom in Germany as they are in England ; 
 and for the sake of our health it is much to be regretted 
 that these games are considered undignified for the adult. 
 The appropriate interchange between rest and active move- 
 ment in these games, and the enjoyment they give are 
 excellent both for body and mind. 
 
 The connection between sexual processes and anaemia and 
 chlorosis needs mention in relation to prophylaxis, especi- 
 ally in the female sex, in whom tliis connection is so often 
 seen, chiefly at the time when the catamenia first appear. 
 The essential nature of this connection which we meet with 
 daily in medical practice is as little understood as is that 
 of chlorosis itself. With the changes in the entire circula- 
 tory system which are ushered in by the commencement 
 of menstruation a tendency to chlorosis appears, and the 
 tendency is greater when menstruation does not develop 
 quite normally. The various anomalies of menstruation, 
 especially menorrhagia and dysmenorrhoea which favour 
 the onset of chlorosis belong to gynaecology, and such cases 
 of chlorosis will be prevented by removing these menstrual 
 anomalies. Even normal menstruation during the years 
 of growth may favour an attack of chlorosis, and it is an 
 important duty to secure suitable conditions for young girls 
 during the catamenia with avoidance of all mental and 
 physical over-exertion — very delicate girls require com- 
 plete rest for several days. There should be an adequate 
 diet and regular evacuation of the bowels. Further details 
 are given in the section on the Prevention of the Diseases 
 of Women. Medical experience shows that the early 
 appearance of puberty favours the development of chlorosis, 
 but we have no definite statistics about this. There are 
 differences in the age at which the catamenia begin which 
 depend upon climate and race : we are not referring to 
 those cases but to the early appearance of the catamenia 
 which depends upon the mode of life. According to 
 Krieger the average age at which menstruation begins is 
 14"69 years among the higher classes and 16 years among 
 the lower classes of society. " Luxury and good living 
 
 91 
 
THE PEEVENTION OF DISEASE 
 
 tend to cause the early appearance of menstruation, and so 
 too do early over-excitement of the nervous system by 
 theatre-going, late parties and exciting literature." 
 
 Menstruation appears earlier in girls who live in town 
 than in country girls whose frugal regular habits of life 
 and hard work delay puberty. The prophylactic measures 
 required to prevent precocity are those so often emphasized by 
 doctors and teachers, namely — Simplicity in the whole mode 
 of life and the preservation of childlike feelings ; a regular 
 plan for the day's work ; early rising and early going to 
 bed ; supervision of her friends and of her reading ; harden- 
 ing the body by cold baths, swimming, gymnastics, games 
 and training in real work. All these are factors which 
 the family physician may use for the prevention of chlorosis 
 in young girls. These measures at the same time tend to 
 prevent the development of habits of masturbation, the 
 prevalence of which among boys and also among girls has 
 often been pointed out, and which not seldom favour the 
 development of anaemia and chlorosis. In many books 
 written on this subject we find the statement repeatedly 
 made but not proved that so-called '' boarding schools " to 
 which young girls in the higher ranks of life are generally 
 sent for completion of their education, are often hotbeds 
 for all kinds of pernicious sexual habits ; as if these did not 
 occur often among girls not sent to boarding schools. 
 
 Marriage has been recommended as a preventive as well 
 as a cure for chlorosis, on the supposition that the complete 
 establishment of the sexual functions counteracts chlorosis. 
 But chlorosis in married women is not rare ; we need 
 merely point out that affections of the heart, and a ten- 
 dency to haemorrhage and nervous diseases often appear 
 as sequelae of chlorosis, in order to understand the great 
 dangers which threaten such a chlorotic woman who has 
 married and has become pregnant. Indeed pregnancy and 
 labour are often important factors in the production of 
 anaemia. It is therefore not right to recommend marriage 
 as a prophylactic or even as a therapeutic measure against 
 chlorosis. On the contrary, as a therapeutic measure we 
 ought rather to discountenance marriage, in order that the 
 
 92 
 
THE PREVENTION OF DISEASES OF THE BLOOD 
 
 complications of chlorosis may be prevented, especially the 
 affections of the heart and vascular system which preg- 
 nancy tends to produce. Consent to marriage should not 
 be given till the chlorosis is completely cured. Similarly 
 marriage as a general prophylactic must not be recom- 
 mended for delicate weakly girls predisposed to chlorosis, 
 particularly if they have already had chlorosis or if there is 
 a family tendency to it. Early marriage should then be 
 discountenanced, seeing that it brings with it the prob- 
 ability of pregnancy. There are however cases in which 
 the health of the girl is injured and she becomes anaemic 
 and chlorotic — not through any congenital morbid tendency 
 but through an unsuitable mode of life through the want 
 of sufficient active occupation, through many kinds of 
 fashionable follies which are so common among the 
 higher ranks of life. In these cases marriage may be an 
 aid to health, chiefly because these young ladies have then 
 the responsible management of their households with serious 
 duties and regular occupation, and their life becomes wider 
 and is led into quiet and regular ways. We then see 
 many a young woman grow strong who was pale and thin 
 as a girl ; others however get only worse. Therefore the 
 mother's question whether her daughter should marry must 
 be answered with great caution and only after considering 
 carefully all the circumstances of the case. 
 
 Another disease of the blood which requires special pro- 
 phylactic treatment is haemophilia, a somewhat rare 
 but extremely dangerous malady. It is not exactly a 
 disease but rather an hereditary constitutional anomaly. 
 It is markedly hereditary and prophylaxis is concerned with 
 the question of marriage with members of such families. 
 According to Immermann's well known researches and 
 statistics it is not necessary to forbid marriage to all the 
 relatives of such families without exception ; the following 
 rules are sufficient for guidance — 
 
 Firstly : men belonging to families of bleeders and who 
 are themselves bleeders generally beget healthy children 
 who are not bleeders if the mother does not come from a 
 family of bleeders. On the other hand children born of 
 
 93 
 
THE PREVENTION OF DISEASE 
 
 mothers who are haemophilic are invariably bleeders 
 also. 
 
 Secondly : men belonging to a family of bleeders who 
 are not themselves haemophilic will practically never have 
 children who are bleeders if they marry a woman not 
 coming from a family of bleeders. 
 
 Thirdly : among the children of women who are not 
 themselves bleeders, but who are descended from families 
 of bleeders, there are almost always children who sufifer 
 from well marked haemophilia. 
 
 This shows, though we do not know the explanation of 
 it, that in haemophilia the tendency is almost entirely 
 transmitted through the mother, and medical consent to 
 marriage should not be given to any woman descended from 
 a family of bleeders, whether she herself be a bleeder or 
 not. Generally the women themselves are not bleeders. 
 Among 650 cases of developed haemophilia recorded in 
 medical literature, Immermann found that women formed 
 only eight per cent, of the cases and men ninety-two per 
 cent. The male members of families of bleeders may marry 
 without much risk if they are not themselves bleeders ; but 
 if they are themselves bleeders Immermann recommends 
 that the history of the family should be inquired into before 
 an opinion is given. If the inquiry shows that haemophilia 
 has repeatedly descended from father to son marriage should 
 not be advised, if on the other hand the tendency to 
 haemophilia appears only on the female side and not at all 
 on the male side, then there is no reason whatever, from a 
 medical point of view, to urge against the marriage of the 
 man who is a bleeder. 
 
 When haemophilia is present or there is a probability of 
 its appearance on account of heredity'-, prophylaxis is con- 
 cerned with avoiding every possible cause of injury. 
 Grrandidier found that the first haemorrhage appeared during 
 the first two years of life in 69-5 per cent, of the cases : 
 children should therefore be specially guarded during the 
 first years of life and shielded from injuries, and later 
 gymnastics must be strictly forbidden. Operative pro- 
 cedures, even the simplest and most trivial ones, should 
 
 94 
 
THE PREVENTION OF DISEASES OF THE BLOOD 
 
 never be undertaken except when urgently needed. The 
 ritual circumcision of Jewish boys in families of bleeders 
 should be omitted, for G-randidier's statistics show eight 
 cases of death from haemorrhage after circumcision. 
 Immermann considers the operation of vaccination free 
 from danger if very carefully performed. Extraction of teeth 
 is an extremely dangerous operation in bleeders ; Grandidier 
 collected thirteen deaths and forty extremely serious 
 cases of haemorrhage which did not however prove fatal. 
 Unfortunately neuralgia of the dental branches of the 
 trigeminal nerve appears to be very common in bleeders, 
 and they are therefore induced to have their teeth extracted 
 in spite of all warnings. 
 
 A means for checking haemorrhage in haemophilia 
 has lately been again brought forward and is worthy of 
 notice. Lanceraux in France recommended the hypodermic 
 injection of a one per cent, gelatine solution to check severe 
 haemorrhages ; the coagulability of the blood is said to be 
 increased thereby and the tendency to formation of thrombi 
 in the bleeding vessels promoted. Favourable accounts 
 have recently been received from different quarters, from 
 French, Russian and German writers, and quite recently 
 from Curschmann, about the effect of these injections of 
 gelatine in various kinds of haemorrhage, especially 
 haematemesis and haemoptysis. Generally 200 grams of a 
 sterile one per cent, solution of gelatine were injected on 
 several consecutive days. Sometimes stronger solutions, ten 
 per cent., were administered by the mouth or by the rectum. 
 Theoretically therefore it might be advisable before under- 
 taking any operation upon a bleeder to inject a solution 
 of gelatine and thus possibly artificially to increase the 
 coagulability of the blood. So far as we know this has not 
 yet been practically attempted but we recommend it as 
 rational in such cases. 
 
 In old medical works scurvy and its prevention occupy 
 a large space. Nowadays scurvy among landsmen is so 
 rare that most doctors never see a case. The general im- 
 provements in the conditions of life, in the dwellings, in the 
 diet, and in the care of the body have caused the disease 
 
 96 
 
THE PREVENTION OF DISEASE 
 
 almost to disappear, thougli formerly it was epidemic iii 
 prisons, barracks and infirmaries. Scurvy still often occurs 
 on ships in the arctic regions, sometimes caused by unfavour- 
 able climatic conditions, sometimes through the unsuitable 
 nature of the food, for the men are compelled from lack of 
 vegetables and especially of fresh vegetables for long periods 
 to eat chiefly meat, and especially salt meat or dried meat 
 and fish. When it became known that the absence of 
 potassium compounds which we generally get from the 
 plants we eat was an important reason of the unsuitability 
 of such a diet, it was recommended in order to prevent 
 scurvy that sailors should take fresh vegetables, potatoes 
 or fruit so far as possible, or failing this preserved 
 vegetables or certain preserved fruits which keep for a long 
 time, to supply the want of potassium compounds. Lime- 
 juice has since proved especially valuable in this con- 
 nection. 
 
 96 
 
The Prevention of the Diseases of 
 Metabolism 
 
 BY 
 
 DR. ROSEN 
 
 97 
 
The Prevention of the Diseases of 
 MetaboHsm 
 
 In earlier times propliylactic treatment in the narrower 
 sense, to maintain normal metabolism of the body, was 
 generally carried out though without any medical prescrip- 
 tions. The "Spring-cure" was much valued ; it consisted 
 chiefly in taking aperients regularly for several weeks in the 
 spring. The object was to expel from the body the effete 
 material which had gathered during the winter and so stimu- 
 late the bodily functions to renewed activity. Regular treat- 
 ment by sweating or by water drinking had the same object, 
 namely to expel impurities by profuse perspirations or 
 copious diuresis. Venesection too was periodically prac- 
 tised and often to such an extent as seriously to injure the 
 patient. These general " cures " are no longer in vogue ; a 
 life lived according to the principles of hygiene is a general 
 prophylactic against diseases of metabolism, and only a 
 certain number of individuals need any other special pre- 
 ventive rules. Diseases of metabolism, such as diabetes, 
 gout and the uric acid diathesis, as well as obesity, tend to 
 be inherited. External injurious conditions, accidents, 
 mental influences, diseases and excesses may help to develop 
 the disorders, but these are generally only the exciting- 
 cause, while the real cause is to be found in the constitu- 
 tion of the individual and in the peculiar functional tenden- 
 cies of his cells. In this way the hereditary nature of 
 these disorders is explained, and prophylactic measures 
 
 99 
 
THE PREVENTION OF DISEASE 
 
 should be commenced earlj^ in those whose ancestors have 
 suffered from them. The similarity of these diseases of 
 metabolism is shown by the fact that they may alternate 
 in different generations, and it follows that certain general 
 prophylactic measures are indicated for all who are heredit- 
 arily predisposed. Preventive treatment should be adopted 
 early, although the disease does not as a rule appear till 
 later life, and the treatment should aim mainly at influen- 
 cing the body in order t'> change the inherited tendency 
 towards abnormal metabolism into normal metabolism. 
 And further these prophylactic measures are indicated in a 
 number of other cases where the individuals are not known 
 to have this hereditary taint but where certain signs 
 point to a predisposition to disease of metabolism. We 
 shall return to this subject later. 
 
 In avoiding external injurious factors special stress has 
 been laid upon diet, and certain foods whose metabolism 
 can in such affections be only imperfectly carried out, 
 were altogether excluded from the diet of those who had 
 any tendency to diseases of metabolism. 
 
 Apart from the fact that we have now given up 
 special diets in the treatment of diseases of metabolism, 
 there is no reason, judging from the aetiology of these 
 diseases, for thinking that a special diet is called for in 
 diseases of metabolism. For example the influence of carbo- 
 hydrates upon the development of diabetes seems to be 
 negatived when we consider that the inhabitants of warm 
 climates live principally upon carbohydrates, and yet 
 the cases of diabetes among them are not more numerous 
 than among the inhabitants of colder countries who prefer 
 a meat diet. Some statements have ascribed to diet an in- 
 fluence in the development of diabetes, as for example 
 diabetes is said to be very common in Ceylon (Hirsch) ; 
 also in Thuringia, in Normandy and in some districts of 
 England where purely agricultural pursuits are followed. 
 On the other hand observations have shown that 
 diabetes is rare in some conspicuously agricultural districts, 
 such as the Antilles and Brazil. Among Jews we find a 
 large number of cases of diabetes, indeed the influence of 
 
 100 
 
THE PREVENTION OE THE DISEASES OF METABOLISM 
 
 race aucl of heredity is so great in diabetes that Senator 
 maintains, and in this he is probably right, that these errors 
 of diet give rise to diabetes only because great over-loading 
 of the gastro-intestinal canal with purely vegetable food 
 readily leads to gastro-intestinal affections, which then 
 seem sometimes to produce diabetes in those predisposed to 
 it (Griesinger and Zimmer). 
 
 The influence of diet has been emphasized in the 
 aetiology of gout even more than in diabetes, especially by 
 English writers (Sydenham, Grarrod), who regard the exces- 
 sive use of meat diet as the chief cause of gout, and therefore 
 in the treatment of gout recommend abstinence from food 
 which contains much nitrogen. Recently we have given 
 up this one sided idea and this treatment of gout : indeed 
 certain physicians even recommend a meat diet for gout. 
 We now know that gout is not a "privilege" of the rich, and 
 that it occurs more often than was formerly assumed among 
 the poor who have never known luxury and the excesses of 
 the table. Nevertheless most clinical observers take the 
 view that good living and excessive eating and drinking, 
 even though they be not the exclusive cause of gout, yet 
 have a certain influence upon gout and especially upon the 
 course it runs by causing an increased formation of uric acid. 
 The present opinion is that this increased formation of uric 
 acid in the body is not the ]3rimary and determining factor 
 in gout but rather the secondary. 
 
 First there occurs some injury of the tissues, especially 
 at the articular ends of bones, the cause of which is still 
 unknown, and then the uric acid salts crystallize out in 
 these tissues. At all events we should certainly try to 
 limit the excessive formation of uric acid in gout and not 
 allow much nitrogenous food. As a prophylactic, those 
 who seem predisposed to gout should observe a definite 
 regimen. Among those predisposed some have an heredi- 
 tary tendency to gout, such that they show signs of having 
 a " gouty diathesis " ; they are people of luxurious habits 
 and excreting much uric acid. Even more cases belong 
 to the class who have already, perhaps many years before, 
 had a typical attack of gout in the joint of the great toe 
 
 101 
 
THE PREVENTION OE DISEASE 
 
 and may have been quite free from trouble since. The 
 diet should in general be moderate : meat once a day with 
 the principal meal is sufficient ; smoked and salt meat and 
 fish and game should be avoided because the salts and 
 extractives irritate the kidneys. For the same reason 
 strong cheese, spices, asparagus and celery should be for- 
 bidden. Spirits, also beer and heavy wines, should not be 
 taken ; light moselle wine in small quantities may be 
 allowed, if mixed with some suitable mineral water, such as 
 soda, seltzer, Biliner, Fachinger and Giesshiibler. 
 
 "With regard to the large number of articles of diet 
 recommended or forbidden in gout and in the gouty dia- 
 thesis we still do not know the reasons and explanations of 
 their therapeutic and jDrophylactic value. A difference has 
 been made between white and red meat, because white meat 
 contains a smaller proportion of extractives and is therefore 
 said to be preferable in gout ; for the same reason boiled 
 meat is better than raw or roast meat. The nuclein of the 
 cell-nuclei appears to supply the material wanted by the 
 organism for the formation of uric acid, and Weintraud has 
 shown that by giving food rich in nuclein, the excretion of 
 uric acid may be doubled in amount or more. The glandu- 
 lar organs which are rich in nuclein — thymus, liver, 
 kidneys and spleen — are therefore forbidden to the gouty ; 
 and the same is true of the roe of fish and caviare. Fat 
 was formerly banished from the diet of gouty j)eople, for 
 according to Cantani the oxidation of nitrogenous foods was 
 interfered with by the more readily oxidized fat. Ebstein 
 has again introduced fat into the diet for gout ; but he and 
 Pfeiffer on the whole reject carbohydrates, while other 
 writers allow them. 
 
 From these contradictory statements and opinions of 
 different writers as to the diet for gout, we gather the gen- 
 eral principle that all excess both in the quality and the 
 quantity of food must be avoided and a regular and simjDle 
 diet adopted ; " ordinary homely fare " best fulfils the indi- 
 cations, it guards us from unnecessary limitation in diet and 
 also from eating too much. 
 
 The quantity and nature of the food are certainly 
 
 102 
 
THE PEEVENTION OF THE DISEASES OF METABOLISM 
 
 factors in tlie prophylaxis and in the treatment of gout, as 
 weJl as in the prevention of diabetes and obesity. There 
 is no doubt that occasionally a grave error in diet may 
 cause a gradual or sudden attack of gout ; but as it is a 
 constitutional disease, it follows that prophylactic measures 
 must affect parts of the body where metabolism occurs, and 
 improve the activity of those structures if metabolism is to 
 be normal. It is therefore essential to assist the excretion 
 of the products of metabolism by suitable means and thus 
 avoid accumulations. The best means of promoting meta- 
 bolism is muscular activity. Muscular exercise adapted to 
 each individual case is therefore of paramount value in the 
 prevention of all the diseases of metabolism. The much 
 disputed question of the relation between bodily activity 
 and the formation and output of uric acid, which is 
 answered differently by different writers, is not of any 
 importance so far as gout is concerned. G-eneral metabolism 
 is probably always greatly increased by muscular activity : 
 the flow of blood and lymph, and the respiration, are 
 increased, the oxidation processes occurring in the tissues 
 are more thorough, and the removal of effete material 
 from the body is promoted. Useless putting on of fat, to 
 which there is a tendency in those predisposed to gout and 
 to diabetes, is prevented by muscular activity ; and it also 
 tends to prevent the various obstructions to the venous circu- 
 lation so common in these patients ; such as haemorrhoids, 
 varicose veins and congestion of the liver. The muscular 
 exercise prescribed for each patient must be according to 
 the functional activity of his muscles and of his heart ; 
 those who lead a sedentary mode of life require games and 
 recreation which need only moderate effort, and in which all 
 the miuscles of the body are exercised ; these are especially 
 swimming, gymnastics, rowing, games at ball. Cycling 
 does not exercise the whole body, and walking does so still 
 less ; but these will probably have to suffice in the case of 
 elderly people accustomed to taking things easily, and a fe-w 
 exercises at home, such as dumbbells and Swedish gymnastics 
 might perhaps be added. In addition to increased muscular 
 activity, hydropathic treatment is a valuable means of 
 
 103 
 
THE PREVENTION OF DISEASE 
 
 promoting metabolism and therefore indicated in the 
 prophylactic treatment of diseases of metabolism. In 
 those predisposed to gout, great care must be taken to avoid 
 cold, because experience has shown that cold may bring on 
 an attack of gout ; it is best therefore to commence with 
 daily lukewarm partial bathing and very gradually lead up 
 to washing with cold water, followed by friction. Cold 
 baths, especially sea baths, are not advisable for those who 
 are predisposed to gout, as they make great demands upon 
 the activity of the vascular system and heart. In general 
 those who are inclined to obesity bear cold baths better, 
 and sea baths are often very useful — but on no account 
 should they be prescribed for old people or for those in whom 
 vascular changes exist. The whole body may be rubbed 
 down with cold water, and tepid baths of short duration at 
 about 85° F. may be taken, and the temperature may 
 gradually be reduced even lower. The action of this cold 
 water treatment is refiexly to deepen the respiration and 
 to strengthen and slow the heart's action, and thus improve 
 the circulation ; further it acts upon the cutaneous vessels, 
 causing them to contract and afterwards to dilate after 
 drying and rubbing, and thus also it improves the circula- 
 tion and thereby promotes metabolism. The feeling of 
 well-being which this treatment gives is also of value, and 
 with it comes a natural desire for bodily movement 
 
 Very recently some drugs have been introduced as 
 prophylactics in gout, with the idea of preventing the for- 
 mation of uric acid in the body ; for the many attempts to 
 render uric acid soluble by administering lysidin, piperazin, 
 or salts of lithia, and so to remove the tendency to gout gave 
 no good results ; as however great was the power of these 
 substances to dissolve uric acid in the test tube, they 
 proved useless when introduced into the human body. 
 Weiss, while recently working in Bunge's laboratory, dis- 
 covered that quinic acid checks the formation of uric acid 
 in the body ; and hippurates which are readily soluble in 
 water are formed instead. Quinic acid is present in lemons 
 and in many other fruits, and this is probably the explana- 
 tion of the good effects of fruit-cures which have been so 
 
 104 
 
THE PREVENTION OF THE DISEASES OF METABOLISM 
 
 long used for gout. Quinic acid can be combined with 
 various other substances, for instance with piperazin, and 
 this new product called " sidonal " is now being manufactured 
 and can be bought. The results so far seem to give reason 
 for hoping that in sidonal we have really a remedy for 
 gout, and the uric acid diathesis, and also a prophylactic 
 against attacks of gout, as the drug prevents the excessive 
 formation of uric acid and its deposit in the tissues. The 
 dose is 60 to 120 grains daily, and no unpleasant bye- 
 effects have yet been noted. It is recommended that the 
 drug be given for several weeks consecutively. 
 
 The preventive treatment of obesity and corpulence 
 requires a few words more. There is not a tendency to 
 corpulence in all people, for in most we find that in spite 
 of all endeavours to put on fat no such increase takes place, 
 and the body maintains a constant balance between intake 
 and output. Prophylactic measures are indicated for all 
 people in whose families obesity is common ; the predisposi- 
 tion to it does not usually appear during the earlier years 
 of life but becomes evident in the middleaged. Neverthe- 
 less such people should early begin to carry out the above 
 mentioned prophylactic measures to strengthen their con- 
 stitutions and to check the hereditary tendency. Sex 
 appears to make no difference. Yet there is a great tendency 
 to obesity among women at the period of the menopause. 
 We do not yet understand the reason for the connection 
 which exists between the menopause and obesity ; but 
 there is no doubt about the fact. It appears to be related 
 to certain results brought about by the administration of 
 ovarian extracts as previously recommended by Landau for 
 the ordinary troubles of the climacteric. P. F. Richter and 
 Lowy proved that the metabolic processes in animals 
 after ovariotomy could be considerably influenced by feed- 
 ing them with ovarian extract : a decided increase in tissue 
 oxidation was found to occur in the animal. These results 
 suggest that it is possible that tabloids of ovarian extract 
 given at the menopause may serve to prevent or to diminish 
 the excessive formation of fat, but we are still without 
 clinical observations on this subject. Thirdly, prophylactic 
 
 105 
 
THE PREVENTION OF DISEASE 
 
 measures against corpulence are indicated for those who 
 have akeady in youth shown a strong tendency to obesity, 
 which increases with advancing years. Boys and girls 
 alike show this tendency, and no hereditary taint can as a 
 rule be discovered. In a large number of cases this exces- 
 sive formation of adipose tissue is accompanied by striking 
 pallor of the skin and weakness of the muscles ; in many 
 cases we find also congenital abnormalities of the generative 
 organs, such as retained testes or absence of one or both 
 testicles, and among women defective functional activity 
 of the generative organs especially manifesting itself by 
 sterility. 
 
 Finally, a number of cases occur in men. mostly past 
 middle life, of phlegmatic temperament and free from cares, 
 who habitually eat too much and drink too much (generally 
 beer), and become abnormally fat. In these cases prophy- 
 lactic measures are urgently indicated and a change of 
 living is followed by marked improvement. 
 
 Seeing that there are different causes producing obesity, 
 no definite scheme of prophylactic and therapeutic measures 
 can be drawn up to suit all cases ; each must be considered 
 by itself. But in all cases it is true that very severe forms 
 of treatment for the removal of obesity are harmful. In 
 the matter especially of diet no general rules can be laid 
 down, but energetic measures in connection with the 
 quantity of food are best adapted for the last class of cases 
 which result from habitual over-eating and drinking. A 
 large number of courses at one meal should be forbidden 
 and a simple diet recommended. The influence of liquids 
 upon the formation of adipose tissue has long attracted the 
 attention of physicians, and the general opinion is that 
 imbibing much liquid promotes the formation of fat. In 
 Schroth's method the quantity of fluid allowed is very 
 small ; and Oertel also restricts it considerably. Probably 
 drinking at meals improves the appetite and the digestion. 
 Some restriction of the quantity of fluid taken is therefore 
 generally indicated as a preventive of obesity, especially 
 for heavy eaters. Spirits and beer should be altogether 
 forbidden. A small quantity of a light acid wine may be 
 
 106 
 
THE PEEVENTION OE THE DISEASES OF METABOLISM 
 
 permitted at meals. In tlie choice of a diet the aim is to 
 supply only as much heat-formiug food as the body 
 requires, and to prevent anything that would cause fat. 
 Formerly very strict rules were laid down, and certain 
 forms of food were absolutely prohibited. Sometimes only 
 carbohydrates with very little fat were allowed, sometimes 
 no carbohydrates, sometimes only nitrogenous food and 
 carbohydrates. Now that we know that fat may be 
 formed from any one of the three chief forms of food when- 
 ever more food material is taken than is required for 
 purposes of combustion, we no longer prescribe any special 
 dietary, but we are able to reach the same end by other 
 means adapted to the individual case. Ebstein's recom- 
 mendation of giving, in addition to meat and other 
 nitrogenous foods, much fat and little carbohydrate food, 
 is at all events chiefly based upon the fact that fat acts as 
 an aperient ; but many people soon get gastro-intestinal 
 disorders from eating much nitrogenous and fatty food, 
 and cannot therefore adopt this treatment. Carbohydrates 
 ill any case should be more or less limited, they are 
 readily absorbed and undergo oxidation easily, and thus 
 diminish the oxidation of the fat ; they may be much 
 restricted in those who are otherwise strong and healthy 
 and are large eaters. Carbohydrates niaj also be limited 
 in women at the climacteric, but they should be less 
 restricted in amount in weak anaemic persons, and in 
 those who have a family predisposition to corpulence but 
 are not themselves yet very fat. In these it may even be 
 dangerous to restrict the amount of carbohydrates ; a 
 regular diet comprising the three forms of food is required, 
 and the body must be kept free from all disorders of the 
 digestive apparatus — its strength be maintained and 
 increased. A sim23le regular fare is required with no 
 spirits and no excess of any kind, and the measures 
 previously recommended for improving metabolism are 
 most necessar3^ In this class of cases we meet with those 
 severe forms of obesit}^ in which there is a progressive 
 deposit of fat and fatty degeneration of organs at the same 
 time, even of the most important, especially the heart. 
 
 107 
 
THE PEEVENTION OF DISEASE 
 
 The fat invades the structures and causes their elements to 
 disappear. These forms of obesity do not depend much 
 upon the nature of the food taken. 
 
 The best way of preventing diseases of metabolism would 
 be to prevent marriage between individuals who have or 
 have had these diseases or who are hereditarily predisposed 
 to them. But this is not a reasonable suggestion for 
 general application ; moreover heredity does not always 
 appear in the direct line of descent : it makes leaps, and 
 sometimes spares a whole generation, or sometimes a number 
 of individuals in one generation. Moreover we often see 
 how a certain predisposition in one parent is compensated for 
 by the other healthy parent, and a child of sound con- 
 stitution is born to them. The laws of heredity are still 
 exceedingly obscure, and we do not know enough to enable 
 us to arrive at any definite conclusions yet ; but with 
 regard to the severer disorders, diabetes and gout, we may 
 assert that marriage between two who are predisposed to 
 these diseases or have already suffered from either of them 
 should be avoided. Further we know that diabetes and 
 gout have certain aetiological relations to mental and 
 nervous disorders, so that in some families all these varieties 
 of disease are met with. As a prophylaxis marriage should 
 therefore be avoided between persons in whom there is on 
 both sides a predisposition to these constitutional diseases, 
 especially to diabetes and gout. 
 
 108 
 
The Prevention of Infectious Diseases 
 
 BY 
 
 DE. RICHAED ROSEN 
 
 This article has been slightly modified with the view of rendering- 
 it more applicable to the English reader. 
 
 109 
 
The Prevention of Infectious Diseases 
 
 From what was said before concerniiig infectious diseases, it 
 follows that the principles which guide us in their prophy- 
 lactic treatment are similar to those in the case of other 
 diseases ; but in addition we need to guard against the 
 external injurious influences, the pathogenic bacteria. It 
 is essential also to employ means to raise the powers of 
 resistance of the individual and to assist the constitution in 
 its battle against the^injurious influence. But in infective 
 diseases, the external injurious factor — infection by the 
 invasion of the body by special bacteria — is probably a 
 more prominent factor than the constitutional one, and our 
 prophylaxis is essentially a battle against infection. The 
 best protection against infection would be the destruction of 
 the infective material. This is the work really of public 
 hygiene, and it endeavours to remove by sanitation the con- 
 ditions necessary for the growth of the germ ; by the removal 
 of refuse, filtration ol drinking water, and similar measures 
 which aim at keeping the bacteria and their toxins from 
 coming into contact with human beings. And indeed such 
 precautions taken by the State and by district authorities 
 have succeeded in almost entirely stamping out certain 
 infective diseases, the infective agents and the mode of in- 
 fection of which are known. For example, when it was 
 recognized that specifically infected drinking water was the 
 most frequent cause of epidemics of typhoid fever, some 
 towns provided a supply of pure water, and such epidemics 
 ceased almost entirely. 
 
 Ill 
 
THE PREVENTION OF DISEASE 
 
 Iiidi vicinal prophylactic measures have for their object 
 the protection of the individual himself against infection. 
 The methods depend upon the manner in which the 
 various infective diseases are conveyed, and will differ 
 according as the infection is conveyed by the air, as in 
 smallpox, or chiefly by the evacuations, as in cholera. 
 For purposes of prophylaxis, infectious diseases may be 
 grouped into those the germs of which are carried by the air 
 and those in which the germs are conveyed by some solid 
 or liquid, whether the diseased body itself or some of its 
 excretions or secretions. Though all infective diseases do 
 not fit at all accurately into this scheme, yet we can on 
 this principle arrange them provisionally somewhat as 
 follows, the channels given being the main, but not the 
 only, media of infection — 
 
 A. Infection is conveyed in 
 
 Measles 
 
 Scarlatina 
 
 Smallpox 
 
 Chickenpox 
 
 Typhus fever 
 
 Whooping cough 
 
 Influenza 
 
 Epidemic pneumonia 
 
 Mumps 
 
 Diphtheria 
 
 Cerebro-spinal fever 
 
 Pneumonic plague 
 
 Internal anthrax 
 
 \ 
 
 mainly by the air, and by 
 the secretions given off by 
 the invaded membranes or 
 
 organs. 
 
 B. 
 
 Enteric fever 
 Cholera 
 Dysentery 
 Communicable diarrhoea 
 
 by the excreta, and by 
 articles, foods, and drinks 
 infected thereby. 
 
 112 
 
THE PREVENTION OF INEECTIOUS DISEASES 
 
 C. 
 
 Glanders 
 
 Syphilis 
 
 Gonorrhoea 
 
 Contagions ophthalmia 
 
 Pnerperal fever 
 
 Tetanus 
 
 Erysipelas 
 
 External anthrax 
 
 Bubonic plague 
 
 mainly by inoculation with 
 the infected secretions, but 
 certain of these diseases may 
 be, at times, air-borne. 
 
 D. 
 
 Malaria 
 Yellow fever 
 Filariasis 
 
 1 by the bites of mosquitoes, acting as 
 r the intermediate host of the specific 
 J parasite. 
 
 Protection against infection must be according to the 
 method or methods in which the infection is conveyed : in 
 diseases of the first group A, in which infection is through 
 the air from man to man, infection may also occur as in 
 group B or C by means of soiled linen used by the patient ; 
 the secretions from the mouth and nose also of these 
 patients are infective. Therefore in all infective diseases, 
 almost without exception, utensils should be set apart for 
 the patient alone and not be taken into general use, and all 
 soiled linen, rags or utensils should be burned or disinfected. 
 All who are brought into contact with infectious disease 
 should carefully wash their hands and cleanse their nails 
 before meals, and should avoid touching their mouths with 
 their fingers ; in the sickroom the attendants should wear 
 linen overalls over their ordinary clothes. 
 
 For diseases where the infection is conveyed through the 
 air, the safest mode of prevention is the isolation of the 
 patient, although theoretically perfect isolation cannot be 
 carried out, as the attendants themselves are liable to carry 
 infection without themselves being ill. In small houses, 
 where it is impracticable to afford one or two rooms for the 
 sole use of the patient and his attendant, it is desirable 
 that the patient should be removed to an isolation hospital, 
 
 113 I 
 
THE PREVENTION OF DISEASE 
 
 and the room and infected articles thoroughly disinfected by 
 the sanitary authority. But where there is no such hospital 
 accommodation a room as far removed from the rest of the 
 household as possible should be set aside for the use of the 
 patient, and an attendant, preferably one who has already 
 suffered from the disease, or is likely to be relatively 
 insusceptible to it, should be told off to take charge of him. 
 In scarlatina the desquamated cuticle is still regarded as 
 one of the means of conveying infection, but infection is also 
 situated in the secretions from the nasal and aural passages in 
 cases where the patient suffers from rhinorhoea or otorrhoea. 
 
 When the infective material is air-borne and reaches the 
 patient directly by the air, it is difficult to ensure absolute 
 protection against it from isolation of the patient. For 
 example, in epidemics of influenza we must assume that the 
 germ of influenza is, if not ubiquitous, at least very generally 
 diffused. Much, however, may be done by preventing the 
 gathering together of large bodies of persons and by the 
 isolation of those affected with the disease. 
 
 The infection of erysipelas is perhaps liable to be spread 
 directly by the air, but conveyance of the infection from 
 person to person by direct contact or close proximity is 
 probably more frequent. Just as in hospitals, strict isola- 
 tion of erysipelas cases is enforced, so also in private 
 practice the patient should be isolated ; very strict and 
 thorough methods of disinfection are essential, and band- 
 ages and dressings should be burnt directly after removal. 
 
 In infective diseases where the infectious material is not 
 carried by the air there is no danger from proximity to the 
 patient. If infection is situated only in the affected part of 
 the body, for example in gonorrhoea and in syphilis, prophy- 
 laxis is merely required to prevent direct contact of a healthy 
 body with the affected part, or the discharges therefrom. 
 For infective diseases which are conveyed to man from 
 animals, such as hydrophobia, glanders and anthrax, pro- 
 phylactic measures should include the destruction of the 
 diseased animals, and also public regulations for the pre- 
 servation of health, such as the compulsory muzzling of 
 dogs and other suitable precautions. 
 
 114 
 
THE PREVENTION OF INFECTIOUS DISEASES 
 
 Wiien the germs of the disease are conveyed chiefly 
 through the evacuations of the patient the prophylactic 
 measures are obvious. Among these diseases are typhoid 
 fever, dysentery and cholera, "where the evacuations from 
 the bowels contain and spread the infection, as also may 
 the vomited matter in cholera. Another member of this 
 class is diphtheria, in which the poison is contained in the 
 secretions of the mouth and nose ; and to some extent also 
 pulmonary tuberculosis may be considered as belonging to 
 this group, for this disease is mainly spread by the sputum 
 of the patient. 
 
 In the case of typhoid fever, cholera or dysentery, or in 
 conditions in which one or other of these diseases is sus- 
 pected, the excreta (in typhoid fever including the urine) 
 should be received into a vessel containing a small amount 
 of some efficient disinfectant, such as carbolic acid (5 per 
 cent.) or acidulated perchloride of mercury (1 in 1000). 
 After the motion has been passed, more of the disin- 
 fectant solution should be added, the whole being intimately 
 mixed together and allowed to stand for some thirty 
 minutes. Care should be taken that sufficient disinfectant 
 is added to prevent the percentage strength of the mixture 
 being reduced below its limit of efficiency by dilution with 
 the excreta. The contents of the bed-pan, or other receptacle, 
 may, after disinfection, be emptied down the slop-sink or 
 water-closet where there is a proper system of sewers ; but 
 in rural districts where drains or sewers do not obtain, the 
 excreta may be buried in shallow holes dug in the ground 
 sufficiently remote from wells or other sources of water 
 supply. It must be borne in mind that the disinfectant 
 itself, altogether apart from the specific virus of the disease, 
 may seriously endanger the purity of a water supply. The 
 soiled bed and body linen should at once be soaked in a vessel 
 of soap and water, and the articles be subsequently raised to 
 the boiling point during the washing process. Soiled articles 
 of bedding such as mattresses and blankets which cannot be 
 thus treated should either be handed over to the sanitary 
 authority for disinfection in a steam apparatus or be 
 destroyed by fire. In these three diseases, namely typhoid 
 
 116 
 
THE PREVENTION OE DISEASE 
 
 fever, dysentery and cholera, the physician may generally 
 prevent any further extension of the disease by giving exact 
 rules to be followed by all the members of the household. 
 " When cholera is prevalent the family physician, as the 
 friend of the household, can guard the inmates in a way 
 scarcely possible at other times " (Leber t). These indica- 
 tions of the way in which individuals may be protected 
 against direct infection will suiEce here. Much the same 
 is true of diphtheria, but in that disease the linen and 
 the plates and drinking vessels require special disinfection, 
 while the excreta do not. Healthy people must be specially 
 warned against coming near the patient's face when he 
 coughs. 
 
 In tuberculosis, too, infection may be conveyed by 
 coughing, small droplets of fluid carrying tubercle bacilli 
 being cast into the are, and inspired by healthy persons. 
 Fltigge has recently drawn special attention to this mode 
 of infection, which he considers far more dangerous than 
 that by dried sputum or dust. As a result of Fliigge's 
 work, B. Frankel has introduced a mask which is some- 
 what similar in form to Schimmelbusch's chloroform mask, 
 is covered with two layers of thick muslin, and fastened 
 around the ears or the head by an elastic band. The mask 
 covers only the mouth and leaves the nose free. The 
 material can be easily removed and replaced by a new 
 piece. It is proposed that this mask should be worn by 
 patients who expectorate much and have advanced 
 phthisis, because apart from the act of expectoration, the 
 small drops of fluid containing tubercle bacilli which are 
 often thrown out in speaking, coughing, and in clearing 
 the throat, would be stopped by the mask. Fliigge's and 
 B. Frankel's experiments seem to show that patients with 
 early phthisis do not convey infection in this way. 
 
 Nevertheless all phthisical patients should be reminded 
 by the physician to hold the hand before the mouth when 
 coughing, and so far as possible to suppress coughing in 
 the presence of others. A little practice will enable the 
 patient to do this. 
 
 Other ways in which tuberculous infection is conveyed, 
 
 116 
 
THE PREVENTION OF INFECTIOUS DISEASES 
 
 and the prevention of infection, will be described later in 
 connection witli the prophylaxis of tnbercnlosis. 
 
 Wliile prophylactic measures are being taken against the 
 agents which cause infection and are mainly applicable 
 to the bodies of those vdio are already affected, other pre- 
 cautions should at the same time be taken to strengthen 
 against disease the bodies of those who are healthy, making 
 them as it were proof against infection and removing or 
 reducing the predisposition to disease. On the other hand 
 the healthy body must be guarded from everything which 
 would call forth or increase predisposition to the disease. 
 Prophylactic measures such as these for the healthy body 
 are of especial value in cases where it is not possible to do 
 much or, indeed, anything against the infective agents, 
 especially when they are conveyed through the air. 
 
 The object of prophylactic treatment in this connection 
 is twofold : to prevent the poison from entering the body 
 by the ordinary channels and to keep these channels in 
 normal conditions. The healthy mucous membrane is able 
 to resist many injurious influences and often even 
 pathogenic bacteria. During cholera epidemics numbers of 
 cholera bacilli are said to have been found in the evacua- 
 tions of healthy people. Pettenkofer and others swallowed 
 cultures of cholera bacilli and were not attacked, the normal 
 stomach and intestines were able to prevent the bacteria 
 from getting into the tissues. The conditions of the 
 mucous membrane which permit the entry of bacteria into 
 the organism may be temporary or permanent, and may 
 be the result of some anatomical lesion or of some functional 
 change. To take cholera as an example, experience has 
 taught us that gastric and intestinal catarrh favour the 
 development of cholera, for the diseased mucous membrane 
 cannot" withstand the infective agents. In times of cholera 
 all errors of diet should be avoided and forms of food 
 likely to start diarrhoea, such as cucumbers, melons, and 
 unripe fruits and acid beverages. Taking cold, over- 
 exertion, and mental emotions also readily exert a bad in- 
 fluence upon the functions of the stomach and intestines, 
 and a regular quiet life with moderation and care in every 
 
 117 
 
THE PREVENTION OF DISEASE 
 
 respect is therefore to be recommended. But the ordinary 
 way of living should on no account be altered if it is normal 
 and sensible. Not only do such injurious influences which 
 are accidental and temporary act upon the gastro-intestinal 
 canal and predispose to the disease, but permanent abnormal 
 conditions act similarly; for persons with "weak" stomachs 
 or with well marked affections of the stomach or intestines 
 are very apt to sicken with cholera. At such times weak 
 and delicate people should be recommended to have a diet 
 adapted to their individual needs, and to take wine, and 
 small quantities of rum or brandy in their tea, keeping the 
 feet and the body warm. Every disorder, even those 
 apparently trivial, especially when affecting the stomach 
 and intestines, should receive careful treatment. 
 
 Similar precautions are required in epidemics of typhoid 
 fever and dysentery ; here as in cholera infection enters by 
 way of the digestive tract. In sporadic cases of typhoid 
 fever early and thorough disinfection, together with the 
 other rules given above for destroying the infective material, 
 will sufi&ce. 
 
 Accidental lesions of the skin or mucous membrane 
 which permit of the entry of infection are often so trivial 
 as to be easily overlooked. In erysipelas of the face the 
 disease starts at some minute excoriation of the skin 
 especially at the nostril, so common in an ordinary nasal 
 catarrh. Special care should be taken when a patient who 
 has once had erysipelas gets a nasal catarrh, because 
 erysipelas belongs to those diseases which leave a predisposi- 
 tion to a second attack. The nasal catarrh should be 
 carefully treated, the nose smeared with boro-vaseline, and 
 the fingers should not be allowed to touch the face. 
 
 To keep the respiratory organs intact is of great im- 
 portance in influenza. The different forms in which in- 
 fluenza manifests itself and the appearance of local affec- 
 tions in addition to the general symptoms may indicate 
 that the germs of influenza can enter the body by differ- 
 ent channels. It is remarkable that in different cases of 
 influenza sometimes the digestive tract is almost exclusively 
 affected, sometimes the respiratory system, sometimes the 
 
 118 
 
THE PREVENTION OF INFECTIOUS DISEASES 
 
 nervous system. The metliocl of infection in influenza is 
 still obscure, but many observations seem to point to infec- 
 tion through the respiratory tract. It has been shown 
 that those are specially apt to get influenza who have also 
 a predisposition to colds, to bronchitis and laryngitis, and 
 those who have some acute or chronic disease of the upper 
 respiratory passages. The influenza germs which may be 
 in the air we breathe readily attack an epithelial surface 
 already pathologically changed and thence more easily pass 
 into the lymph stream. This is in accordance also with 
 Breitung's statement that those children are particularly 
 liable to be attacked by influenza whose nasal respiration 
 is hindered by swelling of the turbinates or by adenoid 
 growths. The tonsils are regarded as a locality where in- 
 fluenza may begin, and slitting the lacunae has been recom- 
 mended as a prophylactic. Recently in the Academic de 
 Medecine at Paris the subject of protection of the individual 
 against influenza was discussed. As a preventive during 
 epidemics of influenza, Huchard recommended disinfection 
 of the nose and mouth with antiseptic solutions ; Labonde 
 recommended washing out the nose and throat twice daily 
 with a weak hot solution of carbolic acid (1 in 3,000) ; 
 Huchard considered that it was also necessary to make the 
 digestive tract aseptic, and to this end a milk diet is best ; 
 the usual drugs employed for this purpose, such as naphthol 
 and salol, are less useful. Breitung regards the inhalation 
 of nascent chloride of ammonium from a special apparatus 
 an effectual protection against influenza ; those whose 
 profession causes any special strain upon the organs of 
 respiration — as teachers, preachers and singers — and who 
 are thereby probably predisposed to influenza should guard 
 against it by regularly inhaling ammonium chloride. 
 
 Not only in influenza but also in other infective 
 diseases the tonsils are supposed to serve as a place for 
 the entrance of the infection. The exciting agents which 
 cause measles and scarlet fever, often seem to gain 
 entrance through tonsillar leisons, and so too does the 
 diphtheria bacillus. Affections of the tonsils whether acute 
 or chronic always require most careful treatment ; often 
 
 119 
 
THE PREVENTION OE DISEASE 
 
 tliere are on tlie tonsils deep pockets and cliannels whicli 
 gradually get filled with, plugs consisting of particles of 
 food and of cellular debris which are undergoing decom- 
 position, smell badly and keep up a chronic irritation of the 
 tonsil. These pockets must be slit up and the plugs 
 removed. The further treatment is that for chronic inflam- 
 mation of the tonsil — painting with solutions of alum or 
 silver nitrate, or removal of the tonsil by the guillotine. 
 
 Having considered thejDredisjDOsitionof individuals to infec- 
 tion through the condition of their mucous membranes, we 
 have now to consider another kind of predisposition wbich is 
 in a sense less definable as it depends upon the general con- 
 stitution. A kind of general weakness in many cases is 
 the basis upon which this predisposition rests ; it is very 
 clearly marked in pulmonary tuberculosis in which a definite 
 inherited constitution predisposes to the disease. Some- 
 times predisposition to infective diseases is the result of a 
 weakness of the body which does not show itself by any 
 outward signs and is not inherited ; this weakness is rather 
 an accidental acquired weakness which may attack even 
 robust natures. For example we know that lobar pneu- 
 monia often results from a plunge into cold water or some 
 other excessive chilling of the body ; and so too does 
 articular rheumatism. This sudden cooling causes a 
 momentary weakness which, makes the body susceptible to 
 infection. In epidemics it has often been observed that 
 people fall victims to the infection directly after some 
 severe over-exertion, after some form of excess, especially 
 venereal excesses or any condition which has weakened the 
 whole body. It follows that during epidemics prophylaxis 
 consists in avoiding all that would in any degree reduce 
 the functional activity of the body. 
 
 In epidemics we see one sicken with, smallpox or scarlet 
 fever, while another — perhaps a brother — remains well ; yet 
 the conditions under which they lived and their mode of 
 life were exactly th.e same, and nei ther showed any signs of 
 ill health or difference in bodily condition. Probably there 
 existed some very minute chemical differences in the blood 
 and lymph which made the one susceptible to the action of 
 
 120 
 
THE PREVENTION OF INFECTIOUS DISEASES 
 
 the infective material. Into this obscure region of aetiology 
 a ray of light has recently been flashed by the work of 
 Ehrlich, Brieger, Behring and others who have shown that in 
 the blood certain chemical bodies (alexins) act under special 
 conditions as antidotes to certain bacterial poisons; these 
 alexins are derived principally from cells, mostly the white 
 corpuscles of the blood. These recent aetiological researches 
 were suggested by the great practical results which followed 
 the use of inoculation • as a therapeutic and prophylactic 
 measure ; the substances used for inoculation stand in a 
 definite relation to the infective bacteria or to their j)roducts, 
 and when injected into the body render it immune against 
 the infective poison. In this way we imitate nature's 
 method of making the body immune ; this immunity 
 against certain infections is inherited by some, by others it 
 is acquired — sometimes because they have already had that 
 particular disease, as in smallpox, measles, scarlet fever, or 
 typhoid. In other cases a person who has once had an 
 infective disease is more predisposed to it and liable to have 
 it again, as in articular rheumatism, erysipelas, influenza 
 and diphtheria. Sometimes increased predisposition to an 
 illness is left as the result of some other illness, for instance 
 measles predisposes to tuberculosis ; scarlet fever and also 
 measles predispose to diphtheria ; measles moreover predis- 
 poses to whooping cough. 
 
 The theory of preventive inoculation cannot be entered 
 into more fully here. Until a few years ago inoculation 
 was undertaken only against smallpox, but of late years 
 Pasteur, Behring and others have inaugurated a new 
 era by preventive and curative inoculations for other 
 infective diseases. The great practical results which have 
 followed from vaccination against smallpox have very fre- 
 quently been quoted. Vaccination, where properly applied, 
 has brought about almost the extinction of a disease which 
 in the eighteenth century and in the beginning of the nine- 
 teenth century was one of the commonest and most dreaded of 
 diseases. Cases of smallpox which occur now and again have 
 always been traced to infection brought from abroad, especi- 
 ally from Russia, where compulsory protective inoculation 
 
 121 
 
THE PREVENTION OF DISEASE 
 
 against smallpox (vaccination and revaccination) has not 
 yet been introduced. Among the most ancient civilized 
 races— the Chinese and the Indians — there was practised in 
 prehistoric times a method by which an attenuated form of 
 the poison of smallpox was employed in order to produce a 
 mild form of " sporadic " smallpox, by which the body was 
 rendered immune against the disease. This method of 
 inoculation of smallpox (variolization) was introduced into 
 Europe in the eighteenth century, but was subsequently for- 
 bidden by law because of the danger of the spread of small- 
 pox by its employment. In 1796 Jenner introduced the 
 valuable method of vaccination, the inoculation of human 
 beings with the infection of cowpox, and it has since been 
 scientifically and experimentally proved to be an effectual 
 protection against true smallpox. It is now many years 
 since vaccination became recognized as a branch of public 
 hygiene. For individual prophylaxis it is advisable that 
 everyone should be revaccinated before going into countries 
 where there is smallpox, because after the lapse of a certain 
 period vaccination no longer affords absolute protection 
 against smallpox, although the disease runs a milder course 
 in one who has been vaccinated. Sometimes, for example 
 in India, we are told it is possible for white men who have 
 travelled thither to be susceptible to vaccination on their 
 arrival, though attempts to vaccinate them failed shortly 
 before they started from home. 
 
 The modern endeavours by bacteriologists to discover 
 methods of protective inoculation against other infective 
 diseases by strictly scientific methods have not yet led to 
 great practical results, though a beginning has been made 
 which augurs well for the future. The value of Pasteur's 
 inoculations against hydrophobia are universally acknow- 
 ledged ; the method has been successful in the treatment 
 of several thousands of people bitten by animals apparently 
 suffering from rabies. The principle upon which this 
 treatment by inoculation is based is to make the body 
 immune against the infection by giving gradually increas- 
 ing doses of the specific antitoxin. For this purpose Pasteur 
 used the spinal cords of rabbits infected with the poison of 
 rabies ; the cord was exposed to*a drying process and dried 
 
 122 
 
THE PEEVENTION OF INFECTIOUS DISEASES 
 
 for different periods to produce virus of different degrees 
 of virulence : the driest is the least potent. Emulsions of 
 these different spinal cords were then injected at regular 
 intervals into the human body. In Berlin a special part 
 of the Institute for Infectious Diseases is now reserved for 
 inoculation against hydrophobia, and any one in G-ermany 
 who has been bitten by an animal which has or is suspected 
 of having rabies is sent to the institute without delay for 
 treatment. The value of Pasteur's protective inoculations 
 against anthrax has not yet been fully recognized. Anthrax 
 occurs very seldom in human beings and the method is 
 used mostly for animals, but in spite of the incontrovertible 
 results obtained in the laboratory the method has not 
 yet been introduced into veterinary practice. 
 
 Behring's serum treatment of diphtheria is recognized 
 by all to be most valuable and successful, but the proposed 
 preventive inoculation against diphtheria has not as yet 
 been generally applied. It is based upon the same principle 
 as curative inoculation, but the serum contains a smaller 
 number of units of the virus ; in children 250 units are" 
 generally injected. The injected serum gives immunity for 
 three weeks, and the inoculations should be repeated every 
 three weeks. Further details about this subject will be 
 found in the section on Diseases of Children. Preventive 
 inoculation against diphtheria is rarely required for adults. 
 
 Quinine, the specific drug for malaria, is also highly 
 valued by authorities on malaria as a prophylactic against 
 this disease. Hertz recommended 5 grains of quinine every 
 morning and evening during epidemics in malarial dis- 
 tricts, and obtained very good results — sometimes no attacks 
 at all occurred, sometimes the attacks were of an extremely 
 mild type. After using the drug for some time the organism 
 gets habituated to it and the drug loses some of its efficacy, 
 and should therefore be discontinued for two or three 
 weeks every now and again. For the ordinary endemic 
 attacks of malaria a longer use of the drug is not of 
 value in prophylaxis, but it is sufficient directly the first 
 symptoms of malaise appear to give 10 grains of quinine 
 in the evening at bedtime for three or four consecutive 
 days, in order to cut short the attack. 
 
 123 
 
The Prevention of Pulmonary 
 Tuberculosis 
 
 The great frequency of pulmonary tuberculosis and the 
 great mortality caused by it justify us in devoting a 
 section specially to the prevention of this most serious of 
 all infective diseases. There are even now those who 
 deny the infectious nature of tuberculosis and look upon 
 the disease as one purely constitutional. Although the 
 constitution is an important aetiological factor in tuber- 
 •culosis, yet clinical observation and experimental research 
 both point to the tubercle bacillus as the exciting cause 
 of tuberculosis. The instincts of the people, which are 
 particularly acute in such matters, long ago convinced 
 them that pulmonary consumption is communicable. The 
 whole of our knowledge points strongly to the conclusion 
 that prophylaxis must concern itself with preventing the 
 tubercle bacillus from entering the human body. We 
 must endeavour to render innocuous the excretions and 
 evacuations of the patient which contain the bacilli. The 
 sputum is by far the most important vehicle for the 
 conveyance of tubercle bacilli outside the body, and the 
 other excretions are comparatively unimportant ; moreover, 
 the bacilli contained in the urine and faeces are very 
 quickly destroyed by putrefaction. It is known, too, that 
 even the bacilli in the sputum may already have lost their 
 virulence (Koch and Kitasato), but this is not always the 
 case, and it has been shown that while one portion of a 
 sputum did not infect animals by the bacilli which it 
 contained, another portion of the same sputum contained 
 
 124 
 
THE PREVENTION OF INFECTIOUS DISEASES 
 
 numerous virulent bacilli (Cornet). The sputum of the 
 patient should therefore be made innocuous. Since the 
 State and the district authorities have turned their atten- 
 tion to this branch of prophylaxis a noticeable diminution 
 of tuberculosis has been recorded in Germany. Before the 
 year 1889 the mortality caused by tuberculosis in Prussia 
 was thirty to thirty-two per 10,000 of the population, now 
 it is only twenty- one to twenty- two per 10,000 (Cornet), 
 In hospitals and in sanatoria where there is adequate 
 supervision it is easy to see that the sputum is not ex- 
 pectorated on to the ground or into the handkerchief but 
 into sputum cups. In private practice it can only be 
 done if the physician ceaselessly instructs his patients 
 about the matter ; bedridden patients should have simple 
 sputum glasses or cups, into which a little water with or 
 without some disinfectant has been previously poured. 
 Plain water answers the purpose, for all we need to do 
 is to prevent the sputum from becoming dry and from 
 being scattered as dust through the air to be breathed by 
 other human beings. Phthisical patients who still get 
 about should carry a pocket sputum flask ; Dettweiler's 
 flask is most generally used. Unfortunately patients often 
 fail to use such flasks because they dislike attracting 
 attention to themselves and being recognized everywhere 
 as consumptives by their use of a flask, and this is only 
 natural from the human standpoint. To do away with 
 this difficulty the use of flasks should he made general 
 for all people who have any expectoration, not only for 
 consumptives but also for all who suffer from bronchitis, 
 asthma, or disease of the throat or larynx. The sputum 
 flask would then not be the sign of a consumptive, but 
 merely an indication of a conventional custom which dic- 
 tates that well bred people expectorate into a flask instead 
 of into a room, a carriage or other similar place. These 
 flasks can then be emptied down the closet, care being 
 taken that none is splashed about, or into special holes 
 dug in the ground. The patient should also be urged not 
 to cough or to sneeze into the air of the room, but to hold 
 a cloth or a hand before his mouth and nose when cough- 
 
 125 
 
THE PREVENTION 0¥ DISEASE 
 
 ing or sneezing. Every physician knows by experience 
 that many patients will cough, towards him without the 
 least concern while he is engaged in examining them : 
 constant instruction will correct such carelessness on the 
 part of the patient. Recent methods introduced to pre- 
 vent the saliva from being scattered into the air when 
 the patient speaks have already been described; we have 
 not yet any definite knowledge whether germs can thus 
 be scattered so as to cause infection, at present there are 
 those who hold Cornet's view about this, while others hold 
 Fliigge's, and it is best therefore for the present to do 
 justice to both views by suitable prophylactic measures. Re- 
 cently too a disposition has been shown more than hitherto 
 to remove patients with advanced consumption from their 
 families ; their copious expectoration which swarms with 
 bacteria is a very great danger as a source of infection 
 for those around them. Patients in the early stage of 
 consumption often have no bacilli in their expectoration 
 or very few compared with the enormous number present 
 during the stage when there are cavities. If the home 
 circumstances do not permit of the patient being properly 
 and adequately nursed, every effort should be made to get 
 him into a hospital during the later stages of the disease. 
 Unfortunately there are not yet sufficient hospitals for 
 these advanced cases. 
 
 The prophylactic measures above mentioned for making 
 the sputum innocuous are those to be observed by the 
 patient, but the healthy should on their part also observe 
 precautions to protect themselves against infection. Ade- 
 quate prophylactic measures are required from childhood 
 onwards. Scrofulosis which nowadays we look upon 
 as also caused by tubercle bacilli and which often is the 
 forerunner of other forms of tuberculosis, is sometimes 
 caused in childhood simply by want of cleanliness. Volland 
 has drawn attention to this fact : small children come into 
 close contact with the ground in their games and when they 
 learn to walk, and with the dust on the floor. They after- 
 wards touch the apertures of the body and scratches and 
 wounds with their dirty fingers, and thus readily convey 
 
 126 
 
THE PEEVENTION OF INFECTIOUS DISEASES 
 
 tlie tubercle bacillus and other germs into their body. The 
 need for cleanliness of the child's hands, fingernails and 
 face should be impressed upon mothers and nurses. The 
 nursery floor should be wiped over once or twice a day, 
 and the toys should be kept clean. Very special care 
 in this matter must be observed when there is a phthisical 
 member in the family who has some expectoration. Further 
 those around the patient should avoid any unnecessary 
 close contact, especially'' kissing and sleeping together. But 
 the fear of infection should not be carried to an extreme 
 so as to wound unnecessarily the patient's feelings. On 
 the contrary those who are afraid should particularly be 
 told that merely to be in the vicinity of the patient is 
 not harmful and that his breath is free from danger ; but 
 the spoon and fork he has used in eating should not be 
 used by another till they have been washed. With regard 
 to the room, special stress must be laid upon the ordinary 
 rules of hygiene, such as ventilation, wiping the floor with 
 a damp cloth, and the avoidance of dust. 
 
 After the death of a consumptive patient at home, the 
 linen, bedding and clothes should be thoroughly disin- 
 fected ; the walls of the sick room should be freshly 
 painted or papered, or the old paper should be cleaned 
 with bread. Until the sanitary authorities undertake 
 the disinfection in cases of tuberculosis every doctor 
 should, in the interests of the survivors, direct the disin- 
 fecting of the rooms. Opinions differ as to whether it is 
 advisable to introduce compulsory notification of tuber- 
 culosis, but all are probably agreed that after a case of 
 death from tuberculosis disinfection should be obligatory. 
 
 To prevent tuberculous infection being conveyed from 
 animals to man, especially by meat and milk, a well 
 organized body of sanitary inspectors is needed, and since 
 the tuberculin test is now extensively used by veterin- 
 ary surgeons for purposes of diagnosis, it is possible 
 to remove tuberculous cattle from the rest and thus 
 gradually stamp out the tuberculosis among cattle which 
 is now so prevalent. Since the introduction in Germany 
 of the compulsory inspection of meat in slaughter houses, 
 
 127 
 
THE PREVENTION OF DISEASE 
 
 private precautionary measures against infection through 
 meat are not generally required ; on the' other hand milk 
 should be boiled or sterilized before being used unless 
 there is an absolute guarantee that the cows are sound 
 in health. Recently market butter was strongly suspected 
 of being the conveyer of virulent tubercle bacilli (Ober- 
 miiller), but examinations made (Rabinovitsch) gave re- 
 assuring results, and proved that the bacilli were perfectly 
 harmless ones, very similar to tubercle bacilli for which 
 they had been mistaken. It would therefore seem that 
 in eating butter and cheese we need not fear infection by 
 tubercle bacilli. 
 
 The prevention of scrofulosis in children was stated above 
 to be a valuable prophylactic against the occurrence of 
 other forms of tuberculosis in adult life. The signs of 
 scrofula may all have disappeared, except possibly some 
 slight swelling of the cervical glands, and the individual may 
 apparently be in good health for years till, when he is over 
 twenty, signs of apical disease of the lungs appear. The 
 opinion held by most authorities is that virulent tubercle 
 bacilli may be lodged and encapsuled in the different parts 
 of the body, most often in the lymphatic glands, and that 
 even after many years some exciting cause may take them 
 into the lymph stream and set up tuberculous disease of 
 some organ. The cervical, bronchial and mesenteric glands 
 are those most often affected ; and in children the lymphatic 
 glands of the neck are by far the most common seat of 
 scrofula. And further, tuberculous disease of a joint or 
 bone, tuberculous affections of the genito-urinarj'" organs, of 
 the skin or mucous membranes, may after an apparently 
 perfect cure and complete functional recovery give rise 
 years afterwards to a fresh development of tuberculosis, 
 especially of the lungs. Tuberculosis is apt to leave small 
 caseous foci which contain germs still capable of life 
 (Grerhardt) ; these foci are encapsuled by scar tissue and 
 are thereby made harmless till some external cause, some 
 injury, breaks as it were the capsule and causes the latent 
 germs to become active again. As a prophylactic measure 
 
 128 
 
THE PREVENTION OF INFECTIOUS DISEASES 
 
 against tuberculosis in the adult, it is necessary there- 
 fore that scrofula in childhood should be perfectly 
 cured. Whenever possible tuberculous foci should be 
 completely removed from the body by operation ; caseous 
 lymphatic glands must be carefully and completely 
 excised, caries of bones must be thoroughly cured by 
 prolonged treatment with iodoform. Not rarely we see 
 children, and even adults, going about with suppurating 
 fistulous openings connected with different bones, with 
 caries of the petrous bone and of the auditory ossicles, and 
 yet these children have not for a long time been under 
 medical treatment. In connexion with this subject, 
 Penzoldt has recently shown how important it is in the 
 treatment of pulmonary tuberculosis to inquire carefully in 
 every case for external manifestations of tubercle and to 
 cure these first. The gums and tonsils and the mucous 
 membrane of the nose and throat are now regarded as very 
 important localities for the development of tuberculosis of 
 the lungs. Primary tuberculosis occurs in these places much 
 more often than was formerly believed, and thence infection 
 of the lungs often follows. This opinion is however not 
 held by all authorities : thus Moritz Schmidt considers that 
 these affections of the nose and throat are secondary to 
 pulmonary tuberculosis, and only very rarely primary. 
 
 The knowledge of the frequent connexion between 
 pulmonary tuberculosis and earlier tuberculous afi^ections of 
 lymphatic glands, bones and other organs, should make us, so 
 far as prophylaxis is concerned, regard all who have had 
 such affections in youth as predisposed to tuberculosis, and 
 they should take as much care to guard against a fresh 
 infection as those who are especially predisposed to pul- 
 monary tuberculosis. It is therefore necessary in prophy- 
 lactic treatment to classify more carefully the individuals 
 who, according to medical experience, have this predis- 
 position to pulmonary tuberculosis. There are first of all 
 those who are hereditarily tainted. Modern bacteriologists 
 deny that this hereditary predisposition has any important 
 influence upon the development of pulmonary tuberculosis ; 
 but the experience of centuries proves the powerful 
 
 129 K 
 
THE PREVENTION OF DISEASE 
 
 influence which heredity has upon the development of 
 tuberculous disease. Bat the opinion formerly held that 
 tuberculous infection may be directly inherited is not 
 correct : infection of the child by germs in the spermatozoa 
 or ovum does not occur. Direct placental infection of the 
 child when the mother has tubercular disease of the gene- 
 rative organs is possible, but is so extremely rare that we 
 need not consider it. The predisposition alone is inherited ; 
 this consists not only in the configuration of the thorax but 
 also in the degree of functional activity of the organs, which 
 seems to us to be generally independent of their anatomical 
 structure, and in the entire conformation of the body which 
 makes it a suitable nidus for the bacilU. By whatever 
 words we express this kind of predisposition, it remains 
 true that we do not perfectly understand the nature of 
 hereditary predisposition and cannot yet refer it to any 
 obvious lesion. The term " general weakness " has been 
 used to designate it, but if by this we mean general 
 weakness of the muscular system and decrease of the 
 functional activity of the body, then the term does not 
 cover all cases of hereditary predisposition, because some 
 individuals who are muscularly strong and active also 
 become affected with tuberculosis. A large number of 
 individuals who are predisposed to tuberculosis have the 
 so-called " phthisical constitution," that is the body is 
 obviously of slight muscular power ; but this phthisical 
 constitution may be present though no case of tuberculosis 
 has occurred in the family. The chest is long narrow and 
 flat, the intercostal spaces are wide and deep, the neck is 
 long and thin ; the muscles are mostly poorly developed, 
 especially those of the chest and back, so that the shoulder 
 blades often stand out like wings and the ribs and clavicles 
 are very clearly seen. Formerly much stress was laid upon 
 the estimation of the " vital capacity " of the lungs, and it 
 was thought that the respiratory capacity in individuals 
 with a phthisical constitution was so greatly reduced as to 
 be an important aid to diagnosis. These measurements 
 have not proved to be of much value in practice. These 
 individuals are also of pale colour, the lips and the con- 
 
 130 
 
THE PREVENTION OF INFECTIOUS DISEASES 
 
 junctivse are only slightly red, they are light in weight, and 
 have little power of resistance against bad weather and over- 
 exertion. 
 
 A predisposition to tuberculosis is also left by several 
 other diseases, not it would seem because of any special 
 weakness left by the disease, otherwise all weakening dis- 
 eases would leave such predisposition ; but rather we must 
 assume because the constitution of the lymph and of the 
 blood after these illnesses favours the implantation of the 
 tubercle bacillus. In children pulmonary tuberculosis often 
 follows measles and also whooping cough ; so during and 
 after these illnesses special care must be taken to guard 
 such children against infection by the precautionary 
 measures enumerated above, and above all by cleanliness of 
 their hands, faces and surroundings. Syphilis in children 
 and in adults increases the predisposition to tuberculosis, 
 so too possibly does influenza; and according to Jiirgensen, 
 also catarrhal pneumonia. After catarrhal pneumonia it is 
 most essential to develop the respiratory muscles and to 
 order a long stay in the country. Those suffering from 
 diabetes are specially prone to develop tuberculosis. Just as 
 colonies of tubercle bacilli flourish more luxuriantly in a 
 nutritive medium containing sugar, so too the growth of 
 the bacilli in the human body seems to be favoured by an 
 increased amount of sugar in the lymph and blood ; one 
 fourth of those who suffer from diabetes are said to die of 
 phthisis (Gr. See). 
 
 In another way certain other affections may also increase 
 the predisposition to tuberculosis by reducing the power of 
 resistance of the epithelium, for instance abrasions afford a 
 passage for the infection. To this category belong the 
 catarrhs of the upper respiratory passages, especially 
 chronic bronchitis and pharyngitis and laryngitis. Also 
 inability to breathe through the nose by reason of swollen 
 turbinates or adenoid vegetations, so that the air fails to be 
 filtered by passing through the nose. And further certain 
 occupations predispose to tuberculosis because the inhalation 
 of sharp particles causes lesions in the bronchial mucous mem- 
 brane ; for example the occupation of workers in stone, glass 
 
 131 
 
THE PREVENTION OE DISEASE 
 
 grinders and file cutters. Infection will then readily occur 
 through intercourse with phthisical patients or through a 
 prolonged stay in crowded rooms where phthisical patients 
 have expectorated. 
 
 All individuals belonging to these classes with a special 
 predisposition to pulmonary tuberculosis need regular and 
 thorough preventive treatment as a prophylaxis against 
 infection as detailed above. But they must also be guarded 
 against all injurious influences which tend to lower the 
 resisting power of the body. The patient often tells the 
 physician that the illness began after a cold, after some 
 over-exertion, or after some accident. Medical observation 
 has shown that such accidental causes not rarely 
 determine the outbreak of tuberculosis, especially when 
 predisposition to it is present. Among these accidental 
 causes are colds, injuries, physical and mental over-exertion, 
 mental depression, alcoholic and venereal excesses. The 
 tendency to taking cold must be combated by regular 
 methodical treatment which hardens the body, and the 
 individual's occupation and mode of life should be so far as 
 possible such as to prevent exposing the body and mind to 
 great changes of condition. Every kind of excess must be 
 absolutely forbidden to such patients ; no alcohol should be 
 allowed except a little beer or wine, no tobacco, and modera- 
 tion in sexual intercourse should be enjoined. Measures 
 should be adopted to improve the general condition of the 
 body and thus at the same time reduce the predisposition to 
 the disease. Great care is required in the matter of diet : 
 thin and weak individuals should have good and appropriate 
 food to increase their body weight ; they should have fresh 
 air in their rooms and be much out in the open air. 
 Breathing exercises should be regularly practised out of 
 doors — deep inspiration. and expiration with intervals, the 
 chest being free. Moderate exercise also, according to the 
 state of each individual, should be taken, and possibly 
 moderate exercise on horseback. In bad weather the 
 exercises should be performed indoors with open windows. 
 
 If it is conceded that tuberculosis generally attacks the 
 apex of the lung because the respiration and the circulation 
 
 132 
 
THE PREVENTION OE INEECTIOUS DISEASES 
 
 are less vigorous at the apex than in the rest of the Inng, 
 then it is important in prophylactic treatment to see that 
 the apices of the lungs are well ventilated by deep inspira- 
 tion while the shoulders are kept low. So often one sees 
 young people during their growth in a faulty attitude, with 
 the head and neck bent forward and the shoulders high ; 
 this position interferes more or less with respiration at the 
 apices of the lungs, and special attention should therefore 
 be given to the attitude. The preventive measures with 
 regard to the care of the body and mind are similar to those 
 required in the treatment of tuberculosis. 
 
 Authorities rightly insist upon the necessity of preventive 
 treatment of tuberculosis, and the physician ought not to wait 
 until he discovers an impaired note at the apex of the lung, 
 or hears rales, or till the discovery of tubercle bacilli with 
 the microscope makes the suspected diagnosis of tuberculosis 
 a certainty, before he begins to treat the patient hygien- 
 ically and dietetically. Hygiene and diet are nowhere so 
 important as in these pale thin youths and young girls with 
 shallow respiration, whose poor appetite and small amount 
 of strength are a constant source of anxiety to their friends, 
 especially when there is consumption in the family. These 
 individuals must not be sent away by the physician, the 
 anxious parents merely being told that there is nothing 
 absolutely wrong with the lungs and that there is no need 
 for anxiety. Although the lungs are not yet attacked, 
 the friends should be urged to do everything possible to 
 strengthen the weak body and make it more capable of 
 resisting disease. The public fully understand and appre- 
 ciate the endeavours of the physician to guard against the 
 disease. The prophylaxis of tuberculosis is closely related 
 to early diagnosis, and early diagnosis is included in 
 prophylaxis. We are not now referring to symptoms of 
 catarrh at the apices, haemoptysis, progressive loss of flesh, 
 night sweats, fever, which even when no bacilli are found 
 in the sputum often sufS.ce for the diagnosis ; we are 
 referring rather to other symptoms which make us suspect 
 commencing phthisis though there is no evident disease at 
 the apices and which should cause us to prescribe prophy- 
 
 133 
 
THE PREVENTION OF DISEASE 
 
 lactic, hygienic and dietetic treatment. These symptoms 
 are general ones and do not specially point to any local 
 disease of the lungs. Thus in commencing phthisis, long- 
 before any certain signs of the disease appear, we may find 
 persistent derangement of the gastric functions, loss of 
 appetite, a feeling of satiety after having taken only very little 
 food, pain after eating, in general the symptoms of nervous 
 dyspepsia which when they appear at an early age in one 
 predisposed to tuberculosis by heredity or by his bodily 
 constitution, should always draw the physician's attention 
 to the lungs. On the other hand when there is a good 
 appetite and good digestion, and yet in spite of rest and care 
 the patient does not put on weight but even loses weight, 
 suspicion of phthisis should again be aroused. Cardiac 
 disturbance may at the same time be present : there may 
 be increased frequency of the heart's beat even when the 
 patient is at rest, there may be palpitation, or the patient 
 gets quickly tired from running or going upstairs, there is 
 a feeling of lassitude, decrease of muscular power and 
 disinclination to activity. The heart is often irritable, and 
 slight muscular exertion or ordinary mental influences at 
 once cause great increase of the heart's action with a small 
 weak pulse. The apex beat often extends farther to the 
 right or left than is usual, it is strong and forcible, and 
 contrasts with the weak pulse. In the early diagnosis of 
 tuberculosis note must be taken too of recurrent attacks of 
 hoarseness which quickly pass away ; no change can as a 
 rule be detected by the laryngoscope, it seems to be due to 
 purely nervous influences. In other cases a true catarrh of 
 the larynx and pharynx which is very obstinate and 
 readily recurs is the initial symptom of pulmonary tuber- 
 culosis. These signs have nothing to do with genuine 
 laryngeal tuberculosis, and this is also true of the peculiar 
 anaemic condition of the laryngeal mucous membrane, 
 especially noticeable near the epiglottis ; this striking 
 degree of pallor is said to be caused by atrophy of the 
 mucous membrane which makes the muscles of the larynx 
 unusually prominent (Roe). Many regard this anaemic 
 condition of the larjaix as of early diagnostic value. 
 
 134 
 
THE PREVENTION OF INEECTIOUS DISEASES 
 
 In very doubtful cases use may be made of the tuber- 
 culin test to establish an early diagnosis, but though, this 
 method has been highly recommended it has not yet been 
 introduced into practice, probably because it requires care- 
 ful observation of the patient during several days such as 
 is generally possible only in a hospital. For two days 
 before the inoculation the patient's temperature should be 
 taken regularly every two hours, in order to ascertain what 
 is the normal condition. The patient is then inoculated 
 with one milligram of tuberculin. Most are agreed that 
 the old tuberculin is preferable to the new. After inocula- 
 tion the temperature is again taken every two hours, and 
 reaction usually appears eight to sixteen hours after inocu- 
 lation. If there is no reaction the patient should be 
 inoculated a few days later with three milligrams of tuber- 
 culin, and if necessary again later with six milligrams. 
 If there is still no reaction we may be tolerably certain 
 that there is no tuberculosis (Cornet). In some cases, even 
 though there is no rise of temperature, inoculation helps us 
 to make a diagnosis, because catarrhal signs at the lung 
 apices become manifest, owing to increased exudation at the 
 places where tuberculous processes are going on. Moreover 
 when there is a positive febrile reaction, it does not neces- 
 sarily point to a diagnosis of pulmonary tuberculosis, but 
 only to the presence of a tuberculous focus somewhere in 
 the body. 
 
 The question of marriage of tuberculous patients about 
 which the physician is often consulted, is of special 
 significance in connection with prophylaxis. The question 
 as regards the effect upon any offspring of the marriage 
 may be put altogether on one side, as it is probably never 
 taken into consideration by those who want to marry. We 
 need consider only the tuberculous partner in the marriage 
 and the healthy one. If the disease has existed for a long 
 time and is progressing the physician will absokitely forbid 
 marriage, not only for social reasons but also because 
 experience proves that such patients get rapidly worse after 
 marriage. 
 
 In the initial stage of pulmonary tuberculosis, no general 
 
 136 
 
THE PREVENTION OF DISEASE 
 
 rules can be laid down as to giving medical permission 
 to marry. It is wisest in all sucli cases first to try to 
 cure the disease ; and this is best done by placing the tuber- 
 culous patient in a sanatorium for consumptives. A patient 
 who is so far improved that he has had no pulmonary signs 
 for two years and who is in a good state of nutrition may be 
 allowed to marry. Medical experience has shown that a 
 phthisical woman is exposed to great dangers by marriage ; 
 pregnancy and parturition often cause very rapid aggrava- 
 tion of the disease. The physician must therefore be even 
 more careful in granting consent to marriage to a tubercu- 
 lous woman than to a tuberculous man, and should never 
 give it till he has first tried to cure the disease. For the 
 sake of the healthy one too, the physician should withhold 
 consent to marriage with a phthisical person. Cornet's sta- 
 tistics show that double tuberculosis in marriage occurs in 
 twenty-three per cent, of the cases, and though we cannot 
 in all the twenty- three per cent, attribute the double tuber- 
 culosis to infection of the sound partner in married life by 
 the diseased partner, yet a number of medical observations 
 leave no doubt that infection through marriage is possible. 
 Those who wish to marry should be told of this danger by 
 the physician. 
 
 136 
 
The Prevention of the Diseases of the 
 Lungs 
 
 By dr. RICHARD ROSEN 
 
 137 
 
The Prevention of the Diseases of the 
 
 Lungs 
 
 The consideration of tlie prophylaxis of the diseases of the 
 lungs, of the heart and of other organs separately is not in 
 accord with the division into "infective diseases" and 
 " constitutional diseases." It is merely the old method of 
 grouping diseases according to the organ affected, and may 
 be retained as useful in describing the prophylactic treat- 
 ment, though not in accord either with aetiology or path- 
 ology. For example, in bronchitis the invasion by bacteria 
 is no less important as regards aetiology than it is in 
 "infective disease" ; it is moreover no purely " local" disease, 
 but nearly always has general symptoms, as does an 
 " infective disease." Nevertheless in bronchitis and other 
 affections classed as " pulmonary diseases," the local dis- 
 turbances are upon the whole by far the most important 
 symptoms, and the old classification is therefore justified. 
 For the prophylaxis of pulmonary diseases, external 
 injurious influences must be avoided and attention must 
 obviously be given to the condition of the air, because it is 
 the element which comes most closely into contact with the 
 lungs, and because meteorological changes react upon the 
 lungs. Indeed from time immemorial the instincts of the 
 people have caused them to attach great importance to 
 changes in the weather in the causation of pulmonary 
 disease. The effect of air upon the lung is twofold : first, 
 there is a direct effect depending upon respiration ; but the 
 breathing of air under varying conditions is not the chief 
 causative factor of disease, because before it actually 
 reaches the lung it has been modified by the natural 
 protective processes. Indirectly however atmospheric 
 
 139 
 
THE PREVENTION OF DISEASE 
 
 changes do cause disease of the lungs, through their action 
 upon the skin. In former times cold was stated to be the 
 cause of disease in far too great a number of cases, and 
 further knowledge has shown that many diseases formerly- 
 attributed to cold owe their origin to bacterial infection. 
 But in diseases of the air passages cold has maintained its 
 footing and is considered of importance aetiologically ; and 
 it makes no real difference that bacteria assist the cold in 
 the production of the disease. 
 
 The many theories about the nature of a "cold" (Rosen- 
 thal, Lode, etc.) none of which adequately explains the 
 phenomena, will not here be further discussed. It seems 
 however to be certain that chilling of a large surface of the 
 body is not always necessary for a cold, but that the cold 
 may be caused reflexly : a very brief action of cold upon a 
 limited part of the body will reflexly produce very con- 
 siderable changes in the distribution of blood to the internal 
 organs, which may lead to circulatory obstruction at 
 definite spots. This hyperaemia is a factor which 
 makes disease possible. We may assume that there is 
 then diminished power of resistance in the cells which 
 enables bacteria to get into the tissues ; but the whole 
 process is not made more intelligible to us by this assump- 
 tion. In different individuals again the locus minoris 
 resistentiae is different ; in some cases it is always one 
 and the same spot which becomes affected by the same 
 injurious influence, a cold. Experience shows that getting 
 wet through often causes a cold, especially when the body 
 does not continue in activity. A cold may also be caused by 
 sudden changes of temperature, whether an atmospheric 
 change — for instance after sunset at the seaside in the 
 height of summer — or a change through going out of a 
 heated house in the winter without sufficient clothing. 
 Damp cold abstracts even greater heat from the body and is 
 particularly liable to give a cold, and since in our latitude 
 the transition months from winter to summer and summer 
 to winter are accompanied by many changes in temperature 
 and moisture, diseases caused by cold are very common at 
 these times, as is proved by many statistics. 
 
 140 
 
THE PREVENTION OF DISEASES OF THE LUNOS 
 
 In Germany the commonest locus minoris resistentiae for 
 colds is the mucous membrane of the air passages, and there- 
 fore catarrhs of the bronchi and of the trachea are very 
 common diseases. The predisposition to bronchitis is general, 
 even robust natures are not free from it, although usually 
 weak anaemic people are more susceptible to it (Riegel), 
 Bronchitis is apt to appear at every period of life, though 
 the mortality is particularly great in childhood. 
 
 Bronchitis is so common that prophylactic measures are 
 indicated for all, particularly when we remember that a 
 large number of pulmonary diseases are often the result of 
 bronchitis — not only chronic forms of bronchitis, but also 
 emphysema, catarrhal pneumonia, capillary bronchitis, 
 pulmonary collapse, and lastly though not so obviously 
 bronchial asthma. It follows therefore that the prevention 
 of bronchitis is at the same time the prevention of a large 
 number of other pulmonary diseases, and to a certain 
 extent also of pulmonary tuberculosis. 
 
 Geigel was the first to point out that during the first 
 year of life more legitimate children die of respiratory 
 diseases than illegitimate children, though the converse is 
 true for deaths from digestive troubles ; and he explains 
 it by the fact of the greater coddling of legitimate 
 children. Many objections may be raised to Greigel's con- 
 clusion, yet it is supported by the fact known to all, that 
 coddhng often leads to bronchitis and to other diseases as 
 a consequence of taking cold, and that bracing the skin is 
 the best protection against taking cold, and therefore also 
 against bronchitis, which is the most common result of the 
 cold. Children in their first year of life and very old people 
 may, to a great extent, be directly protected against such 
 injurious influences if they remain in warm ventilated 
 rooms when the weather is bad, or very windy, or damp 
 and cold. With most people such prophylactic measures 
 are naturally not practicable, they are obliged to go out in 
 all weathers. Those who are able to take such precautions 
 and who know by experience that a particular state of the 
 weather readily gives them cold, should be urged to guard 
 against such direct influences so far as possible. Others 
 
 141 
 
THE PREVENTION OF DISEASE 
 
 must be directed to wear suitable clothing according to the 
 weather and the principles of hygiene. 
 
 Recently dress material has been manufactured which is 
 impregnated with substances to make it waterproof, but 
 the impermeable material causes a retention of vapours 
 given off by the skin, which is disagreeable and will 
 prevent this material from being extensively used. 
 
 For the large majority therefore the most valuable 
 preventive measure against bronchitis is to harden the skin, 
 that is to accustom it to the most diverse conditions of the 
 weather. Through his dress and by constant living in rooms, 
 the civilized man seems to have lost the power which his 
 skin possessed, in common with that of animals and of 
 uncivilized races, of reacting promptly to the various 
 changes of temperature by different degrees of contraction. 
 This function of the skin is merely a question of practice, 
 in the same way as the functional activity of all other 
 organs is brought about in response to various demands 
 made upon them. For this reason the countryman is upon 
 the whole more robust than the town dweller ; the country- 
 man's skin is exercised from his youth and is therefore har- 
 dened and needs no special artificial methods. The town 
 dweller on the other hand gets too little away from the 
 even temperature of his room, and the streets moderate 
 considerably the power of the wind. Yet an atmosphere 
 which is in movement deprives the body of more heat than 
 a calm atmosphere, even though the latter be colder. The 
 town dweller gives his skin too little practice as an organ 
 which regulates the heat of the body, and if he exposes 
 himself to any great change of atmosphere, to a wetting or 
 similar influence, the compensatory activity of the skin 
 fails him. 
 
 For this reason the skin should not from the very 
 earliest years be too anxiously protected from coming into 
 direct contact with the atmosphere; the dress should be 
 porous and not too much in quantity. Lately more 
 attention has been given to the matter, and it is taught 
 that children should, from their earliest youth, not be kept 
 too warm ; that binders should not be used, that bed cover- 
 
 142 
 
THE PREVENTION OE DISEASES OF THE LUNGS 
 
 ing in the summer should be simple, a blanket and sheet, 
 and in the winter a moderately thick eider-down quilt ; 
 and the child should not lie upon a feather bed. The 
 bedding of adults is liable in general to be far too much, 
 and so too the clothes they wear. A physician has many 
 opportunities for observing this. No small number of men 
 wear a woollen vest under the linen shirt in summer, much 
 the same indeed as they wear in winter, and they wear it 
 for fear of catching cold. Indeed they would take cold if 
 one day they suddenly altered their habit and left off the 
 woollen vest. Through coddling their skin has lost its com- 
 pensatory power. This is not the place to discuss in full 
 the question of dress, and we shall merely point out the 
 necessity of avoiding from youth up the wearing of too 
 many clothes. In the summer linen underclothing and a 
 light woollen or cotton suit over this is sufficient ; in the 
 winter a thicker under garment should be substituted, or 
 perhaps two thinner ones. It is impossible to give rules for 
 dress which are suitable for all. Weak anaemic people require 
 more clothes than the robust. The one-sided " dress 
 systems" advocated by some apostles of health are not based 
 upon scientific principles, nor are they of practical value for 
 all. It is important that physicians should concern 
 themselves more with the dress of patients and its suit- 
 ability. G-reat mistakes are made about clothing, and it is 
 most essential that a beginning should be made in the very 
 earliest years to strengthen the skin. 
 
 With clothes we introduce something which is artificial 
 into the domain of nature, and the natural function of the 
 skin is restricted from the very outset. To remove the 
 effect of this disturbing element in the economy of nature, 
 it is desirable to use some counter-effect upon the skin and 
 to subject it systematically to the stimulus of cold for brief 
 periods, and cold water is best adapted for this purpose. 
 Cold water produces a powerful contraction of the cutaneous 
 vessels, and when afterwards the skin is well rubbed or the 
 body is exercised, the vessels dilate and a feeling of well- 
 being and of warmth pervades the whole body. This cold 
 water procedure should bo gone through daily, best in the 
 
 143 
 
THE PREVENTION OF DISEASE 
 
 morning after getting up, and should be commenced in the 
 first year of life. In this way the activity of the skin is 
 stimulated, and it reacts promptly to the stimuli of changes 
 of temperature to which it may be exposed. If children 
 are fairly strong, one may begin a few weeks after birth, 
 and pour cool water over them after the daily warm bath. 
 Children are generally bathed in water which is much too 
 hot : the bath water should never be above 95° F. A bath 
 thermometer is too seldom used in the nursery : the heat of 
 the water is judged by the hand or the elbow, and the result 
 is that the temperature is frequently too high. A differ- 
 ence of only two degrees in the heat of the bath water will 
 make a very great difference in the effect of the bath upon 
 the body. Baths at a higher temperature than 95° F 
 generally stimulate strongly and are followed by exhaustion, 
 and should therefore as a rule be avoided. After the first 
 months the bath temperature is gradually reduced for 
 children from 95° F to 93° and 90° F ; the bath should not 
 last longer than five or ten minutes. After the bath cooler 
 water should be poured over the child and the skin be well- 
 rubbed. Later, in place of the daily bath, the whole body 
 should be rubbed down daily with a rough towel dipped in 
 •cold water and then rubbed dry. Warm baths with the 
 addition of aromatic substances, and brine baths, are no 
 longer so much in vogue for children as formerly ; the 
 increased metabolism which one hoped to bring about in 
 anaemic and scrofulous conditions often did not appear. 
 Rubbing down with water, gradually colder and colder, is 
 now preferred (Heubner), as its stimulating effect is found 
 to be greater. Lukewarm brine baths of short duration, at 
 intervals of a few days, may be used with advantage, but 
 should always be followed by the pouring of cold water 
 over the body. 
 
 If a commencement has thus been made in early youth 
 in hardening the body, cold water applications will be well 
 borne all through the year and should be daily practised 
 even in winter — cold rubbing down of the whole body, cold 
 douches, cold baths, or possibly only cold sponging one part of 
 the body. In his Recollections of an Old Physician^ Kuss- 
 
 144 
 
THE PREVENTION OF DISEASES OF THE LUNGS 
 
 maul narrates in a most interesting manner how as a young 
 country practitioner he suffered much from colds, and how 
 he made his body, which was weak and very sensitive to 
 changes of the weather, quite weatherproof by washing his 
 feet with cold water every evening shortly before going to 
 bed ; and from that time till the present he has never had 
 a cold. 
 
 This shows that even when measures to harden the body 
 have been neglected in youth, it is still possible later and in 
 adult life to harden the body by the action of cold water, 
 but it must then be undertaken with greater caution, must 
 not be begun in winter, and the measures must not be too 
 vigorous and the water not too cold at first. 
 
 There are people who are particularly susceptible to a 
 chilling of some one part of the body, who cannot go out of 
 doors with the head uncovered without taking cold, and 
 who have always to wear a neckerchief, or chest protector, 
 or abdominal belt, or mittens, or gaiters, to keep themselves 
 in good health. All these are coddling ways which could 
 generally be done away with if the body were properly 
 hardened. Moritz Schmidt says it is astonishing to see how 
 many people coddle and weaken their bodies in the most 
 terrible way, although they know and see the obvious 
 advantages possessed by one who is robust ; it is probably 
 because the sensation of warmth is pleasanter than that of 
 cold ; but when once the body is hardened the cold will no 
 longer be felt to be unpleasant. 
 
 However there are individuals who have some real 
 locus minoris resistentiae and who would at once become ill if 
 they neglected the ordinary precautions they have been 
 accustomed to take. This must be specially considered in 
 the case of old people, and it would be altogether wrong to 
 proceed with measures to harden the body regardless of this. 
 In such case the wearing of flannel next the skin is a good 
 protection against changes of temperature, and it may be a 
 flannel under-garment covering the whole body, or a flannel 
 binder, cloth or wrap to be applied to that part which is 
 known to be specially susceptible. The feet are often the 
 most susceptible parts, as they are farthest from the heart 
 
 145 L 
 
THE PEEVENTION OF DISEASE 
 
 and the circulation there is most feeble. Many people suffer 
 constantly from cold feet which are either moist or dry ; 
 and these cold feet are often a cause of bronchitis which in 
 such cases soon becomes chronic and will not be cured till 
 the original cause has been removed. We have known 
 many chronic irritative conditions of the tracheal and 
 bronchial mucous membrane cured by simple directions 
 about changing the stockings once or twice a day, 
 and proper care of the feet, by means of baths and rubbing 
 with a spirit lotion and so on. All physicians know how 
 negligent and careless about their body the large number of 
 people are, and that a doctor has to ask searching questions 
 about all the details of the bodily functions ; till then a 
 patient often does not know that some part of his body is 
 not acting normally, because he has no pain. And often he 
 has not noticed that his feet are damp and cold until the 
 doctor puts the question to him. One should not neglect to 
 advise weak and susceptible persons to be careful to wear 
 galoshes in rainy weather ; often too it is useful to wear 
 soles inside the boots, which are made of some material that 
 is not a good conductor of heat. 
 
 The air in inspiration is brought into direct contact with 
 the air passages, and faulty physical or chemical conditions 
 of the atmosphere may cause disease : for the prophylaxis of 
 these diseases the condition of the air inspired must be 
 normal. This subject is really a part of general hygiene : 
 it is concerned with the methods for regulating the con- 
 dition of the air in rooms ; the removal of certain gases and 
 vapours generated in various industries, which if breathed 
 would lead to severe acute or chronic pulmonary affections ; 
 the prevention of excessive quantities of dust in the air of 
 workshops, which in the case of mineral dust would 
 gradually lead to extensive injuries of the pulmonary tissue 
 — for instance siderosis and chalicosis; and the measures 
 which would protect the workmen against the dust. 
 
 The nose is a natural protection against the usual 
 oscillations in the condition of the air, variations in tem- 
 perature and amount of moisture and dust ; and it is most 
 essential in the prophylaxis of diseases of the lungs that 
 
 146 
 
THE PREVENTION OE DISEASES OF THE LUNGS 
 
 this nasal function be normal. The nose in its natural 
 condition has an important function to perform in respira- 
 tion, and deviations from the normal condition soon lead to 
 diseases of the air passages. 
 
 Normally the nose prepares as it were the air for the 
 lungs, saturates the air with moisture — at least this is the 
 view held by most authorities — and warms it almost to the 
 temperature of the body. Aschenbrand and Bloch found 
 that the air was warmed up to 86° F. whatever the 
 temperature of or amount of moisture in the external air. 
 Normally too the nose removes all impurities from the air, 
 retaining dust and micro-organisms on the moist mucous 
 membrane of the meatus ; and some are prevented from 
 entering by the vibrissse at the nostrils. Abnormal internal 
 conditions will be occasioned by any deviations from the 
 normal of the air which has reached the lower part of the 
 respiratory tract. Obstruction of the nasal passages by 
 polypi, swelling of the turbinates, adenoid growths and 
 similar affections will more or less limit nasal respiration, 
 and oral respiration becomes necessary. But oral respiration 
 cannot permanently take the place of nasal respiration 
 because the mucous membrane of the mouth and throat soon 
 gets dry, as everyone knows who has had to breathe through 
 his mouth when suffering from a nasal catarrh, particularly 
 in a dry heated room. After tracheotomy too the air has 
 to be kept permanently moist by artificial means. Dust 
 and other injurious particles are not filtered from the air by 
 oral respiration, and for this reason the trachea and bronchi 
 soon become affected. Though there is no obstruction to 
 the passage of the air through the nasal cavity, yet if the 
 mucous membrane of the nose is affected and unable to 
 perform its normal function of preparing the air, especi- 
 ally in chronic atrophic conditions of the membrane, the air 
 is then not properly prepared and reaches the deeper air 
 passages in too dry a state, and the result is again bronchitis. 
 The normal nasal mucous membrane alone has the mar- 
 vellous capacity of compensating for differences in the degree 
 of warmth and of moisture by reflexly regulating the blood 
 supply of the mucous membrane over the turbinate bones. 
 
 147 
 
THE PREVENTION OF DISEASE 
 
 In the prophylaxis of bronchial affections much attention 
 must be given to the condition of the nose. Nasal affections 
 must not be regarded as purely local disturbances, but in 
 view of the important part played by the nose in respiration 
 should also be regarded as important factors in the pro- 
 duction of serious and generally chronic affections of the 
 lower respiratory passages. Diseases of the nose should 
 therefore be treated early. There is a reflex action between 
 the nasal mucous membrane and the mucous membrane of 
 the finer bronchial tubes, and for this reason too it is an 
 important prophylactic measure to keep the nose in a 
 normal condition. B. Frankel and Voltolini were the first 
 to point out that some cases of bronchial asthma are 
 connected with affections of the nasal mucous membrane, 
 more particularlj^" with polypi of the nose and throat ; for 
 when the polypi were removed, the attacks of asthma 
 ceased, but recurred when the polypi grew again. What- 
 ever may be our theory about bronchial asthma, whether 
 we incline towards Biermer's view and regard contraction of 
 the muscular elements of the bronchi as the essential cause, 
 or whether towards Weber's, and think the essential cause 
 is the swelling of the bronchial mucous membrane through 
 dilatation of the vessels and subsequent exudation, never- 
 theless it is probable that central nervous influences are the 
 main cause, and that the nasal affection can act as the 
 exciting cause of the central irritation. So that removal of 
 polypi and other affections of the nose may be regarded as a 
 prophylactic against asthma. 
 
 The maintenance of the natural elasticity of the lungs or 
 the prevention of emphj^-sema is another important object 
 for prophylaxis. Pulmonary emphysema is one of the 
 most frequent pathological conditions. Not only is there the 
 primary essential emphysema, but secondary emphysema 
 sooner or later is liable to develop after all diseases of the 
 lungs. In certain chronic pulmonary affections and in 
 whooping cough in children we should always remember 
 to take measures to prevent emphysema ; such precautions 
 are specially needed in illnesses accompanied by violent and 
 long continued attacks of coughing, such as occur in many 
 
 148 
 
THE PEEVENTION OF DISEASES OF THE LUNGS 
 
 forms of chronic bronchitis and pleural affections. Traube 
 teaches that the chronic dry bronchitis of the finer 
 bronchial tubes readily leads to emphysema, less so the 
 chronic bronchitis accompanied by copious expectoration 
 and large sized rales. By the forced efforts of expiration 
 the pressure in the thorax is so greatly increased that the 
 counter pressure exerted by the auxiliary expiratory 
 muscles of the thorax is not sufficient to compensate for the 
 increase ; the alveoli then yield to the pressure and become 
 distended. Frequent repetition of this distension in course of 
 time leads to the disappearance of the alveolar interstices, 
 characteristic of emphysema. For these reasons, as well as 
 for others, measures should be taken to prevent those 
 violent paroxysms of coughing, which are particularly 
 common in so-called "dry coughs" — either by sedatives, 
 by the avoidance of all causes that are known to set up 
 coughing, by residence in a suitable climate, possibly in a 
 southern climate, or by other means which the physician 
 may find necessary for any special case. 
 
 Some callings predispose to emphysema of the lungs, 
 namely those which require prolonged and excessive respira- 
 tory ejfforts, such as the playing of wind instruments or 
 blowpipe work ; packers and porters often get emphysema, 
 as the continuous strain due to the heavy work is in 
 addition to the compression of the chest, and the expiration 
 of the air in the lung, which is at a greater pressure than 
 normal, is prevented. Occasionally emphysema comes on 
 somewhat suddenly in healthy people after some un- 
 accustomed great overstrain, especially when in addition 
 there is a predisposition to emphysema brought on by any 
 of the callings mentioned above ; it may set in after lifting 
 a heavy weight, after excessive exercise, such as cycling, 
 rowing against the wind, or wrestling. Prophylaxis 
 naturally requires that all unaccustomed overstrain should 
 be avoided which would make excessive demands upon the 
 activity of the lungs. Yet as in the case of other organs, so 
 too with the lungs, exercise is a valuable means of keeping 
 them sound, and when an increased demand is made upon an 
 organ, the organ which has not been exercised gives way, 
 
 149 
 
THE PREVENTION OF DISEASE 
 
 while one which has been exercised responds to the extra 
 demand and remains healthy. An hygienic mode of life by 
 exercising the lungs will preserve their elasticity, and 
 walking is good and deep breathing out in the fresh air, or 
 for the young gymnastics, out-of-door games, running and 
 sports in moderation. Barth has lately in a very interesting 
 work recommended singing as a preventive against diseases 
 of the lungs, it deepens the inspirations and increases the 
 exchange of gases, and it is at the same time good 
 gymnastic exercise for the lungs, which are thereby 
 accustomed to adapt themselves to considerable variations 
 in breathing. 
 
 To a certain extent the diseased lung also is able to adapt 
 itself to the demands made on it by developing increased 
 respiratory activity in those parts of the lung which are 
 still unaffected. This compensatory hypertrophy of the 
 healthy parts occurs when only small parts of the lung 
 become successively affected, and there is time afforded for 
 the healthy parts to adapt themselves to the demands made 
 upon them. There are cases in which the whole of one 
 lung has thus become useless, while the other lung has 
 remained healthy and sufficed for the needs of the body. In 
 cases of chronic bronchitis, fibrosis, collapse of the lung, and 
 pleural adhesions, the healthy lung tissLie that remains is 
 often sufficient only however when the whole body is at 
 rest or at the most only slightly exerted. The usual 
 result of these affections is the development of so-called 
 vicarious emphysema : the air is unequally distributed 
 through the lungs, and the normal pulmonary tissue is 
 exposed to greater pressure and gradually becomes dis- 
 tended. This vicarious emphysema develops the earlier the 
 greater the intra-thoracic pressure : that is, the more the 
 diseased condition is disregarded and the greater the 
 demands made upon the still healthy parts of the lungs. 
 In these chronic conditions where large parts of the lung 
 tissue are unable to act, the amount of work to be done 
 must be very carefully regulated and over-exertion avoided, 
 so that the increased functional activity of the normal parts 
 of the lung, even when the body is at rest, may not be still 
 
 150 
 
THE PREVENTION OF DISEASES OF THE LUNGS 
 
 furtlier increased and thus the development of emphysema 
 assisted. When the inflammatory processes have subsided 
 or have considerably improved, methodical respiratory 
 exercises are most valuable as a prophylactic, gradually to 
 increase the functional activity of the lungs. For this 
 purpose graduated walking exercise is of value, and also 
 going up and down stairs, a few stairs being added from 
 time to time, and other similar graduated exercises. 
 
 Prophylaxis of the various forms of so-called catarrhal 
 pneumonia is in the wider sense similar to the prophylaxis 
 of bronchitis, in so far as catarrhal pneumonia generally 
 follows bronchitis, and rarely occurs independently. It 
 follows therefore that when there is bronchitis, measures 
 should be taken to prevent catarrhal pneumonia. This 
 opens a wide field for prophylaxis, especially in the case 
 of children and old people in whom this form of pneumonia 
 frequently occurs. The way in which bronchitis in children 
 must be treated to prevent collapse of lung and the 
 development of pneumonia in these collapsed parts is dealt 
 with in the special section on the diseases of children. In 
 old people who for any reason have become bedridden, 
 hypostatic congestion is apt to cause the development of 
 bronchitis and broncho-pneumonia, and even lobar or so-called 
 hypostatic pneumonia. Similar conditions arise in patients 
 of any age when serious illness has confined them to bed for 
 a long time and when wasting and cardiac weakness are 
 present, so that the blood, obeying the law of gravitation, 
 sinks to the lower parts of the lungs. It is most often met with 
 in typhoid fever after the third week. The prevention of 
 hypostatic congestion in such cases requires careful nursing ; 
 the patient should not lie always on the back, other positions 
 should be adopted in turn, and when possible the prone 
 position is much to be recommended. Old people should be 
 propped up as often as possible and should be confined to bed 
 only so long as is absolutely necessary. Old people should 
 not for slight reasons be kept in bed, for experience shows 
 that it is very difficult for them again to leave it. The 
 patient should several times a day practise taking deep 
 inspirations, and whenever possible should sit upright for 
 
 151 
 
THE PREVENTION OF DISEASE 
 
 this exercise. If respiration is especially shallow and rapid, it 
 must be deepened and made slower reilexly through, stimuli 
 applied to the skin, such as cold sponging, perhaps lukewarm 
 baths followed by douching with cool water. It is also 
 useful to rub the patient with spirit liniments: a five per cent, 
 solution of menthol is the best. 
 
 Reference must here be made to serious pulmonary affec- 
 tions, such as bronchitis, bronchitis foetida, broncho-pneu- 
 monia and gangrene, caused by food particles getting down 
 the respiratory passages, and to the necessity of preventing 
 this in patients who are very ill by careful instructions to 
 the nurse. In feeding such patients the head must always 
 be supported in the nurse's left hand, while with her right 
 hand she gives food with a teaspoon. It is best to raise the 
 patient, because in the horizontal posture food is much more 
 easily drawn into the respiratory passages in inspiration. 
 The patient should at the same time be asked to swallow ; 
 the spoon, a teaspoon being best, should be carried as far 
 back as possible into the mouth and exactly in the middle 
 line. The sides of the food passage are very much more 
 sensitive to stimuli than the median parts, and if the food 
 does not pass along the median line but touches the sensitive 
 lateral walls, reflex movements are set up which carry the 
 food into the respiratory tract with inspiration. (Mendelsohn 
 and Gutzmann.) The more the body deviates from the 
 upright j)Osture towards the horizontal, the more easily, 
 especially in the case of fluids, will food leave the middle 
 line of the body and flow towards the sides. To give food 
 while the patient is in the lateral position is therefore 
 obviously wrong. 
 
 152 
 
The Prevention of Diseases of the Heart 
 
 BY 
 
 PROF. MARTIN MENDELSOHN 
 
 OF BEELIN 
 
 153 
 
The Prevention of Diseases of the Heart 
 
 HEAET LESIONS AND HEART WEAKNESS 
 
 A "cardiac lesion" becomes a disease directly the heart 
 is no longer able to fulfil completely at every moment of 
 life the demands made upon it which are essential for the 
 maintenance of the functional activity of the organism. 
 No other organ of the body can be considered to be similarly 
 circumstanced — for other organs when diseased or threatened 
 with disease may be rested and for a time saved from all 
 functional activity ; but this is not possible with the heart, 
 which has to act uninterruptedly and continuously from a 
 time long before the first breath is drawn until the last 
 moment of life. Any cessation of the heart's action would 
 mean cessation for ever. The heart then must act cease- 
 lessly during the whole of life ; it must also constantly keep 
 up a circulation which shall be adequate for all physiological 
 processes. This is the essential criterion of a clinically sound 
 heart and is indeed the only criterion. " Heart disease " 
 begins — no matter whether the heart has already undergone 
 anatomical changes or not — only when the functional 
 activity of the heart becomes inadequate ; and the sole 
 object of prophylaxis is to prevent such a condition of 
 functional inadequacy from setting in prematurely. 
 
 The prophylaxis of heart disease has two special features. 
 First, in those cases where there is already heart disease 
 in the purely anatomical sense, but in which the functional 
 activity of the heart has not yet fallen below the normal, 
 the aim must be to maintain this functional activity not- 
 withstanding the anatomical change: this is prophylaxis 
 not therapeutics. This cardiac lesion is not a disease until 
 
 155 
 
THE PEEVENTION OF DISEASE 
 
 the functional activity begins to be inadequate ; and to pre- 
 vent the development of disease in spite of the anatomical 
 changes which are present is in these cases one of the most 
 important objects of medicine, without which there would 
 only be a hopeless struggle against irreparable anatomical 
 changes in the muscle substance or the valves of the heart. 
 Prophylaxis during the development and course of a 
 disease is probably of wider application in heart disease 
 than in any other branch of internal medicine. And the 
 second special feature about heart disease is that the 
 measures which are useful in preventing the development 
 of functional disturbances are essentially much the same 
 for whatever form of heart disease they may be required ; 
 because, as already indicated above, the chief and most 
 important object of prophylaxis is not so much the possible 
 prevention of anatomical changes, as the maintenance of 
 normal functional activity in a heart which has already 
 undergone such changes. For this purpose the appropriate 
 prophylactic measures are the same whatever be the 
 anatomical lesion of the heart which has caused the 
 functional inadequacy. 
 
 The prophylaxis of heart disease rests then chiefly upon 
 regulating so far as j)Ossible the relation between the 
 functional demands made upon the heart and the functional 
 capacity of the organ. The aim of all internal therapeutics 
 indeed is an attempt to equalize the demands made upon an 
 organ and the functional activity of that organ at the same 
 time that the possible duration of life is not shortened : that 
 is to make the relation which exists between these two 
 magnitudes a fraction in which the numerator is equal to 
 the denominator ; and therapeutics fulfils its object just as 
 completely when, without ".ny ill effect upon the organ and 
 the whole body, it has tei wrarily or permanently reduced 
 the demands upon the or/ to its functional capacity, as 
 when on the other hand / succeeded in increasing the 
 
 functional activity thq/ le demands made upon the 
 
 organ are as great as ¥ "When a heart whose func- 
 
 tional activity is reducf nanently spared from some 
 
 of its work so that it / liently to meet the remain- 
 
THE PREVENTION OF DISEASES OE THE HEAET 
 
 ing demands made upon, it, therapeutics has completely 
 fulfilled its object, and considered from the standpoint of 
 prophylaxis has in this way prevented an anatomical affec- 
 tion from becoming a functional one, and a morphological 
 lesion from becoming a physiological disease. 
 
 The quantitative functional activity of the heart is made 
 up of two components : firstly, the minimum functional 
 activity required for the maintenance of an uninterrupted 
 circulation in the body, when that circulation is not made 
 more difficult or complicated by external or internal influences 
 of any kind whatsoever ; and secondly, a varying quantity 
 of functional activity required in addition to the former to 
 meet the demands of daily life. These demands result from 
 bodily and mental activity, or are the effect of external 
 stimuli or of internal stimuli due to bodily functions, and to 
 the overaction of organs which thus influence the distribu- 
 tion of blood, as well as of all the accidental occasional 
 demands made upon the heart. The former or minimum 
 of cardiac activity is approximately that of the heart during 
 sleep ; and this amount naturally cannot be reduced in any 
 way. But the second component includes a great amount 
 of work which may be reduced ; and though naturally, even 
 when patients' surroundings are most favourable, it is not 
 possible to remove entirely all such extra demands upon the 
 heart, yet a very large part of such demands may be 
 avoided ; and when this is carried out carefully and con- 
 tinuously and above all is done early and adequately, heart 
 disease may be entirely prevented : that is disturbances 
 of function may be prevented. This is the task of 
 prophylaxis ; and when we succeed in keeping a patient 
 who is suffering from mitral incompetence free from dis- 
 turbances of function till his eightieth year of life, the 
 defect of the valves may possibly have some interest for 
 pathologists, but the physician considers throughout the 
 patient's life only the diminished functional activity of the 
 heart ; and it was his duty to maintain the organism in its 
 normal functional condition in spite of the valvular 
 deficiency. Moreover the prophylactic measures required 
 are the same in any given case, whether the diminished 
 
 157 
 
THE PREVENTION OF DISEASE 
 
 functional activity of the heart is the result of any 
 valvular lesion or of some other diseased condition which 
 reduces the power of the heart muscle. 
 
 For every heart — for the healthy heart, and still more for 
 the heart predisposed by some heart lesion to the risk of 
 becoming incompetent — there is a maximum of total func- 
 tional capacity, up to which maximum work may be done 
 without injury to the heart. Of this total quantity a certain 
 greater or less amount of work is essential for the "vegeta- 
 tive " or " internal " work of the body. The less capable 
 and efficient the heart, the greater is the proportion of the 
 total work which is required for these internal functions, 
 and the smaller will be the proportion which remains for the 
 various other demands which may be made upon the heart. 
 The relation may be expressed in terms of political economy 
 as follows : when the general conditions of life have risen, 
 when prices have risen and everything in the market 
 becomes dearer, an individual who has the same fixed income 
 every year will be obliged to spend a considerably larger 
 amount of his yearly income upon the necessaries of life, 
 house, dress and food, and there will remain a smaller pro- 
 portion of income for luxuries. So long as a head of a 
 family restricts his expenditure upon luxuries to this surplus 
 of his income, the two sides of his account, the debtor and 
 the creditor, will balance. So too with the heart — if its 
 total capacity for work has been lowered, a greater relative 
 part of its functional capacity is required for its indispens- 
 able work, and prophylaxis is concerned with seeing that 
 the surplus alone is expended upon other forms of activity, 
 in order that the balance may be maintained. 
 
 For the medical treatment therefore of any case it is essen- 
 tial that a diagnosis of the functional capacity of that indi- 
 vidual heart should first be made. The question is not what 
 special morbid condition has affected this heart which is to 
 be prevented from becoming incompetent, but rather what 
 amount of loss of functional capacity has it undergone. A 
 great and necessary step forward will have been taken when 
 the diagnosis of diminished cardiac capacity has been made, 
 and adequate prophylactic measures have been adopted, before 
 
 158 
 
THE PREVENTION OP DISEASES OP THE HEART 
 
 those extensive and irreparable changes in the heart have 
 developed which alone make a physical diagnosis possible. 
 
 This is not the place to discuss the details of the func- 
 tional diagnosis of heart disease ; for this reference should 
 be made to textbooks on the diagnosis and pathology of 
 cardiac disease, especially the excellent one by 0. Rosenbach. 
 A truly scientific prophylaxis of heart disease can only be 
 carried out by the physician who makes a functional 
 diagnosis, not an anatomical one. It is not enough merely 
 to auscultate and percuss, and when nothing abnormal has 
 been detected by this procedure to conclude that special 
 prophylactic measures are unnecessary. Even when there is 
 no such organic abnormality present in the heart, its con- 
 dition and functional capacity should be determined in 
 every possible position of the body — when sitting, when 
 standing, when lying down, at rest and after different 
 degrees of bodily exertion, when the breath is held and 
 during forcible respiration, when the abdominal pressure 
 is increased, after a full meal, and after much liquid has 
 been taken up by the circulatory system through drinking 
 a large quantity of fluid, as well as when other influences 
 have been at work. In this way by noting the results of 
 such influences it is possible to determine which external 
 influences suffice to call forth pallor, cyanosis, coldness 
 of the extremities, or stupor, giddiness, pains over the 
 heart, and other signs of cardiac weakness ; and thence 
 it is possible to draw conclusions as to the functional 
 capacity of the heart. The degree of limitation of func- 
 tional capacity of the heart gives us the clue to the prophy- 
 lactic measures required for any given case. 
 
 DISEASES WHICH PREDISPOSE TO CARDIAC WEAKNESS 
 
 The most important aim of prophylaxis in heart disease 
 is to prevent cardiac weakness, whatever be the nature of 
 the cardiac affection out of which such cardiac weakness 
 may arise ; and further whenever it is possible another 
 object of prophylaxis will be to prevent the development of 
 conditions which will in course of time lead to cardiac weak- 
 
 159 
 
THE PEEVENTION OE DISEASE 
 
 ness. This is extremely difficult and seldom practicable, 
 because almost all lesions are secondary lesions arising out 
 of primarj'- affections, some of wbich may date back to 
 foetal life ; in these cases prophylactic treatment to prevent 
 the cardiac lesion is impossible, or is possible only in so far 
 as it is coincident with the treatment of the primary affec- 
 tion. In describing the prophylaxis of heart disease it is 
 not necessary here to describe in detail the prophylaxis of 
 the numerous affections during the course of which myocar- 
 ditis, or more correctly myopathic cardiac weakness, may 
 develop ; it will suffice briefly to allade to these ; their 
 prophylaxis is described elsewhere and also their treatment. 
 The more thoroughly these affections are treated the greater 
 is the possibility that the subsequent development of cardiac 
 affections will be prevented. 
 
 The chief of the affections which lead to heart disease is 
 acute articular rheumatism. It is obvious that the preven- 
 tion of subsequent heart disease is best accomplished by 
 preventing as far as possible attacks of acute rheumatism, 
 particularly in patients who have already had an attack of 
 this very dangerous malady. The measures intended to 
 prevent articular rheumatism itself are at the same time 
 prophylactic measures against the endocarditis, and need 
 not be described here at length — a suitable method of life, 
 precautions after overheating the body, methods to harden 
 the body, careful treatment by baths and friction, adequate 
 clothing appropriate to the season of the year, and many 
 other similar precautions. And when the patient is attacked 
 by articular rheumatism the most adequate treatment of 
 the rheumatism will again be the best preventive of a heart 
 lesion. There is not however always an exact relation 
 between the two. Although endocarditis in acute rheuma- 
 tism is doubtless one of the local manifestations of acute 
 rheumatism which has affected both the joints and the 
 endocardium, yet the severity of these two local manifesta- 
 tions is often very different. Often but not always in a case 
 of severe acute rheumatism affecting many joints we find 
 endocarditis also well marked ; yet recently I saw a case of 
 severe endocarditis in a mild attack of rheumatism affecting 
 
 160 
 
THE PREVENTION OF DISEASES OE THE HEAUT 
 
 only a single joint. "Whatever may be the explanation of 
 siicli exceptional cases nevertheless careful treatment of the 
 articular rheumatism is the most essential factor in the 
 prophylaxis of cardiac disease. 
 
 The same remarks are applicable to all infective diseases. 
 It is well known that endocarditis and myocarditis are apt 
 to develop after measles, scarlet fever, smallpox, typhoid 
 fever and pneumonia. Diphtheria is specially dreaded 
 because of its dangerous effect upon the muscular substance 
 of the heart, which often manifests itself by a sudden dimi- 
 nution of the functional activity of the heart long after the 
 diphtheria has been cured and while the individual is 
 apparently in the best of health. Here too the most 
 thorough treatment of the acute disease is identical with 
 the prophylaxis of the subsequent cardiac affection, although 
 a mild and uneventful course of the diphtheria will not 
 necessarily prevent the heart from becoming affected. 
 
 All febrile affections, particularly when the temperature 
 has long remained high, tend to cause cardiac degeneration 
 and myocarditis, which will be the more severe and irre- 
 parable the longer the hyperpyrexia has lasted. If, as 
 seems to be the case, the changes in the myocardium are 
 brought about not so much by the original cause or by the 
 toxines and ptomaines but by the long continuance of the 
 high temperature, then antipyretic treatment of the original 
 affection will at the same time be an effectual prophylaxis 
 of the consecutive cardiac weakness. 
 
 Further, in all diseases which affect the nutrition of the 
 heart prevention and adequate treatment of the disease is 
 at the same time prophylactic treatment for the heart. All 
 diseases of the blood, especially chlorosis, the different forms 
 of anaemia and leukaemia, reduce the nutrition of the car- 
 diac muscle, but if the disease has not lasted too long the 
 nutrition of the heart muscle can be restored, even though, 
 as often is the case, the weakened myocardium has under- 
 gone a slight degree of dilatation. Here again treatment 
 of the constitutional disease is identical with prophylaxis of 
 the cardiac affection. So too with arterio-sclerosis : it is 
 well known that sclerosis of the coronary arteries prevents 
 
 161 M 
 
THE PEEVENTION 0¥ DISEASE 
 
 the efficient nutrition of the heart, damages the heart 
 muscle and gives rise to serious symptoms. 
 
 This is also true about poisons : prevention of the original 
 cause is prophylaxis for the heart. Phosphorus is the most 
 important of these poisons. In close relation with it are 
 acute yellow atrophy of the liver and similar degenerative 
 processes which give rise to cardiac degeneration. 
 
 Special mention must be made of obesity. The fat accu- 
 mulates in large masses beneath the epicardium and 
 mechanically hinders the movements of the heart ; or 
 layers of fat may extend between the bundles of muscle 
 fibres, or the muscle substance of the heart may itself later 
 undergo fatty degeneration and become less and less capable 
 of contracting. The prophylactic measures are those for 
 obesity in general, for they will tend to prevent this form 
 of weakness of the heart at the same time as they prevent 
 the general obesity. 
 
 INDIVIDUAL CAEDIAC TUNCTIONAL CAPACITY 
 
 Although in many cases the preventive and curative 
 treatment of various diseased conditions will serve at the 
 same time to prevent cardiac lesions, yet there are cases 
 which we must now consider by themselves in which the 
 physician is called upon to treat existing cardiac lesions 
 which are anatomically irreparable, and to devise suitable 
 prophylactic measures. Many individuals are exposed to 
 the danger of cardiac insufficiency though they have never 
 suffered from articular rheumatism nor from any of the 
 primary diseases enumerated above which are apt to affect 
 the heart. Those with "sound hearts" as well as those with 
 " diseased hearts " should be considered by the physician in 
 respect to prophylaxis because, as we stated at the begin- 
 ning, one of the most valuable and most satisfactory tasks of 
 the physician is to suggest prophylactic measures to prevent 
 cardiac insufficiency from developing. Just as the optical 
 apparatus of every eye possesses its own power of refraction 
 and every biceps muscle has its own power of contraction, 
 so too every heart has its own total functional capacity, 
 the differences in capacity being the result either of indi- 
 
 162 
 
THE PREVENTION OF DISEASES OF THE HEART 
 
 vidual idiosyncrasies of the heart itself or of the mode of 
 life, or more especially of the after effects of other diseases 
 which have affected the muscle or valves of the heart. To 
 estimate this individual functional capacity and then to 
 adapt the life to the capacity of the heart is the aim of 
 prophylaxis in heart disease. 
 
 In describing prophylaxis it is necessary to consider one 
 by one the various symptoms which may arise from heart 
 disease. Then we shall consider the main causes in every- 
 day life which tend to injure the heart, and especially a 
 heart already threatened with insufficiency, and then shall 
 take into consideration how in daily life these injurious 
 effects may be prevented. 
 
 REST AND ACTIVITY 
 
 The most important of the measures for preventing the 
 heart from becoming insufficient is the regulation of the 
 amount of physical work which the patient may do. Dur- 
 ing the last ten years, mainly through Oertel's vigorous 
 and energetic initiative, the statement has been made that 
 every heart which has been weakened by disease of its 
 valves or of its muscle substance or from any other cause 
 may be strengthened by methodical exercise, that by steady 
 and gradual increase of the demands made upon the heart 
 a large amount of compensatory hypertrophy may somehow 
 be established, and the heart be thus rendered permanently 
 capable of satisfactorily doing its work. This opinion, 
 especially when stated as a general fact, is surely incorrect. 
 Nature in the wise and inscrutable efforts she makes for the 
 preservation of the individual certainly produces a compen- 
 satory hypertrophy of some part of the heart when that 
 part is unable efificiently to fulfil its work. That is doubt- 
 lessly correct. But the amount of the hypertrophy required 
 and the degree of hypertrophy beyond which it may not be 
 arbitrarily increased can only be determined by the organism, 
 never by the physician. All cardiac hypertrophy must 
 rather be looked upon as a makeshift, a using up of the 
 capital instead of the interest on the capital, and clinical 
 experience is continually showing us that even when such 
 
 163 
 
THE PREVENTION OF DISEASE 
 
 liypertrophy of the heart has in any individual case restored 
 the functional activity of the heart to its normal amount, 
 the hypertrophied muscle produced by the increase in the 
 work soon gives way. The object of well devised prophy- 
 lactic measures is not the attainment of a merely momentary 
 increase of functional activity. "When the heart muscle is 
 degenerating, either indirectly through excessive demands 
 upon its activity as with valvular lesions, or directly 
 through changes affecting the muscle as in myocarditis, it 
 is never possible, least of all by renewed and oft repeated 
 over exertion, to increase its contractile power beyond the 
 limit which its constitution has fixed and convert it into 
 energy. When it has apparently been possible by such 
 exercise to produce hypertrophy and increase the heart's 
 strength, we have merely built up one part at the expense 
 of another, and the greater the hypertrophy thus built up 
 the more quickly does the degeneration proceed. But this 
 is the very thing we have to prevent. The object of pro- 
 phylaxis should be to maintain cardiac compensation as 
 long as possible, and the attempt to stimulate the heart to 
 increased activity by exercise will, as soon as the increased 
 demands made upon it are excessive, produce cardiac insuffi- 
 ciency which may be temporary or even permanent. I have 
 often observed this in clinical practice, and quite agree with 
 Liebermeister who says that death has been hastened in 
 many cases of heart disease during the last few years. " A 
 good horse dies in the shafts " when the driver is ignorant. 
 It is true that exercise for the cardiac muscle is indicated 
 sometimes : in cases in which the muscle itself is healthy 
 and the diminished functional activity is caused mechanic- 
 ally by deposits of fat outside the muscle substance. The 
 conditions are then similar to those met with in the arm 
 muscles of an athlete, which are normal and healthy in 
 themselves, but which have not yet reached the highest 
 possible degree of development, and therefore may be 
 strengthened by systematic exercise. Those persons in 
 whom want of activity has reduced the cardiac power 
 may supply this want by systematic exercise which makes 
 demands upon the heart, increasingly greater and greater, 
 
 164 
 
THE PREVENTION OF DISEASES OF THE HEART 
 
 and thus increases its functional activity. Even here we 
 must act slowly and with moderation, and the condition of 
 the functional activity of the heart should be carefully and 
 constantly watched ; even the very slightest degree of over- 
 strain must be avoided, because it is well known that over- 
 strain may seriously affect a heart which was originally 
 perfectly healthy. 
 
 One single acute over exertion may lead to acute dilata- 
 tion. This depends partly upon the severity of the sudden 
 over exertion, but still more upon the heart itself and its 
 individual capacity of reacting against the injury. This 
 shows how important it is that, as already stated, the 
 functional capacity of the heart should be examined in every 
 patient. It is most valuable in such a case to have made 
 the discovery that the heart responds by signs of commen- 
 cing insufficiency to a certain amount of extra demand 
 made upon it, and thus be able to warn the patient against 
 future exertions which are beyond the capacity of his 
 heart, and so save him from developing cardiac insufficiency. 
 The observation has often been made that severe infective 
 disease leaves the heart so weak that the mere effort of 
 raising himself up in bed has caused the patient to faint : 
 here the mere physical effort of raising himself has over- 
 strained the heart. In a considerable number of other cases 
 too, some one excessive bodily effort has sufficed to call forth 
 signs of cardiac incompetence. Prophylaxis is here of the 
 utmost importance, and when we have determined with 
 tolerable certainty the functional capacity of the heart, 
 whether this be normal or subnormal, and the amount of 
 extra exertion of which it is capable without injury, we are 
 able to forbid all that would cause overstrain. 
 
 An even more important cause of injury to the heart, 
 because less obvious and very common, is over exertion at 
 sports and especially in cycling. Several years ago I 
 pointed out that cycling is characterized by the peculiarity 
 that the strain and overstrain caused by that form of 
 physical exercise are not subjectively felt by the cyclist in 
 the same degree as in other forms of physical exertion ; and 
 that fatigue and the need for rest are not felt till some time 
 
 165 
 
THE PEEVENTION OF DISEASE 
 
 after excessive demands have been made upon tlie heart, 
 and during this time the heart has been subjected to consid- 
 erable overstrain. A careful prophylaxis is very essential 
 in this connection ; the functional capacity of the heart, 
 whatever be its condition, should be carefully estimated, 
 and the effect of cycling noted before it is permitted 
 as an exercise, and even the strongest cyclist's heart 
 should be watched and the exercise regulated and adapted 
 both in kind and in degree to its capacity. Where these 
 precautions have not been observed, serious injury and not 
 a few cases of sudden death have been known to result from 
 cycling. The same is true of running, and of rowing, of 
 mountain climbing and of all forms of excessive and contin- 
 uous physical exertion. 
 
 A more difEcult task confronts the physician when the 
 over exertion is necessitated by the patients' occupation, 
 and he cannot regulate this as he can the amount of 
 cycling. The regulation of the amount of physical exercise 
 is the more necessary as a prophylactic measure, because in 
 many occupations where men have to work hard, several 
 injurious factors are apt to be combined, all of which cause 
 injury to the heart ; for example, Jiirgensen has pointed 
 out that the " Tubingen heart," a myopathic form of 
 cardiac insufficiency which is so common in the district of 
 Tubingen among the people who are employed in the vine- 
 yards, is to be attributed to the fact that the men 
 have to carry heavy weights and at the same time go up 
 the steep mountain sides. Similar conditions are met with 
 in those who carry heavy weights and in boatmen and in 
 similar callings, particularly when these individuals are 
 accustomed to take much alcohol. Restriction of alcohol 
 is a valuable prophylactic, because alcohol has been proved 
 to injure the heart. 
 
 Rest not exercise is therefore the main principle in the 
 prophylaxis of heart disease ; and our duty is to reduce the 
 amount of physical exercise and not to increase it. The 
 activity of the heart is increased directly in proportion to 
 the physical exercise. This is effected through the nervous 
 system which is constantly regulating the activity of the 
 
 166 
 
THE PREVENTION OF DISEASES OF THE HEART 
 
 heart, so that whenever metabolism is increased — especially 
 by muscular exercise — the heart's action is at once increased 
 in proportion ; and a heart which expends all or most of 
 its functional activity in the mere " vegetative " carrying 
 on of the circulation, must be spared from further demands 
 upon it made by avoidable physical exercise. The exercise 
 should be restricted and reduced to a minimum. The in- 
 creased demands made upon such a heart by phj'-sical exercise 
 must never exceed those which can be responded to without 
 causing any sign of commencing cardiac insufficiency, those 
 for which the heart still possesses a sufficient surplus of 
 functional activity. In other words, rest is the first essen- 
 tial in the prophylaxis of heart disease. 
 
 THE FORM AND AMOUNT OF REST FOR THE HEART 
 
 Thorough rest for the heart should at once be commenced 
 and most carefully carried out in cases where an acute sudden 
 reduction in the heart's functional capacity has occurred in 
 the course of acute endocarditis or of any of the severe ill- 
 nesses which are apt to injure the heart muscle. No great 
 extra demand must be made upon the heart, sometimes indeed 
 no extra demand at all, until the organ has gradually been 
 restored to its normal functional activity. The patient 
 should be kept at absolute rest in bed. If there is valvular 
 disease the rest in bed should continue till adequate compen- 
 sation has developed. 
 
 It is obviously impossible for every individual whose 
 heart is not functionally quite healthy to remain in bed 
 all his life or to be wholly inactive : every one desires to use 
 his life and also to enjoy life, and a sensible man does both 
 only up to the degree which is reasonable for him. Our task 
 is to determine the amount of rest and of activity possible for 
 each individual who needs to take precautions on account 
 of his heart, and to show how this is possible in ordinary 
 life. The total activity of which a heart is capable consists 
 of two parts. Firstly, a constant part which is continuously 
 and uninterruptedly required for " vegetative" cardiac work, 
 for the simple carrying on of the circulation of the blood. And 
 secondly, an inconstant part — a surplus constantly varying 
 
 167 
 
THE PREVENTION OF DISEASE 
 
 in amount and dependent upon the sum of all the stimuli 
 both external and internal which act upon the body. Thus 
 there is for every individual a certain definite " physiological 
 latitude" in the external influences which may be brought 
 to bear upon the body — all the bodily and mental stimuli. 
 Upon the metabolism which results from these, and upon 
 the regulation of the heart through special nerve centres, 
 the activity of the heart at any time depends. 
 
 Physical exercise is the most important and most frequent 
 of these stimuli. This physiological latitude of the stimuli 
 which act upon the heart is subject to great variations, 
 and the heart remains efficient within certain limits. The 
 lower limit is that amount of work done by the heart when 
 the body is at rest and inactive, which is necessary merely 
 to carry on the vegetative function of the circulation of the 
 blood ; the upper limit is the maximum of work which the 
 heart can perform, and represents the largest possible sum 
 of stimuli which can excite the heart to increased activity 
 without making it inefficient. "When the functional activ- 
 ity of the heart is small in itself or has become small by 
 reason of acquired changes in the heart, then a large pro- 
 portion of its total functional activity will be expended 
 upon carrying on the circulation while the circulation is 
 uninfluenced in any way, and a very small part, often a 
 mere trifle of the heart's functional activity, remains over 
 for possible use when demands are made upon it. 
 
 This is of the greatest significance in connexion with 
 prophylaxis. Such a heart uses up a large part of its 
 reserve strength in merely maintaining the circulation of 
 blood, which in a healthy heart would be ready for use for 
 physical and mental activity and all the other influences of 
 life. The physiological latitude of such a heart is a very 
 small one, and the limit up to which the heart's action may 
 be increased by activity, especially by physical activity, 
 without overstrain to the heart, is a very low one. The 
 object of prophylaxis is to restrict bodily activity to an 
 amount which will not cause the heart to work beyond this 
 small physiological latitude. 
 
 Reference has several times been made to the diagnosis 
 
 168 
 
THE PREVENTION OF DISEASES OF THE HEART 
 
 of the heart's functional capacity, and when it becomes 
 necessary to adopt prophylactic measures in any individual 
 case, the physician can by repeated examination quite well 
 form an opinion about the physiological latitude beyond 
 which the cardiac activity must not be called forth by 
 stimuli. He can find out what is the maximum increase 
 of activity which the heart which has been working 
 quietly while at rest can be called upon to perform, and 
 thence can fairly accurately prescribe the amount of 
 physical exercise which any given individual may take in 
 addition to the other demands made upon that heart. But 
 it is of course very difficult and often impossible to put 
 side by side the many factors which in the form of stimuli 
 combine to raise the activity of the heart when the indi- 
 vidual is at work, and to estimate their mutual quantita- 
 tive relations and thus be able, not only to prescribe the 
 amount of bodily activity permissible, but also the amount 
 of the manifold other activities. We can therefore give 
 the patient only general directions, can explain to him so 
 far as possible the nature of his condition and further urge 
 upon him the duty of recognizing and keeping within the 
 limits which he must not overstep. If the physician has 
 thus properly instructed the patient and if the patient will 
 carefully observe himself he will be far better able to guide 
 his way aright than if he followed some scheme of rules 
 drawn up for him. 
 
 To do this he must be guided by his subjective sensations. 
 They constitute an extremely good sign of commencing 
 disturbance of compensation and of commencing excess in 
 the demands upon the heart. First there is palpitation of 
 the heart, felt whenever the patient has undergone bodily 
 exercise which is too severe or too long continued. One 
 must not think that hypertrophy of the heart produces 
 palpitation because the hypertrophied heart increases the 
 heart's activity ; that is not the case. The subjective sensa- 
 tion of palpitation is never produced by hypertrophy but 
 is always a sign whenever it occurs that demands are being 
 made upon the heart which are beyond its capacity. 
 Dyspnoea has a similar significance. In the prophylaxis 
 
 169 
 
THE PEEVENTION OF DISEASE 
 
 of heart disease patients should be told to notice when 
 palpitation or shortness of breath is produced by physical 
 exertion, to discontinue the exertion directly either of 
 these symptoms appears, to rest, and not to resume the 
 physical exertion until these signs have completely dis- 
 appeared. Such self observation is not always easy, because 
 the patient has to be on the lookout for the onset of two 
 symptoms which are not very noticeable and are often over- 
 looked and unobserved by indolent individuals and by 
 people who are not very sensitive, and particularly by 
 people belonging to the working classes who are under the 
 impression that pain or some very obvious severe disturb- 
 ance is the only sign of illness. Others too, even people 
 with the highest and most delicate organization, often show 
 remarkable carelessness as to the importance of subjective 
 symptoms. In such cases we must with the assistance of 
 the patient's friends employ the frequency of the pulse as 
 the test of the amount of bodily exertion which is desir- 
 able. A patient whose heart is not sound must never 
 attempt bodily exertion which makes his pulse beat more 
 than one hundred times per minute. Directly the pulse 
 has reached this frequency the patient must cease exercise 
 and must rest the heart completely imtil the pulse rate has 
 again fallen to the normal. Exercise approximately up 
 to the limit of the heart's functional activity, and cessation 
 of all exercise at the very first and most transient sign of 
 cardiac tiredness, and resumption of activity only after the 
 heart has completely recovered itself — such heart exercise 
 only may be practised by a patient with diminished 
 functional activity, and such exercises only are useful. 
 
 It has already been pointed out that only a normal 
 muscle which has undergone no degeneration is capable of 
 being developed by exercise, and reference was made to 
 the biceps muscle of athletes as a case in point. Though 
 exercise of the healthy muscle will with certainty develop 
 its strength, it would be folly to exercise that muscle if 
 myositis were present. It is exactly the same with the 
 heart, and let us once more clearly state that these principles 
 apply to all forms of heart disease, whether the result of 
 
 170 
 
THE PEEVENTION OF DISEASES OF THE HEART 
 
 valvular lesions or of alteration of the muscle substance 
 itself, and that in this respect we may consider these diseases 
 collectively. Finally all diseases of the heart of whatever 
 kind are diseases of the muscle substance ; even valvular 
 disease, the importance of which has recently been experi- 
 mentally proved by Eomberg, Krehl, His, Eosenbach and 
 others to be due less to the lesion of the valve than to the 
 resulting insufficiency of the cardiac muscle. 
 
 On the one hand to compel an inefficient muscle to work 
 beyond the limit of its capacity, and on the other daily 
 and systematically to stimulate a muscle to work up to the 
 limit of its capacity and to maintain or even to increase this 
 capacity, are two very different things. A superficial con- 
 sideration might seem to suggest that it is desirable to 
 keep the patient at absolute rest and not permit any extra 
 demands whatever to be made upon the heart ; such however 
 is not the case, but an endeavour must rather be made to keep 
 the heart up to its greatest functional capacity and never 
 allow it to go in the least beyond. The subjective sensa- 
 tions of the patient are the surest guide for keeping within 
 these limits when both physician and patient are striving 
 to keep the heart from becoming incompetent by overstrain. 
 It is often possible in this way to increase the heart's 
 activity very considerably. After the development of an 
 acute heart lesion the total strength of the heart may have 
 sunk so considerably and the physiological latitude be so 
 small that the additional demands made upon the heart even 
 by simply trying to raise himself up in bed may cause the 
 patient to faint. Such a patient must be kept altogether in 
 bed till the heart has recovered its strength or compensation 
 has set in ; but as soon as the patient is able to raise himself 
 in bed he should daily, very slowly and carefully and under 
 constant supervision, exercise the heart up to the limit of 
 its strength by bodily movements. 
 
 Thus he will gradually succeed in doing more and more 
 and may be further helped afterwards by those " exercises 
 against resistance " which are so much used at the present 
 moment. If these " resistance exercises," which should 
 always be given by the physician himself and never by 
 
 171 
 
THE PREVENTION OF DISEASE 
 
 the aid of a machine, do not exceed the strength of the 
 patient at any time, they are curative, and act in the same 
 way as the other methods sketched above for systematically 
 strengthening the heart. When with much patience and 
 care the heart has in this way been long enough exercised 
 — and " exercise " merely denotes working the organ to the 
 capacity of its function and not exceeding it at any time — 
 then the patient will finally be able to bear without any 
 bad after effects occasional greater demands made upon 
 his heart temporarily, such as are unavoidable in everyday 
 life. If however such excessive demands are made too 
 frequently, especially soon after the heart injury was 
 sustained, or the demands are made regularly and system- 
 atically by the medical order of a physician who has 
 taken a wrong view of the condition of the cardiac muscle, 
 then cardiac insufficiency will be developed even earlier 
 than it would have been had such exercise been omitted. 
 
 MENTAL BEST 
 
 A further important part of prophylaxis is mental rest 
 and the prevention of too great an increase of the heart's 
 activity as the result of mental stimuli. It is obvious 
 that this is too complicated to permit us to draw up a 
 simple scheme of rules ; the main outlines can alone be 
 sketched and will enable the intelligent physician to form 
 an opinion in any given case and draw up rules for it. 
 
 It is well known that mental stimuli excite the heart's 
 action just as do bodily stimuli. Here also, though less 
 obviously, we see the great regulating power possessed by 
 the organism which, acting through the nervous system, 
 adequately increases the heart's movements whenever 
 there is increased metabolism at any part of the body with 
 the object of replacing the used-up material as rapidly as 
 possible. And as it is necessary to limit bodily exercise to 
 the reduced capacity of the cardiac activity in any case, 
 so too it becomes necessary adequately to limit severe 
 mental exertion. The strain of mental exercise acts upon 
 the heart just as physical exercise does, and may act upon 
 the heart to such a degree that, combined with other 
 
 172 
 
THE PREVENTION OF DISEASES OF THE HEART 
 
 unavoidable demands upon it, the limit of tlie heart's 
 capacity is overstepped. Reading especially should be 
 regulated both in amount and in kind. It is a recreation 
 and diversion in which 23atients whose heart condition pre- 
 vents much physical activity are very apt to over-indulge. 
 Sudden emotion, which is another form of mental excite- 
 ment, must be j^revented and guarded against even more 
 carefully than regular and long lasting mental exertion. 
 Patients suffering from heart disease should, so far as it is 
 possible in the imperfect regulation of our human life, be 
 shielded completely from everything that would arouse in 
 them terror, anger, excitement, sorrow or worry. Natur- 
 ally this is more easily said than done. But much of the 
 harm is caused by the thoughtless unsympathetic friends 
 around the patient, and with great care it is possible to save 
 him from some of this — sometimes from much, sometimes 
 from little. All such mental excitement and depression 
 which act strongly on the organism are as injurious to 
 the heart as sudden very severe physical over exertion, 
 and may disturb for a long time or even permanently a 
 compensation which was previously well maintained. They 
 do harm not only by increasing the heart's activity but 
 also by direct action upon the nervous apparatus of the 
 heart, and as a result they prevent the proper nutrition of 
 the body and of the heart. 
 
 In connexion with this regulation of mental excitement 
 there is an important factor to be noted, both in the 
 interest of the patient and of the physician ; a factor 
 which under certain circumstances exercises the most 
 injurious action upon the body. This factor is the opinion 
 which the patient has formed and holds about his " heart 
 disease" and the symptoms which it has produced. In 
 regard to this the physician can be of the greatest help to 
 the patient entrusted to his care. We have already pointed 
 out how the individual patient might judge of the amount 
 of bodily exercise of which he is capable, by observing the 
 condition of his heart during exertion and noticing 
 symptoms of palpitation, shortness of breath and increased 
 frequency of the pulse. But patients can only do so 
 
 173 
 
THE PREVENTION OF DISEASE 
 
 without injurious results when they have been suffi- 
 ciently instructed and know which symptoms are impor- 
 tant and which symptoms have little or no signifi- 
 cance. Patients who have heart disease or think they 
 have it anxiously watch every symptom which seems 
 to be connected with the heart's action, and are only too 
 apt to regard the most trivial and natural symptoms as bad 
 and dangerous. The mental effect of this reacting upon 
 the heart is extremely bad. They must be taught that the 
 symptoms are not all of significance. The constant atten- 
 tion which they bestow upon their heart reacts upon the 
 heart through the increased mental activity which it calls 
 forth, and increases the heart's action and constitutes a 
 " vicious circle." So too when attention is given to it 
 palpitation is much more quickly and readily noticed and 
 observed than when such an interest in the subject has 
 not been artificially stimulated. It is very necessary to 
 explain to the patient that it is perfectly normal that he 
 hears distinctly the beating of his heart when he lies in 
 bed at night with one ear to the pillow; and that every 
 one, even one with the soundest and most capable heart, 
 will plainly feel the heart beating whenever he assumes 
 any position in which the heart, from the way in which 
 it is suspended, comes to lie heavily against the chest. 
 The same result may be brought about in the reverse 
 way, when the chest wall is pressed up against the heart 
 by leaning against some firm object or by pressure of the 
 clothes and many similar causes. And other physio- 
 logical changes in the heart's action must also be 
 explained to the patient. These changes are met with in 
 every one ; they remain unobserved and unnoticed by the 
 healthy individual but are readily observed by a patient 
 who has heart disease, and are apt also to be more marked 
 because the diseased heart reacts quickly to slight stimuli : 
 for example the fact that the pulse becomes irregular when 
 the breath is held for long should be mentioned and 
 explained to these excessively anxious and sceptical persons, 
 so that they may know how unimportant this is. And it 
 is only when they are no longer unnecessarily anxious 
 
 174 
 
THE PREVENTION OF DISEASES OF THE HEART 
 
 about cardiac symptoms that mental prophylaxis may be 
 considered adequate. 
 
 In order that such mental prophylaxis may be successful 
 the patient must have absolute confidence in the physician. 
 Confidence in the physician is a general and necessary con- 
 dition for the successful treatment of all diseases, but is 
 probably of greater value in heart disease than in any other. 
 The various signs and symptoms of their cardiac trouble 
 mentally excite such patients, but even greater mental harm 
 is done by the knowledge that their heart is diseased and 
 the conclusions they draw from it. The existence of a 
 cardiac lesion or of heart disease is still generally regarded 
 even by educated people as necessarily leading to the result 
 that the patient is doomed. This opinion is altogether in- 
 correct in the large majority of cases of heart disease if the 
 prophylactic measures described in the preceding pages are 
 carefully and thoroughly carried out. This erroneous opinion 
 produces great depression which reacts unfavourably upon 
 the patient and can only be removed by a physician in whom 
 the patient places the fullest and most immovable confidence. 
 
 It is difficult to describe in a book how this is to be done. 
 The physician has to point out again and again, with 
 caution and with gentleness but also with earnestness and 
 emphasis, that a " lesion," a " weakness," is not yet a 
 " disease," and that it is quite possible for a very very long 
 time to get on perfectly well with a heart whose functional 
 activity is reduced, if only the demands made upon this 
 vital organ are not greater than those of which it is capable ; 
 and that actual serious disease arises only when prophylactic 
 measures have been neglected and disregarded. 
 
 We should be cautious too in the use of such ominous 
 words as " heart lesion " or " fatty heart," because people 
 are apt to attach a very serious meaning to them. "When 
 the physician has made a definite and exact diagnosis it is 
 his duty to explain to the patient as fully as is possible 
 what is the condition of the heart. This knowledge will 
 save the patient from all unnecessary fear which an 
 erroneous opinion about his condition might cause him, and 
 will also save him from the anxiety of feeling that he does 
 
 175 
 
THE PBEVENTION OP DISEASE 
 
 not know what things are wrong and injurious for his 
 condition, and it is therefore of the greatest possible pro- 
 phylactic value against mental distress. 
 
 How one will give such explanations and instruction 
 to the individual patient and how much it is well to say- 
 will depend entirely upon the character and temperament 
 of the patient. The difficult task of the physician is to 
 distinguish between the characters of different patients, 
 and to paint the disease and its probable course in some- 
 what dark colours to the thoughtless and indifferent, to 
 point out the possible consequences of neglecting to follow 
 medical advice, and the risks and dangers which such 
 neglect entails. On the other hand he must inspire hope and 
 confidence in the anxious and timid patient, allaying his 
 anxieties and painting the picture in brighter colours. Two 
 results will simultaneously be brought about by such wise 
 treatment of a patient who places implicit confidence in the 
 physician : the patient will carry out carefully the various 
 instructions given him for the prevention of heart disease and 
 will at the same time be carrying out the mental prophylaxis. 
 
 OCCUPATION 
 
 The choice of an occupation is an important matter when 
 we have to protect the heart from being overstrained by 
 bodily or mental exertion. It is obvious that an individual 
 with valvular disease of the heart or with a heart whose 
 functions are not perfectly normal should avoid every 
 vocation which would necessitate great muscular exertion 
 or much bodily activity. Heavy work of every kind is 
 injurious. An easy sedentary quiet occupation requiring 
 little active exertion should be chosen ; and the heart's 
 functional activity must be carefully exercised up to its 
 full limit but never beyond it, by regular walking and 
 other methods already described. In the mode of life 
 (sitting, writing), the dress (uniform) and other conditions 
 everything is to be carefully avoided which by compression 
 would tend to hinder the circulation. These precautions are 
 the more necessary when +he heart affection has developed 
 late in life ; all severe muscular exertion should at once be 
 
 176 
 
THE PREVENTION OF DISEASES OF THE HEART 
 
 stopped, and though in the majority of cases it is very 
 difficult yet the patient's occupation must be changed and 
 adapted to the new circumstances. 
 
 "When the heart muscle is affected any lifting of heavy 
 weights and especially any sudden strain must be most 
 carefully avoided. The heart is no longer able to adapt 
 itself to great variations in the demands made upon it, 
 and is most seriously injured by such efforts. It is well 
 known that even moderate overstrain — the running after 
 a tramcar or an effort involving some slight strain or 
 pressure as in defecation — may suffice to stop the heart's 
 action and lead to sudden death. 
 
 The same is true of mental excitement. Vocations which 
 involve much mental excitement should be avoided. Here 
 too theory is easier than j)ractice ; no vocation is altogether 
 free from mental emotion, but speculating on the stock 
 exchange or lecturing should not be chosen as occupations 
 by one who has heart disease. 
 
 MARRIAGE 
 Marriage is the vocation of the woman. It will remain 
 so however much women may in the future study medi- 
 cine. Indeed when women have received a thorough 
 scientific training they will recognize that the division 
 of occupation between the two sexes as seen today has 
 developed as the outcome of differences in organization of 
 the two sexes and not through any arbitrary action of 
 the " stronger " sex, and that such differences must there- 
 fore always exist. A woman who has heart disease does 
 not thereby become necessarily unfitted for marriage. The 
 opinion of the physician is often asked on this question, 
 and it is by no means always easy to answer. The 
 decision must rest essentially upon the two kinds of ex- 
 cessive demands which will be made upon the heart, 
 namely sexual life and pregnancy which both react upon 
 the heart. There is no doubt that these two factors may 
 in some cases act very injuriously upon the heart, even 
 when the pregnancy runs a normal course and the social 
 conditions of the patient enable every care to be taken. 
 
 177 N 
 
THE PEEVENTION OF DISEASE 
 
 This is often seen in the course of medical experience. 
 Here again we see, what pathology is so constantly show- 
 ing us, that the organism can adapt itself to changes of 
 condition which come on slowly and gradually but cannot 
 respond to sudden great changes when its functional 
 activity is no longer perfect, and that one such great 
 sudden overstrain may suffice to cause a permanent injury. 
 In view of the possibility of one or more pregnancies 
 cardiac insufficiency is not a contra-indication to marriage 
 provided the woman is otherwise well developed, and that 
 with proper care fair cardiac compensation is possible. In 
 these cases women may pass through several labours and 
 completely recover. The case is different to that of pul- 
 monary tuberculosis, and C. Gerhardt has recently pointed 
 out most emphatically that pulmonary tuberculosis is 
 always a contra-indication to marriage. 
 
 The matter is somewhat different in the case of the 
 sexual excitement which marriage brings with it in greater 
 or less degree according to the temperament and individu- 
 ality of the partners of the marriage. Here one single 
 excessive demand made upon the heart — in men as well 
 as in women — may be extremely serious, especially when 
 it is oft repeated or is excessive in degree. It is well 
 known that sudden death has not seldom occurred during 
 coitus, because the sexual act so greatly increases the blood 
 pressure that the heart fails. When any one who has a 
 heart affection marries the physician should advise the 
 amount of moderation necessary. This aspect of prophy- 
 laxis requires naturally great tact on the part of the 
 physician. 
 
 In other cases marriage may sometimes act very favour- 
 ably upon the heart condition. For not rarely marriage 
 may prove a " haven of rest." When marriage will lead 
 to more stable and better conditions of life, when marriage 
 will bring with it the possibility of better care and better 
 nourishment, then it is to be recommended, though the 
 advantages and disadvantages of the new condition should 
 be very carefully weighed. 
 
 178 
 
THE PREVENTION OF DISEASES OF THE HEART 
 
 INSTITUTIONS FOR THE TREATMENT OF HEART 
 DISEASE 
 
 In regard to a suitable abode for those wbose hearts 
 require special care the general social conditions are un- 
 fortunately such, that only a very small number of these 
 patients are in a position which allows them to select the 
 place they would like and that suits them from the point 
 of view of the requirements of their health. However 
 this is not absolutely essential in cases of heart disease, 
 we need only shield such patients from the injurious effects 
 of climate, especially upon the organs of respiration, which 
 would disturb the pulmonary circulation and so disturb 
 and render more difficult the work of the heart. Windy 
 localities must therefore be avoided. It is this that makes 
 elevated localities not well borne by those suffering from 
 heart disease, and probably when the right side of the heart 
 is no longer effi.cient the rarefied air and low atmospheric 
 pressure of elevated places make the heart's action in- 
 adequate. It is best certainly that these patients should 
 spend the hot summer in the mountains not in a town, 
 but a spot of medium elevation should be chosen, for there 
 they feel best. The temperature should be cool rather 
 than warm, because difficult breathing is considerably 
 relieved by a cool or even a cold atmosphere, but obviously 
 great care must be taken to prevent catarrh of the respir- 
 atory passages. A southern mild climate is necessary 
 only when there is catarrh or congestion of the lungs. 
 The seaside is also very good and useful as a place of 
 residence. Indeed there are no very precise indications as 
 to climate. All depends upon the individual's power of 
 adapting himself to circumstances. In fact it may be said 
 that any medium climate is suitable and offers a good 
 prospect to one with heart disease. 
 
 The most essential point in connexion with heart pro- 
 phylaxis is the necessity of allowing all possible measures 
 to act for a long time and in combination. This is possible 
 to the fullest extent only by residence at an institution 
 specially adapted for the purpose and fitted up with every- 
 
 179 
 
THE PREVENTION OF DISEASE 
 
 thing wliicli is required in the prophylaxis of heart disease. 
 The tendency of medicine is more and more to treat special 
 classes of diseases in places where the many different 
 applications and methods which are required can be used 
 simultaneously and to their full extent, and where all the 
 indispensable appliances and helps are at hand. It is only 
 necessary to mention sanatoria for diseases of the lungs, 
 where just as an artist in his studio himself personally 
 carries out every part of his work till it is finished, the 
 physician not only advises as to the measures to be adopted, 
 but watches too the actual carrying out of the treatment, 
 or rather himself carries it out. Faust rightly sets aside 
 the maxim "in the beginning was the word," and replaces 
 it by " in the beginning was the act." So too in the 
 treatment of disease we should endeavour ourselves to do 
 for the patient all that we possibly can, and not rest content 
 with merely giving him advice which will be forgotten 
 or neglected. 
 
 The establishment of institutions for the treatment of 
 heart disease is therefore an urgent need for the future. 
 It will be necessary to establish such institutions, not 
 only for the richer members of society, but also for the 
 other classes of the population. These institutions would 
 be of greatest service in the prevention of those injurious 
 effects which result from the improper mode of life of 
 patients who require to be careful because of the condition 
 of the heart. Here the patients would learn how thej'' 
 ought to live, and later on returning home and going back 
 to their vocations would take with them the knowledge 
 which they have acquired of the necessary prophylaxis. 
 This knowledge would not then rest upon verbal instruc- 
 tions and teaching only, but upon previous practice to 
 which they would have become so accustomed that it had 
 set up a habit which they would continue to follow almost 
 unconsciously and involuntarily for the rest of life. A 
 man who has once been a Prussian soldier will have ac- 
 quired a bearing and a gait and many other bodily actions 
 which he will retain during the rest of his life, and he 
 will unconsciously repeat them in the way in which he 
 
 180 
 
THE PEEVENTION OF DISEASES OF THE HEART 
 
 acquired and practised them ; so too will a patient who 
 lias stayed long enough in an institution for the treatment 
 of heart disease have acquired a habit of prophylaxis 
 which will be of the greatest benefit for the rest of his 
 life. 
 
 In the therapeutics of heart disease such an institution 
 would do for all classes of the population even more than 
 what today the various " watering places " do for the few 
 patients who are able to afford to go to them. For 
 example, carbonic acid baths are exceptionally valuable 
 and efficacious in the treatment of heart disease ; the reason 
 why we have not described them here is that they belong 
 to therapeutics rather than to prophylaxis. In addition 
 to the baths the many other useful prophylactic measures 
 in force at these places are also of the greatest therapeutic 
 value — all the bodily and mental factors are present, 
 especially the necessary rest and the exclusion of all busi- 
 ness matters. In special institutions for diseases of the 
 heart this could all be carried out even more perfectly, and 
 still greater success would result from the treatment of 
 these cases than is possible at the present time in these 
 public " bathing places." 
 
 There are numbers of people whose feeble bodies make 
 them unfit for the social conditions in which they live. 
 Government and society should endeavour to provide 
 work and occupation for these of a kind which is suitable 
 for their reduced physical strength. From the standpoint 
 of political economy it is absolutely foolish that hundreds 
 of sufferers from heart disease are employed as masons and 
 locksmiths because no one takes any trouble in the matter. 
 They pass a wearisome existence, their work often inter- 
 rupted by illness and their life considerably shortened, 
 while many others of great physical strength are em- 
 ployed in such easy occupations as horticulture or office 
 work. How this is to be done is not for me to say, but 
 all our prophylactic and therapeutic measures can only be 
 of permanent good to the individual when their entire 
 mode of life and their work are adapted to their needs, and 
 this is the main factor in all prophylaxis and therapeutics. 
 
 181 
 
THE PREVENTION OF DISEASE 
 
 First of all there is need for institutions for the treatment 
 of heart disease ; and next there is no less need for arrange- 
 ments and organizations to provide for the patients who 
 leave these institutions conditions of life in which it is at 
 least possible for them to continue the prophylaxis necessary 
 in their case. To establish such institutions is the first 
 essential, to make arrangements for suitable conditions of 
 life for discharged patients whose strength has been im- 
 proved is the second. 
 
 CLOTHING 
 
 With regard to the clothing there are two essential con- 
 ditions for prophylaxis in cases where the heart's functional 
 activity is below the normal. First, it is of the utmost 
 importance to prevent all pressure by the dress. The 
 commonest and most injurious form of such compression is 
 that produced by unsuitable corsets in women; for a 
 patient suffering from heart disease should never wear a 
 corset. Compression acts injuriously in two ways : it 
 may directly interfere with the heart's movements, or it 
 may make the circulation of blood at the more remote parts 
 of the body more difficult. The corset produces both these 
 effects, it directly compresses the lower part of the thorax, 
 and reduces the size of the space required by the heart in 
 its contractions ; it forces the diaphragm and liver down- 
 wards and compresses the abdomen, and so indirectly ob- 
 structs the circulation of the blood. The rest of the dress, 
 whichever part of the body it covers, must also be such as 
 not to constrict or press upon any part ; attention is especi- 
 ally to be directed to the collar, waistband and garters. 
 The whole dress, of whatever kind it may be, should be 
 made to cover the body loosely, but nowhere be closely 
 fitting, because even a small amount of pressure is injurious 
 in heart disease. Moreover the dress should be light in 
 weight, made of a supple material to prevent respiration 
 from being made more difficult, particularly during exer- 
 cise. It is very much a question of the cut and make-up, 
 for the clothes should be so adjusted that they are not felt 
 as a weight on any part of the body. 
 
 182 
 
THE PREVENTION OF DISEASES OF THE HEART 
 
 The second requirement is tliat the dress of those -who 
 have heart disease should be warm, though at the same 
 time not thick or heavy. Excess in warmth must be 
 avoided ; and the dress must not be too thick, otherwise it 
 will cause excessive perspiration. These patients must how- 
 ever constantly and continuously be protected against a 
 chilling of the skin, otherwise the cutaneous vessels will 
 contract too greatly and cause increased work for the heart, 
 which might have been avoided by suitable clothing. 
 
 FOOD AND DRINK 
 
 Food exercises a most important influence upon the 
 course of a disease, and even more upon the strength of the 
 organism and upon its metabolism ; this is so universally 
 recognized that we need not enter into further details. 
 While emphasizing this important value of food neverthe- 
 less it is not possible to draw up any special rules and 
 dietary for each separate form of disease. In this connec- 
 tion often too little stress or none at all is laid upon the 
 individual conditions of absorption and assimilation in 
 health and in disease. Yet all depends entirely upon this 
 and not upon any " nitrogenous equilibrium," not upon 
 any abstract theories about the relative nutritive values of 
 foods, nor upon the heat value of foods, which have 
 apparently been determined to be necessary under certain 
 conditions, but which are not universally applicable. All 
 these theories omit the fact of the existence of great 
 di£Perences in the power of assimilation of different indi- 
 viduals, and further the conditions under which these 
 experiments have been made were unusual — as Rosenbach 
 well puts it — the conditions are different, and it is quite 
 impossible that the food suitable for a strong working 
 man in full work is that which is required by a patient 
 in a hospital leading a perfectly inactive life. This would 
 indeed imply that the food required by a man engaged in 
 carrying heavy loads is the same as that required by an 
 attendant in a museum. 
 
 I have elsewhere referred to this subject in an address 
 in which I drew a not unsuitable analogy from the growth 
 
 183 
 
THE PREVENTION OF DISEASE 
 
 and development of a child. Obviously for the proper 
 assimilation of food, it is essential that there be a suffici- 
 ent quantity of food, with its constituents in the proportions 
 and of the nature in which assimilation is quickest and most 
 easy for the organism ; but from this it does not follow 
 that the amount absorbed by all is identically the same. 
 If, for example, one were to take six children of the same 
 age, if possible even of the same body weight and so far as 
 possible of the same apparent constitution, and were to feed 
 each on exactly the same amount and kind of food, never- 
 theless in the course of a short time, though none of them 
 had suffered from any intercurrent disease or unusual 
 circumstance, it would be found that the weights and 
 bodily condition of these six children would all differ con- 
 siderably one from another. The individual constitutions 
 were different. Such individual constitution is the chief 
 factor in the development of disease; just as the factor 
 which we term the power of resistance may determine 
 whether an infective disease, when the infective matter is 
 present, shall develop or not. So too another very im- 
 portant factor in the constitution is the individual's power 
 of assimilation which determines whether in any given 
 case a certain definite amount of food will maintain the 
 balance and replace loss by metabolism, or whether it will 
 be an insufficient quantity or an excessive quantity of food. 
 However a few valuable guiding principles can be laid 
 down as to the food suitable for patients with heart disease. 
 Omitting for the moment the kind of food and even its 
 total quantity, it is most important to regulate the way in 
 which the food is taken and the amount of food taken at 
 a time. I have described the technique of dietary in Von 
 Leyden's " Textbook on the Therapeutics of Diet," and have 
 laid down the physiological results of the different ways of 
 taking food, and I refer the reader to that work. For 
 patients with heart disease the most essential point is that 
 the food shall be taken in a way which will not increase 
 the work of the heart. As is the case with tight clothes, 
 so here the freedom of action of the heart may be interfered 
 with by a direct limitation of its movements ; for when the 
 
 184 
 
THE PREVENTION OF DISEASES OF THE HEART 
 
 stomacli is overfilled it reduces the space in which, the 
 heart can move in the same way as pressure from without. 
 
 The amount of food which may be taken at a time is 
 different in individual cases, and sometimes even a com- 
 paratively small amount of food is too much. Patients 
 with heart disease require food often, and only a little at a 
 time, to prevent any over filling of the stomach, and they 
 must be very moderate in the use of food which tends to 
 cause flatulence and in the use of aerated waters. 
 
 Another way in which the circulation may be impeded 
 is by food which is difficult of digestion because it is close 
 and hard ; the gastric functions may be so greatly increased 
 thereby, as to cause a large flow of blood to the digestive 
 organs and so to increase the work of the heart. 
 
 For these reasons stress must be laid upon the necessity 
 of sufficiently masticating food and upon the teeth being in 
 good condition. The patients should always eat leisurely, 
 slowly chewing and swallowing their food. Care must be 
 taken also to vary the food as far as possible ; the disinclina- 
 tion of such patients for food, and especially for meat and 
 milk which are so valuable as food, makes it very difficult in 
 practice to supply an adequate amount of food. When hot 
 meat is not taken in sufficient quantity, let cold meat be 
 substituted ; there is often less objection to cold meat, and 
 even in ordinary life we can eat larger quantities of cold 
 meat than of hot. When the quantity taken is still insuffi- 
 cient, the meat should be given cut up small or minced. 
 Preserved meats of various kinds may also be very useful 
 as a change, and especially caviare and oysters. Eggs also 
 should be given in every possible form. Patients with 
 heart disease in the stages for which the prophylactic 
 measures mentioned above are most valuable generally 
 take food fairly well ; and we must again emphasize the fact 
 that patients with heart disease require to take sufficient 
 good food in addition to observing all the precautions which 
 have been laid down. They must not take any excess of 
 food which only fattens them and produces digestive dis- 
 turbances — but short of this, they must take sufficient food 
 to repair the wear and tear of the tissues. 
 
 185 
 
THE PREVENTION OF DISEASE 
 
 In the prophylaxis of heart disease, it is seldom necessary 
 to have recourse exclusively to fluid diet, but if the neces- 
 sity arises, beef tea and other liquid foods, white of egg dis- 
 solved in water, and especially milk, should be given. 
 When ordinary food is eaten the amount of liquid taken 
 must be limited. It is not necessary to go so far as Oertel 
 does and stop all fluids ; for when the patient is forbidden 
 to drink at meals, it is often found that he eats much less 
 solid food. All the various " cures " for obesity are based 
 upon one and the same principle, of preventing the patient 
 from eating much ; but the methods employed dijBfer. 
 When drinking is forbidden at meals even a healthy 
 person is soon satisfied. Still the fact is undeniable that 
 no drop of fluid leaves the body without having passed 
 through the circulatory system and having thus increased 
 the quantity of fluid in circulation ; and if much fluid is 
 quickly ingested the vessels are much overfilled for a time, 
 the blood pressure raised considerably, and the heart bur- 
 dened with an excessive and injurious amount of work. 
 It is necessary therefore that the patient should take 
 liquids in moderate quantities at a time ; and if thus 
 properly divided up, two to three pints a day may very 
 well be allowed, which is the normal quantity also for a 
 healthy person. 
 
 It is not a matter of indifference what form of liquid is 
 taken. Milk, broth, cocoa, chocolate, lemonade, the juice of 
 fruits, non-aerated mineral waters, and even light wines 
 may be taken ; concentrated forms of alcohol especially 
 when hot, are to be forbidden. Though beer may in 
 some cases be permitted it must not be regarded as a suit- 
 able beverage ; when it is taken only a little of the lighter 
 form of beer should be permitted, and effervescent beers 
 must be carefully avoided. Tea and coffee if taken at all 
 must be well diluted with milk ; the measurement of the 
 cardiac stimulation caused by them will be a guide in 
 special cases. The same holds good for strong wines. They 
 should, as mentioned above, be excluded from the patient's 
 ordinary diet, though they may occasionally be taken with 
 good result, but rather as a drug than as a food. 
 
 186 
 
THE PREVENTION OF DISEASES OF THE HEART 
 
 Prophylaxis in heart disease embraces a wide scope and 
 consists of many factors. When all the measures briefly 
 described in the preceding pages are carried out, a patient 
 whose heart has through predisposition or disease under- 
 gone some loss of functional activity, may for a long time, 
 often up to the normal limit, live a life which is bearable, 
 and which does not materially deprive him of the enjoy- 
 ments of life or hinder him from work, provided the latter 
 is of a suitable kind. But medical directions alone, with 
 however great detail given, will but seldom make such 
 adequate prophylaxis possible ; in this respect, the most 
 important task which the medical profession and the public 
 authorities have before them is, as was said above, the 
 establishment of sanatoria for persons with heart disease. 
 
 187 
 
The Prevention of the Diseases of the 
 Digestive Organs 
 
 BY 
 
 DR. MAX EINHORN 
 
 Professor in the New York Post-Graduate Medical School 
 
 189 
 
The Prevention of the Diseases of the 
 Digestive Organs 
 
 GENEEAL SECTION 
 
 The prevention of diseases of the digestive organs in 
 many respects coincides with the prophylaxis of other 
 diseases. A rational mode of life, in accordance with the 
 rules of hygiene, is of the greatest importance. To enjoy 
 good health, work and rest must go harmoniously hand in 
 hand. In the civilized world, where work is often of an 
 intellectual nature, it is necessary to see that the body has 
 sufificient exercise. An incorrect mode of life with regard 
 to eating and drinking will often lead to harmful results. 
 Many diseases of the stomach and intestines are caused by 
 improper food, and it is therefore advisable to indicate 
 briefly what should be done. 
 
 Meals should whenever it is practicable be taken punctu- 
 ally at regular hours. The time given to a meal should 
 not be too short, and during the meal the body should be 
 completely at rest, physically and mentally, and no thought 
 be given to business matters or other exciting subjects. 
 Some pleasant light conversation is not only permissible 
 but is good. Food should be taken slowly, and well masti- 
 cated ; liquids too must be taken slowly and in moderation. 
 A short interval between the courses is useful. 
 
 The number of meals and the kind of food at a meal 
 may best be left to the customs in vogue among the people. 
 It appears to me however to be desirable to point out 
 that a healthy man should not always confine himself to 
 food which is very easy of digestion. On the contrary 
 one should purposely from time to time eat food which 
 
 191 
 
THE PREVENTION OF DISEASE 
 
 is less easy to digest. Every other organ of the body is 
 strengthened by work, and in the same way the digestive 
 system can only be improved and strengthened by giving 
 it more work to do. People who endeavour always to avoid 
 indigestible food will be more apt to get indigestion by 
 eating it than those would who eat indiscriminately all 
 that is put upon the table. 
 
 In health the amount of food taken is efficiently regu- 
 lated by the feelings of hunger and of satiety, but at a 
 dinner party or other festive gathering the appetite may 
 be so whetted by the dainties that an excessive quantity of 
 food is taken, and one should remember on such occasions 
 not to overburden the stomach. It is advisable to eat only 
 a little of each course, or to omit several courses altogether. 
 
 After meals it is well to rest for a short time — a quarter 
 to half an hour. This is specially necessary after the chief 
 meal, and many people are accustomed to take a short nap 
 after dinner. If the sleep is only a short one — not exceeding 
 half an hour — there is no objection to it. But if the sleep 
 is permitted to last one or two hours, it is decidedly bad 
 both for digestion and health. 
 
 CONDIMENTS AND STIMULANTS 
 
 Condiments and similar substances serve to whet the 
 appetite by stimulating the nerves of taste. Upon the 
 whole they seem to exercise a favourable influence upon 
 digestion. Among these aids to appetite are spices which 
 are added to food, and coffee, tea and alcoholic beverages. 
 Food should be made palatable, but care must be taken not 
 to use too much seasoning, otherwise the digestive organs 
 are soon irritated and disease produced. 
 
 Tea and coffee are generally taken with meals or shortly 
 after. The object of both is to counteract the feeling of 
 fatigue and sleepiness which sets in soon after a meal. It 
 is well to add sugar and milk to the coffee, and thus make 
 this beverage also a food. In moderation tea and coffee 
 are not followed by any bad effects, but are useful. If 
 however they are taken in excess, they certainly lead to 
 digestive and to nervous disorders. Restless nights are 
 
 192 
 
DISEASES OF THE DIGESTIVE ORGANS 
 
 often caused by a strong cup of coffee taken late at night. 
 In excess coffee may produce disturbances of the stomach 
 and intestines, and sometimes cause diarrhoea. The exces' 
 sive use of tea may cause constipation. 
 
 In the history of all civilized peoples we find that alcohol 
 was in use. Sometimes it was the juice of the grape, 
 sometimes mead or beer, and sometimes one or other of the 
 many forms of spirit, such as cognac, arrack and rum. The 
 antiquity and the long survival of this custom of taking 
 alcoholic drinks tend to show that they have some use. 
 As is generally known, these drinks act as stimulants. 
 They increase the bodily strength, enliven the mind, and 
 help to produce a feeling of cheerfulness and of well-being. 
 It is also known that all alcoholic beverages taken in excess 
 lead to serious organic disease ; it is therefore evident that 
 all excess must be avoided. The more concentrated forms 
 of alcoholic drinks, such as brandy and the heavy wines, 
 seem to be the most injurious. Light table wines and beer 
 less often cause disease. Total abstinence from alcoholic 
 drinks is unnecessary ; indeed it is in many respects dis- 
 advantageous. In advanced age and in most conditions of 
 exhaustion, alcoholic liquids are regarded as valuable aids 
 for strengthening the body. To prevent the production of 
 diseases by alcohol, these beverages should be taken only 
 in moderation. One should be careful therefore never to 
 exceed a given amount ; and it is moreover advisable to 
 drink only at table and occasionally in the evening in 
 company, but not to drink with friends at all hours of the 
 day. 
 
 Although this habit of constant drinking should be 
 entirely avoided, it is not necessary to make any absolute 
 rule in the matter. On festive occasions it may be per- 
 mitted to take somewhat more than usual. Such enjoy- 
 ments, if only indulged in occasionally and moderately, add 
 to the value of life. 
 
 Among the luxuries of modern life must also be reckoned 
 the use of tobacco. Smoking of cigars, cigarettes and pipes 
 should always be in moderation. There is no doubt that 
 smoking in excess brings with it evil results. It causes not 
 
 193 
 
The prevention of disease 
 
 only functional disturbances of the heart, but also digestive 
 troubles. Severe colic and obstinate diarrhoea are often due 
 to abuse of tobacco and cannot be cured until the smoking 
 is discontinued. How much one may smoke without bad 
 results is not easy to determine ; it depends very much upon 
 individual peculiarities. Many men are always smoking, 
 and yet reach old age without feeling any ill effects from 
 their misuse of tobacco. Others again suffer from tobacco 
 poisoning if they smoke two or three light cigars a day. 
 The use of tobacco is a luxury and of no special advantage, 
 and we would therefore counsel growing youths not to 
 accustom themselves to the habit. The pleasure which 
 smoking gives will not be missed by one who has never 
 smoked. Smokers should be advised to smoke only at cer- 
 tain hours in the day, and to use tobacco in moderation. 
 Directly after meals is the best time for smoking. It is 
 hardly necessary to add that light cigars are preferable 
 to strong cigars, because the latter contain a much larger 
 proportion of nicotin. In America the custom of chewing 
 tobacco is very common, especially among the lower classes. 
 By this method the tobacco is brought into close contact 
 with the mucous membrane of the mouth and cheeks, and 
 the nicotin is quickly absorbed, and therefore obviously 
 symptoms of tobacco poisoning appear earlier than after 
 smoking. This is a fact, and it would be a valuable pro- 
 phylactic measure to do away with this evil custom. 
 
 The natural instinct with regard to sexual enjoyment 
 may, in so far as it exists, be satisfied. But excesses lead 
 to general conditions of weakness and to nervous disorders 
 of the digestive apparatus. The golden rule here, as in so 
 many other matters, is the happy medium. Although for 
 the prevention of digestive troubles it would be safer to 
 abstain altogether from many enjoyments, such as drinking 
 and smoking, yet we do not advise absolute prohibition of 
 tobacco and alcohol. 
 
 194 
 
DISEASES OF THE DIGESTIVE ORGANS 
 
 The Prevention of Digestive Disorders in the 
 Course of other Diseases 
 
 The rules given above are mainly for prophylaxis against 
 digestive troubles in healthy individuals. It is now neces- 
 sary to refer to the prevention of gastro-intestinal disorders 
 in the course of other diseases. The first essential in acute 
 diseases should be to take precautions to spare the digestive 
 apparatus. The acute stage is generally of short duration, 
 and no harm will result from restricting the diet for a short 
 time. The diet should be small in amount, and should con- 
 sist of food which is most easy of digestion, and preferably 
 liquid food. But if the acute illness lasts more than one or 
 two weeks, or if a patient already very weak is attacked 
 by an acute illness, more food must be given earlier, and 
 moreover it should be as easy of digestion as possible. 
 During convalescence after acute illness the change to 
 ordinary food must be made very slowly and cautiously, 
 because after the acute illness the appetite is very keen, 
 and if left to his own inclinations and unwarned the patient 
 is very apt to eat impropsr food which will set up other 
 troubles in the digestive tract. 
 
 A weakened body is always a favourable soil for the 
 development of most pathological conditions, and the fore- 
 most and most important task in prophylaxis is to restore 
 strength to the weakened body. This can be done chiefly 
 by a suitable diet, and it will not be superfluous here to 
 state the fundamental principles of dietetics which are so 
 important in relation to those who have been weakened by 
 chronic disease. 
 
 Two important facts have been discovered during recent 
 years of the greatest significance in the treatment of 
 patients suffering from gastric trouble, and they have in- 
 fluenced considerably the entire field of dietetics. The first 
 fact discovered (by von Noorden and others) was that the 
 
 195 
 
THE PEEVENTION OF DISEASE 
 
 emaciation in chronic diseases of the stomach is not the 
 result in a large majority of cases (if not in all) of poisons 
 circulating in the blood, but is entirely the result of in- 
 sufficient ingestion of food. On the other hand, by analogy 
 drawn from animal and vegetable life, where if any one 
 organ is injured or removed some other allied organ takes 
 on the function of the injured organ and vicariously does 
 the work, it seemed probable that when serious disturbance 
 in gastric digestion was present the intestines might do 
 the work instead. That this is a fact has now been 
 experimentally and clinically proved ; several observers 
 (Leube, Ewald and von Noorden) have made observations 
 and found that in cases of atrophy of the gastric mucous 
 membrane where the gastric secretion has completely 
 ceased, patients may nevertheless keep up their weight. 
 My own work on achylia gastrica, that is absence of gastric 
 secretion, shows that these patients can get on perfectly 
 well without gastric juice ; indeed if they follow a suitable 
 plan they may even increase in weight and live the full limit 
 of life without suffering any trouble : that is to say when 
 the chemical functions of the stomach are entirely lost, the 
 intestines may completely carry out these functions. 
 
 These two facts — (1) that the emaciation in chronic gastric 
 disease rests upon insufficient ingestion of food, and (2) that 
 even in serious disorders of the gastric functions the in- 
 testines may act vicariously and perform all the work of 
 digestion — are of fundamental importance in dietetics. It 
 is therefore evident that the chief aim in the feeding of 
 patients must be to give them a sufficient quantity of food. 
 
 As the substances needed to maintain life in patients 
 suffering from digestive troubles are not less in amount 
 than those required under normal conditions, they will 
 probably require to take (1) as large a quantity of food, 
 (2) the same kinds of food, as under normal conditions. 
 The only possible difference will be the choice among the 
 variety of foods and the choice as to the form and prepara- 
 tion of the food. 
 
 The digestibility of a food depends, firstly upon its form 
 and consistence, secondly upon the amount of nutritive 
 
 196 
 
DISEASES OF THE DIGESTIVE ORGANS 
 
 matter which it contains. " Corpora non agunt nisi fliiicla," 
 is an old axiom, and the following table of foods, drawn up 
 mainly according to their conditions as liquids or solids, 
 ranges the foods according to their digestibility. 
 
 1. Most digestible are foods in the fluid form— either (ci) 
 fluids : milk, meat juice, broth, beef extracts, solutions of 
 peptones, toast water, mucilaginous decoctions, rice water, 
 oyster soup, solutions of white of egg ; (6) substances which 
 become liquid at the temperature of the body : jellies, fruit 
 jellies, ice cream, fruit ices. 
 
 2. Broths : foods cut up very small and well cooked in 
 water; soup in the form of broth (barley soup, oatmeal, 
 semolina, rice, sago), egg soup, Leube's meat essence, 
 pounded meat, powdered biscuits in milk, water or broth, 
 koumiss, skim milk, cream and butter. 
 
 3. Foods which are easily broken up by stirring in 
 water: white bread in milk or water, the tops of well- 
 cooked asparagus, carrots, mashed potatoes, baked potatoes, 
 hard boiled yolk of egg, and oysters. 
 
 4. Solid foods : white bread, rye bread, meat, hard-boiled 
 eggs, fish and cheese. 
 
 5. Substances very difficult of digestion : meat of coarse 
 fibre, lobsters, sausages, and Swiss cheese. All substances 
 containing much cellulose, especially when they are eaten 
 raw : vegetables, salads, cucumbers. Uncooked fruits : 
 apples, pears, pineapples. Fruits containing much acid, 
 namely, all unripe fruits, strawberries. Substances which 
 contain mach sulphur, and thus tend to cause flatulence : 
 all forms of cabbage, especially white cabbage, beans. 
 
 This list is arranged on theoretical principles, and for the 
 most part accords with the opinion founded on experience, 
 and by this experience I am generally guided. 
 
 To prevent insufficient food being taken by the patient, 
 it is best not to forbid any food except such as we know to 
 be directly injurious to the patient, and to let the patient 
 have a large variety of food. 
 
 With regard to the number of meals and the times for 
 meals, it is best not to make any change unless there is 
 some special indication for it. 
 
 197 
 
THE PEEVENTION OF DISEASE 
 
 There are many prejudices against certain foods, both 
 among the public and among medical men. For example 
 fat and butter were formerly strictly forbidden in all 
 dyspeptic conditions. But fat is one of the food-stuffs 
 which possesses the [greatest value as a heat-producer, and 
 butter moreover is not a bulky form of food. Fat which is 
 not rank passes through the stomach without affecting it 
 at all, and is digested in the intestine ; there is therefore 
 no ground for withholding butter, and indeed it should be 
 strongly recommended. Bread and other carbohydrate food 
 is often forbidden or its use restricted for fear that it will 
 cause fermentation. Even though it be true that carbo- 
 hydrates readily give rise to fermentation, yet the cases in 
 which much fermentation occurs in the stomach are fairly 
 rare, and it only occurs when food is delayed in the stomach 
 for a very considerable time. The adult consumes daily, 
 according to Konig, f pound to 1^ pounds of bread, and 
 60 to 60 per cent, of his total food and 50 to 75 per cent, 
 of his carbohj'-drate food is taken in the form of bread. 
 This shows plainly how valuable bread is, and the use 
 of it should generally be recommended. It is usually said 
 that bread crust, stale bread and biscuits are more easily 
 digested because a larger proportion of the starchy material 
 they contain has been converted into dextrose. Although 
 I think that new bread should be avoided, yet I seldom find 
 any great difference in the ease with which patients digest 
 crust and the other parts of well-baked white bread. 
 
 The use of stimulants, such as wine, beer, coffee and tea, 
 may generally be permitted as occasion necessitates, but 
 they must be taken in moderation and in a suitable form. 
 Strong spirits and spices should be avoided. 
 
 Substances to promote appetite are beneficial, especially 
 if directly indicated ; a little caviare, some sardines or 
 anchovies can be given with bread or a biscuit a quarter 
 of an hour before a meal time. 
 
 These principles are applicable to all cases of chronic 
 disease, whether of the digestive system or of any other 
 organ, as in tuberculosis, in diseases of the heart, kidney, 
 liver or spinal cord. 
 
 198 
 
DISEASES OF THE DIGESTIVE ORGANS 
 
 The Prevention of Diseases of the Stomach 
 
 GASTRIC CATARRH 
 
 Acute gastric catarrh may be best prevented by avoiding 
 errors in diet, sucli as overloading the stomach, ingestion 
 of improperly cooked or decomposed food and ice-cold 
 drinks. Eating too quickly and swallowing large un- 
 masticated pieces of food should also be carefully avoided. 
 
 Chronic gastric catarrh may be best prevented by care- 
 fully treating acute gastric catarrh, and not allowing it to 
 pass into a chronic condition ; and by avoiding everything 
 which tends to cause chronic gastric catarrh. One should 
 not eat too quickly, should well masticate the food before 
 it is swallowed, and not overload the stomach with large 
 quantities of food. Highly seasoned dishes and ice-cold 
 drinks irritate the stomach and may produce a catarrhal 
 condition. Iced water and eating too fast are the two chief 
 causes of the so-called " American dyspepsia." Tea and 
 coffee taken in excess can also give rise to chronic gastric 
 catarrh. Alcoholic drinks, especially the stronger kinds, 
 such as whisky, liqueurs, and " bitters," and the excessive 
 use of tobacco, by smoking and more particularly by 
 chewing, may also cause gastric catarrh. 
 
 In addition to suitable dieting, the patient should lead a 
 rational healthy life. Business hours should not be too long ; 
 and sufficient bodily exercise should be taken. Walking 
 or driving, riding, cycling and rowing should be strongly 
 recommended ; but care must be taken not to overstrain 
 the body. Gymnastic exercises at home are also useful, 
 say for ten minutes every morning. A cold bath in the 
 morning, and thorough friction with a thick rough towel 
 are valuable. Moreover the patient should live in well 
 ventilated rooms, and be forbidden to stay long in smoky 
 places and restaurants. 
 
 199 
 
THE PREVENTION OF DISEASE 
 
 GASTEIC ULCEE 
 
 Yon Sohlern lias pointed out tliat in many districts 
 ! where the inhabitants' diet consists chiefly of vegetables 
 ■^ gastric nicer is unknown. A vegetable diet is very rich 
 in potassium salts, for it contains about a third more than 
 does a mixed diet ; and as the red blood corpuscles are the 
 chief carriers of potassium, Von Sohlern thinks that the 
 greater amount of potassium salts in their food confers 
 immunity against gastric ulcer on the inhabitants of these 
 districts. For these theoretical reasons. Von Sohlern re- 
 commends the administration of potassium salts and of 
 foods rich in vegetable substances as a prophylactic against 
 gastric ulcer. 
 
 Certain occupations greatly predispose to ulcer of the 
 stomach, and in cases of gastric ulcer these occupations 
 should be avoided. Cooks often suffer from gastric ulcer, 
 and the tasting of very hot food has often been thought to 
 be the cause. Cooks should therefore be cautioned and 
 advised to let the food cool before they taste it. Shoe- 
 makers are said often to suffer from gastric ulcer, most 
 probably from the bent position of the body assumed in 
 their occupation. It is advisable therefore to hold the 
 body as upright as possible when at work. 
 
 Chlorosis and anaemia are important factors in the 
 causation of gastric ulcers, and it is therefore important to 
 treat these disorders at the very beginning, and remove 
 the condition favouring the development of gastric ulcer. 
 Excess of hydrochloric acid is very often met with in 
 gastric ulcer, and it is highly probable that this is favour- 
 able to the development of an ulcer. This excessive forma- 
 tion of hydrochloric acid therefore should be treated. 
 
 Grastric ulcer is often accompanied by serious complica- 
 tions, haematemesis and perforation being the most 
 i dangerous. It seems desirable here to say a few words with 
 regard to the prevention of these. A strict diet is of first 
 importance, it should be liquid or semi liquid, and all 
 indigestible and highly seasoned food should be avoided ; 
 and next in importance is the avoidance of severe bodily 
 
 200 
 
DISEASES OF THE DIGESTIVE ORGANS 
 
 movements, siicli as riding and golf. When the haemor- 
 rhage is of frequent occurrence, it may be advisable to think 
 of performing a gastro-enterostomy in order that the 
 gastric contents may more rapidly be passed on into the 
 intestine, and the surface of the ulcer be thus to some 
 extent relieved from irritation. This operation is often of 
 great value in preventing recurrence of haemorrhage, and 
 moreover it may lead directly in some cases to recovery. 
 
 EEOSIONS OF THE STOMACH 
 
 In a large number of cases of erosion of the stomach, a 
 chronic catarrh coexists and seems to be the cause of the 
 erosion. The prophylactic measures which are best for 
 preventing erosions are those which prevent the chronic 
 gastric catarrh. 
 
 CAECINOMA OF THE STOMACH 
 
 The cause of cancer is not yet known, it is therefore 
 scarcely possible to state how it may be prevented. "VVe 
 can merely name a few of the factors which are said to 
 play a part in the aetiology of cancer, and say how they 
 are possibly to be avoided. Some accident was formerly 
 regarded as definitely a cause of the development of cancer 
 of the stomach. Of late this opinion has been much em- 
 phasized by Boas. It is advisable therefore that all blows 
 upon the abdomen be avoided. During recent years many 
 authorities have stated that cancer is more frequent among 
 the upper classes, who live well and eat much meat, than 
 among the poorer classes. If such be the case, care should 
 be taken to live less luxuriously and to eat less meat. 
 According to Eichorst and Cloquet the frequent consump- 
 tion of cider and of sour wines is said to favour the 
 development of cancer. Another matter should also receive 
 attention. As Eosenheim has shown that cancer sometimes 
 develops upon the site of an ulcer, it is advisable that 
 every effort should be made to heal an ulcer, in order to 
 prevent the formation of a cancer. 
 
 201 
 
THE PREVENTION OF DISEASE 
 
 HYPEECHLOEHYDEIA AND HYPEESECEETION 
 
 Sorrow and anxiety and mental overwork must be 
 strictly forbidden. All highly seasoned food, strong 
 alcoholic beverages and iced water must be avoided. These 
 causes all contribute greatly to the development of hyper- 
 chlorhydria, that is the excessive formation of hydrochloric 
 acid, and hypersecretion. "When hyperchlorhydria is already 
 present, every possible means should be taken to prevent 
 the disorder from getting worse. The daily life of the 
 patient must then be regulated with reference to the 
 amount of work he does, bodily exercise, mental rest and 
 amusements. "What suits one does not suit another, and it 
 is therefore necessary to treat each patient individually. 
 Business men upon whom great responsibilities rest, lawyers, 
 politicians and physicians must be taken away from their 
 work and sent into the country in order to allow the brain 
 to rest from the strain for a time. Ladies in high circles 
 of society who frequent all social functions must adopt a 
 quiet life. There are others again possessing much pro- 
 perty and having no occupation who get ill merely because 
 they devote too much attention to their bodily functions, 
 and it becomes necessary to find some mental occupation 
 for them. Sponging the body all over with cold water 
 every morning, and bodily exercise for about eight or ten 
 minutes on rising are valuable in most cases. The patient 
 should be advised to take a walk once or twice a day for 
 half to one hour, or to ride, drive, or cycle. 
 
 ACHYLIA GASTEICA 
 
 Gastric atrophy can only rarely be prevented. Chronic 
 gastric catarrh which has existed a long time passes into 
 atrophy. Careful treatment of the gastric catarrh is there- 
 fore often serviceable as a prophylactic against the develop- 
 ment of atrophy. G-eneral nervous conditions must be 
 carefully treated by the usual measures, so that these pre- 
 disposing conditions for atrophy may be removed. There 
 are however cases in which gastric atrophy has existed 
 
 202 
 
DISEASES OF THE DIGESTIVE ORGANS 
 
 so long tliat we have to look upon it as a congenital 
 abnormality. In such cases no prophylaxis is possible. 
 
 DILATATION OF THE STOMACH 
 
 Acute dilatation of the stomach can bs prevented by 
 avoiding all errors in diet and overloading of the stomach. 
 
 Chronic dilatation of the stomach may result from various 
 causes : (1) stenosis of the pylorus ; (2) hypertrophy of the 
 pylorus ; (3) distention and muscular weakness of the 
 stomach. Stenosis of the pylorus may be caused by non- 
 malignant as well as by malignant new growths. Pre- 
 vention of stenosis of the pylorus can have reference only 
 to the non-malignant forms, and these are for the most part 
 due to the development of scar tissue after an ulcer has 
 healed For these reasons the ulcerative process must be 
 very carefully treated while still recent, and treatment 
 should be continued till the ulcer has permanently healed. 
 As soon as there are symptoms of a commencing ulcer a 
 fluid diet must be adopted and continued for a long time, 
 in order to prevent any severe irritation of the spot. The 
 region around the ulcer near the pylorus, which becomes 
 irritated and inflamed, will thereby be more easily restored 
 to its normal condition. The cause of simple hypertrophy 
 of the pylorus is not yet understood, and its prophylaxis is 
 therefore impossible. Prophylaxis of malignant stenosis of 
 the pylorus is similar to that for cancer of the stomach. 
 To prevent dilatation of the stomach from weakness of the 
 muscular wall, all atonic conditions of the stomach must 
 be treated early by electricity, massage, and general gym- 
 nastics, and by proper diet. The imbibition of large 
 quantities of fluid should also be avoided. 
 
 TETANY 
 
 Tetany is occasionally a complication of dilatation of the 
 stomach. It can only be prevented by not permitting 
 food to accumulate in the stomach. This is best done by 
 giving liquid food, by washing out the stomach, and by 
 administering drugs which check fermentation. Bouveret 
 
 203 
 
THE PREVENTION OF DISEASE 
 
 and Devic have shown that when much alcohol is taken 
 more toxic products are formed in the stomach in the 
 presence of hydrochloric acid ; and it is therefore obvious 
 that to prevent tetany alcohol must be forbidden. 
 
 ENTEEOPTOSIS 
 
 Much may be done to prevent enteroptosis. In a large 
 number of cases it is the result of mechanical action. 
 Compression of the lower part of the thorax and of the 
 upper half of the abdomen pushes the organs downwards. 
 It is of the utmost importance that women should not wear 
 corsets, or at least that the corsets should be loose. Tight 
 clothes round the waist must also be avoided. Enteroptosis 
 may also arise from rapid changes in the contents of the 
 abdomen, as after childbirth or the removal of large abdo- 
 minal tumours. In these cases there is a sudden lowering 
 of abdominal pressure, and organs which have occupied a 
 higher position slip down to fill the empty space, The best 
 means of preventing enteroptosis in all these cases are rest 
 in bed for several weeks, and the use of suitable abdominal 
 belts to keep the abdominal walls in position and reduce 
 the size of the abdomen. Enteroptosis may be caused also 
 by great emaciation and inanition ; and attempts should be 
 made to prevent it by administering nutritive food. It is 
 also important to strengthen the abdominal muscles by 
 gymnastic exercises. 
 
 NEEVOUS AFFECTIONS OF THE STOMACH 
 
 Excessive mental exertion, grief, unusual excitement 
 and sexual excesses are the chief causes of neuroses of 
 the stomach. These points should all receive attention. 
 Several neuroses of the stomach continue or become worse 
 by constant repetition, for example nervous eructations, 
 regurgitation, rumination and nervous vomiting. In 
 such cases it is important to get the patient to suppress 
 the desire to bring up gases and food. Habit plays a 
 great part in prophylaxis, and whenever there is a ten- 
 dency to these disorders the patient should be properlj^ 
 
 204 
 
DISEASES OF THE DIGESTIVE ORGANS 
 
 instructed wliat to do. In neuroses affecting other organs, 
 general treatment is required to prevent the development 
 of any neurosis of the stomach. 
 
 The Prevention of Diseases of the Intestine 
 
 ACUTE AND CHEONIC INTESTINAL CATAEEH 
 To prevent acute intestinal catarrh the following rules 
 must be observed. 
 
 1. One must carefully avoid heavy indigestible food, ice- 
 cold drinks, tainted meat or fish, unripe fruit, stale or sour 
 beer, and bad water. 
 
 2. Excessive ingestion of food and drink, even though 
 wholesome, must also be forbidden. 
 
 3. Many organic and inorganic substances which 
 chemically irritate the intestinal mucous membrane and 
 cause inflammation must be prescribed as seldom as 
 possible: such are the drastic purgatives like croton oil, 
 colocynth and jalap ; and among inorganic substances, 
 tartar emetic, arsenic, lead, copper sulphate, all prepara- 
 tions of mercury, concentrated acids and strong caustic 
 alkalies. 
 
 4. Mechanical irritation by faecal masses, gallstones, 
 enteroliths ; or foreign bodies which have been swallowed, 
 as large fruit stones and coins, may cause inflammation. 
 
 5. Influences of temperature: the susceptibility to 
 changes of temperature seems to be very different in 
 different individuals. Some people get diarrhoea if they 
 sleep in summer without much bedclothes and the tempera- 
 ture happens to fall ; others by getting their feet wet. 
 
 Chronic intestinal catarrh arises either out of a severe 
 acute enteritis which has not perfectly subsided, or after 
 repeated attacks of acute enteritis in rapid succession and 
 before the intestine has had an opportunity of recover- 
 ing completely. This often occurs in patients who take 
 but little notice of an apparently trivial affection and do 
 
 205 
 
THE PEEVENTION OF DISEASE 
 
 not carry out the physician's instructions about diet. The 
 direct causes are similar to those of acute enteritis. For 
 prophylaxis it is therefore necessary to take the pre- 
 cautions required to prevent acute intestinal catarrh, and 
 moreover to treat an acute intestinal catarrh carefully and 
 thoroughly and prevent relapse. In regard to this the 
 following is important : the patient should wear warm 
 clothing, especially over the abdomen (flannel belt) and on 
 the feet, and take care not to get wet feet ; in rainy 
 weather shoes with thick soles or goloshes should be worn. 
 "When there is diarrhoea, we must forbid acid and sweet 
 wines, all aerated mineral waters, lemonade, all fruits, 
 salads, all kinds of cabbage and cauliflower, and brown 
 bread and pastry. Instead of these we should give only 
 eggs (lightly boiled or beaten up), tender meat, calf's brain, 
 chicken, lamb cutlets, oysters, light fish, well baked white 
 bread or toast, fresh butter, and mucilaginous soups, meat 
 broth, rice, sago, macaroni, mashed potatoes or baked 
 potatoes, milk, cocoa, tea, koumiss, ginger ale, good red 
 wine, or tokay. 
 
 All food must be taken only in small quantities at a time ; 
 drinks should be warm or cool (at the temperature of the 
 room), but not cold. "When there is a tendency to constipa- 
 tion, light fruits may be taken, such as oranges, grapes, or 
 ripe pears, green vegetables, green peas and cauliflower. 
 The addition of more nutritive foods, easily assimilated fat, 
 butter, cream and liquids will bs useful. Indigestible 
 food, such as brown bread, Grerman sausage, lobster salad, 
 mayonnaise, cabbage and cucumber should be avoided. 
 Beer, porter, or Rhine wine in moderate quantities may be 
 allowed. 
 
 DYSENTEEY 
 
 It is best to keep away from those latitudes where 
 dysentery is endemic. In epidemics care should be taken 
 to regulate the life according to the best hygienic principles. 
 Food should be taken regularly, as hunger or want of food 
 predisposes to this disease. Recent investigations show 
 that most cases of dysentery are caused by invasion of the 
 
 206 
 
DISEASES OF THE DIGESTIVE ORGANS 
 
 body by amaeboe. Tlie latter enter tlie body mainly with 
 the food or drink, and scrupulons care should therefore be 
 taken that the food and liquids taken are absolutely free 
 from contamination. The food should be eaten boiled or 
 roasted, and the water filtered and afterwards boiled. Raw 
 fruit and salad should be omitted from the dietary. Care 
 must be observed that the evacuations of dysenteric 
 patients do not contaminate anything, or very thorough 
 disinfection should be employed. 
 
 INTESTINAL ULCEES 
 
 It will scarcely be possible to prevent duodenal ulcers. 
 Upon the whole the indications for prophylactic treatment 
 are similar to those for gastric ulcer. After extensive 
 burns duodenal ulcers are apt to form, and it is therefore 
 necessary to keep the burnt surface carefully dressed and as 
 aseptic as possible. 
 
 Tuberculous ulcers in the intestine may be primary or 
 secondary. To prevent primary ulcers care must be taken 
 that the flesh of tuberculous animals is not eaten, nor the 
 milk from tuberculous cows. It is difficult to ascertain 
 whether the milk is from a healthy or tuberculous cow, 
 and it is therefore very advisable to boil the milk regularly 
 before use. Secondary tuberculous ulcers occur in phthiscal 
 patients and are generally caused by sputum which is 
 swallowed and so infects the bowel. Phthisical patients 
 should therefore be directed never to swallow their sputum 
 but always to expectorate it. 
 
 Syphilitic ulceration of the intestines is best prevented by 
 thorough treatment with mercury directly the first signs 
 of syphilis appear. 
 
 Yery little can be done to prevent lardaceous disease of 
 the bowel. Conditions of malnutrition should be avoided. 
 
 NEW GEOWTHS OF THE INTESTINES 
 
 New growths both malignant and benign in the intestine 
 cannot be prevented, because we are at present completely 
 in the dark as to the aetiology of these tumours. 
 
 207 
 
THE PREVENTION or DISEASE 
 
 HAEMOEEHOIDS 
 
 All conditions wliicli lead to permanent hyperaemia of 
 the lower part of the rectum tend to cause haemorrhoids. 
 These points should be carefully noted. Occupations which 
 necessitate prolonged sitting or standing should be avoided. 
 Clerks, students, shoemakers, tailors, cavalrymen, needle- 
 women and washerwomen must take especial care against 
 haemorrhoids. Those who live well and those who take 
 highly spiced and fatty food suffer from congestion of the 
 portal circulation and thus are predisposed to haemorrhoids ; 
 such patients should adopt a simpler, more suitable mode of 
 life. Habitual constipation and the use of strong pur- 
 gatives, such as aloes, colocynth, or gamboge, are a frequent 
 cause of haemorrhoids, and this must be borne in mind in 
 prophjdaxis. Patients who are predisposed to haemorrhoids 
 should observe the following rules : they should take 
 plenty of exercise in the open air, eat little, avoid alcoholic 
 or venereal excess, and see that the bowels are daily 
 evacuated. If there is any tendency to constipation the 
 following purgatives are useful — salines, sulphur, or rhu- 
 barb : for example a teaspoonful of the compound powder 
 of liquorice every evening, or a teaspoonful of equal parts of 
 flowers of sulphur and cream of tartar. Rhubarb in the form 
 of the tincture or as a powder, ten to fifteen grains twice 
 daily, is useful for more constant use. The waters of Karlsbad, 
 Kissingen, Marienbad, Tarasp and Saratoga are also of 
 use, more especially when taken at these springs in 
 combination with a suitable diet. With regard to the diet 
 the following points should be observed : full meals should 
 be avoided, and food taken more often but little at a time. 
 Fish, well cooked fresh vegetables and ripe fruit should 
 compose the main bulk of the food. Alcoholic drinks, strong 
 coffee and highly spiced dishes should be avoided. The 
 various kinds of cheese, very coarse brown bread, cabbage, 
 peas and beans are best omitted. Salad, potatoes, carrots, 
 spinach, asparagus and cauliflower are permissible in small 
 quantities because they make the intestinal contents more 
 liquid ; boiled and raw fruit, such as apples, pears, plums, 
 
 208 
 
DISEASES OF THE DIGESTIVE ORGANS 
 
 oranges and grapes are useful. For a beverage water is 
 best, taken between meals, rather less than a pint at a time. 
 In some cases, especially in anaemic conditions, a little 
 skimmed milk may be given instead of water. A small 
 quantity of light beer may be permitted. 
 
 APPENDICITIS 
 Formerly, as a prophylactic, one forbade the swallowing 
 of fruit stones, pieces of bone, and portions of indigestible 
 food, but now we know that these play no part whatever 
 in the production of appendicitis. Regulation of the 
 bowels and removal of constipation were also regarded as 
 important prophylactic measures, but recent investigations 
 show that this is not so. Regulation of the bowels is 
 important and to be recommended, but the only means we / 
 possess of preventing appendicitis is to remove the appendix. ^ 
 This cannot be recommended in all cases, because the 
 operation is not quite free from danger, but it may always 
 be undertaken when a laparotomy is necessary for some 
 other reason and when it does not take too long. 
 
 INTESTINAL OBSTRUCTION 
 
 Prophylactic measures against acute intestinal obstruction 
 are only possible in the sense that all conditions should be 
 avoided which tend to produce it. AVe should take care that 
 all herniae are radically cured or a suitable truss applied. If 
 gallstones are present, purgatives should be used to prevent 
 the gallstone from becoming impacted and causing obstruc- 
 tion. In severe chronic constipation intestinal obstruction 
 may result from the occlusion of the lumen of the intestine 
 by hard faecal masses. In these cases care should be taken 
 not to let constipation exist for long, and to soften the 
 faecal masses if they have become hard. In constriction of 
 the intestines, acute intestinal obstruction must be avoided. 
 For such cases mild aperients should be often used, and all 
 food should be avoided which gives rise to much faecal 
 matter or which irritates the intestine. Thus, green vege- 
 tables, salad, fruit, vinegar, mustard and pepper should be 
 strictly forbidden ; but the patient may take milk, milk 
 
 209 p 
 
THE PEEVENTION OF DISEASE 
 
 soups, eggs, tender meat witliout much fat and without any 
 gristle, butter, toast, or well baked white bread, gruel, rice, 
 or sago, well cooked. Patients should eat frequently and 
 not too much at a time. Cold drinks should be avoided. 
 Care must be taken to give sufficient food. 
 
 DIAEEHOEA 
 
 Diarrhoea is either a symptom of intestinal catarrh, or is 
 associated with abnormalities of the functions of the stomach, 
 or is an independent purely nervous affection. Prophylaxis 
 of intestinal catarrh has already been described, and we 
 need only refer here to the two latter forms. To prevent 
 diarrhoea which occurs in connexion with abnormal 
 conditions of the stomach — " dyspeptic diarrhoea " — the 
 abnormal condition of the stomach must be treated as soon 
 as it is diagnosed, and every available means taken to cor- 
 rect it. To prevent nervous diarrhoea, it is necessary by the 
 usual means to strengthen the nervous system of all who 
 are predisposed to neurasthenia or to any nervous disease. 
 
 Bromides, iron and arsenic will often be needed. A 
 sufficient amount of food must be taken and of great variety, 
 and the bowels must be made to act regularly. After the 
 bowels have acted in the morning, the patient should not 
 allow them to act again unless it is absolutely unavoidable. 
 Any slight desire to defaecate should be suppressed. 
 
 CONSTIPATION 
 
 Habitual constipation is in many cases caused by re- 
 peatedly neglecting the calls of nature. Young girls at 
 school suppress the desire to defaecate from a sense of false 
 modesty, and this leads to irregularity in the action of the 
 bowels and afterwards to constipation. G-reat punctuality 
 should be observed with regard to this act. The exhibition 
 of purgatives for slight temporary digestive disturbances 
 should be avoided and nature should be allowed to act. A 
 patient should never be too long restricted to an exclusive 
 diet ; exclusion of vegetables, fruit and of carbohydrates 
 from the diet often leads to marked constipation. An 
 hygienic mode of life, regular habits, less strain from work, 
 
 210 
 
DISEASES OF THE DIGESTIVE ORGANS 
 
 less worry and more fresh air and out-of-door exercise are of 
 the greatest value in preventing constipation. As a rule I 
 give very little or no aperients. "When there is a tendency 
 to slight constipation the following measures will be found 
 to be best : one should drink simple cold water upon an 
 empty stomach, or skimmed milk, take grapes, oranges, and 
 other fruit, raw or cooked, such as apples, plums, pears and 
 peaches, lemonade, honey, salmon, sardines, herrings, plenty 
 of vegetables, spinach, green peas, cauliflower, cabbage, 
 salad, rye bread and butter. One should avoid strong tea, 
 red wines, bilberries, cocoa and chocolate, 
 
 METEORISM OR FLATULENCE 
 
 This affection, when not produced by some organic ob- 
 struction in the intestine, is caused by some anomaly in 
 peristalsis and absorption. For the former cause hardly 
 anything can be done in the way of prophylaxis. For the 
 latter two causes the following points should be observed : 
 one should avoid taking much gas, as in aerated waters 
 or substances which give rise to much formation of gas, 
 such as cabbage, beans and peas, and large quantities of 
 carbohjT-drates. Care should be taken that the bowels act 
 regularly, and any slight tension in the abdomen should be 
 relieved by a mild aperient. 
 
 INTESTINAL PARASITES 
 
 For the prevention of infection by intestinal parasites 
 the following measures are of importance : (I) The hands 
 should be kept very clean. If soiled with any faecal 
 matter, and after touching domestic animals, the hands 
 should be carefully washed and possibly a disinfectant 
 used. (2) All meat and vegetables should be well cooked, 
 or exposed to a sufficiently high temperature. All fruits 
 and salads should be thoroughly washed before being put 
 on the table. (3) Drinking water should be filtered and 
 boiled. (4) Navvies and brickmakers should wash their 
 hands thoroughly before meals and on leaving work. 
 
 211 
 
Prophylaxis in Surgery 
 
 BY 
 
 PROF. A. HOFFA 
 
 OF WiJEZBUEG 
 
 AND 
 
 DR. A. LILIENFELD 
 
 213 
 
Prophylaxis in Surgery 
 
 The following pages are a presentment of one aspect of 
 hygiene, indeed a kind of clinical hygiene. In reality, 
 every method of treatment is preventive, since from the 
 moment that the patient comes into our hands for treat- 
 ment, we endeavour to prevent further mischief, and 
 to remove the mischief which already exists. In the 
 special department of surgery, however, there is, if one may 
 say so, a special prophylactic treatment. In every case we 
 are obliged, Avhenever it is at all possible, to act conserva- 
 tively ; and when the conservatism is not possible and 
 operation is inevitable, we remove as little as possible and 
 adopt the safest course and method we can. All the great 
 results of modern surgery are the outcome of prophylactic 
 measures. By anaesthesia we prevent the patient feeling 
 pain and cause relaxation of the muscles ; by Esmarch's 
 method of depriving a part of its blood supply, haemor- 
 rhage is reduced to a minimum, and by aseptic or anti- 
 septic treatment of wounds we guard our patients against 
 the risk of infection. In other ways too preventive 
 treatment plays an important role in surgery, and we 
 cannot too strongly urge the surgeon to perfect himself in 
 prophylaxis. From how much trouble, for instance, he can 
 save a patient if he treats a fracture rightly from the very 
 beginning ; and how much trouble will be caused, not only 
 to the patient himself, but also to the doctor and the 
 accident insurance company, when the injured part has not 
 healed properly. Such accidents and their results have 
 proved to us how much formerly was lacking in the treat- 
 ment and especially in the after treatment of such injuries, 
 
 215 
 
THE PREVENTION OE DISEASE 
 
 and how much better able we are now to treat these cases 
 correctly from the very beginning. 
 
 We have endeavoured in the following pages to expound 
 the general principles according to which preventive treat- 
 ment in the various departments of surgery should be 
 carried out. 
 
 A. General Prophylaxis 
 
 I. PEEVENTIVE MEASUEES IN THE PEfiFORMANCE 
 OF OPERATIONS 
 
 The report of Heimann shows that 569,576 patients were 
 treated in the various hospitals of Prussia during the year 
 1894 ; and that 58,988 patients out of this total number 
 underwent serious operations. He calculates that twelve 
 per cent, of the total number of deaths occurring in 
 hospitals were after operations. These figures warn us that 
 in spite of all advances in antisepsis and asepis, and in spite 
 of all improvements recently introduced to minimize the 
 risks of anaesthesia, we should in every case consider very 
 carefully whether all the indications for the operation are 
 present, and we should constantly keep before our minds 
 the dangers to which we expose our patients in major 
 operations. The nature of the dangers is twofold, some- 
 times arising from threatened infection, at other times from 
 the anaesthetic itself. One of the noblest aims of the 
 surgeon is to relieve pain, and we can readily understand 
 the enthusiasm aroused by the introduction of anaesthesia, 
 as described by Diffenbach in his book, " Ether, a Preventive 
 of Pain." Yet this must not blind us to the great moral 
 responsibility which we take upon us when we give anaes- 
 thetics. 
 
 What then are the dangers of anaesthesia, especially of 
 chloroform anaesthesia (that anaesthetic being still most 
 frequently used in Grermany) and how can we prevent these 
 risks as far as possible ? 
 
 Every time an anaesthetic is given we should be on the 
 lookout for acute chloroform-asphyxia with its manifold 
 symptoms, and next we must guard against its after effects. 
 As to the latter, the researches of Fraenkel, Kindskopf and 
 
 216 
 
PROPHYLAXIS IN SURGERY 
 
 others have shown that degenerative changes are produced 
 in various organs, especially in the kidneys and heart, by 
 the toxic action of chloroform. In patients with renal or 
 cardiac disease chloroform must be administered with the 
 greatest caution, or some other anaesthetic must be substi- 
 tuted for it. "VVe see how important it is to examine 
 thoroughly the patient before giving him an anaesthetic ; 
 for the right choice of an anaesthetic depends chiefly upon 
 a previous careful examination of the heart, the lungs and 
 the kidneys : in this way only can we hope to reduce the 
 risks of anaesthesia. Valuable though chloroform is, yet 
 we should always regard it as a poison, and should adminis- 
 ter the smallest quantity possible. 
 
 During the last few years certain rules have been drawn 
 up to remove the direct dangers of chloroform narcosis, and 
 though it is impossible to remove all the dangers, yet 
 they are considerably lessened when these rules are care- 
 fully followed. 
 
 It is self evident that the anaesthetist should be a qualified 
 medical man, and this is expressly required by law. This 
 regulation is unfortunately not always obeyed in hospitals, 
 and the responsibility of giving an anaesthetic is entrusted 
 to nurses, though it is a duty which only a doctor can 
 rightly perform.. The custom which is said to obtain in 
 England of allowing unqualified persons to give chloroform, 
 we consider most reprehensible. 
 
 The various stages of narcosis will now be considered, 
 and the possible dangers which may supervene. It is 
 absolutely necessary, when circumstances permit, that the 
 patient should be prepared for the anaesthetic by emptying 
 the stomach and intestines. For some hours before the 
 anaesthetic is given the patient should have no food, and 
 the bowels should be emptied by a purgative, followed if 
 necessary by an enema. These measures suffice in many 
 cases to remove the tendency to vomiting. After having 
 had a warm bath, the patient is placed upon the operating 
 table, which should be in a warm room (GS° to 75° F. 
 according to the nature of the operation), as it has been 
 proved that there is always loss of body-heat after pro- 
 
 217 
 
THE PREVENTION OF DISEASE 
 
 longed anaesthesia. Gas-jets should be avoided in order to 
 prevent the formation of products, especially of chlorine 
 compounds, which affect injuriously the respiratory organs. 
 The patient should be placed in the horizontal position. 
 The anaesthetist should ascertain that the patient has 
 no foreign body such as artificial teeth in his mouth, 
 and then the mask should be applied, but so as to admit 
 free access of air. It is most essential to use as little 
 chloroform as possible when beginning to induce narcosis, 
 and the drop method now so universally employed is 
 best. The chloroform should be absolutely pure and kept 
 in a small brown stoppered bottle to protect it from light 
 and air, and should be given by the drop method, about 
 twenty to forty drops per minute being used. 
 
 One of the first symptoms which may appear is the so- 
 called " stage of excitement " in those who have been addicted 
 to alcohol. To prevent or diminish this, it is best to give 
 one or two wineglasses of good brandy a quarter of an hour 
 before the anaesthetic. Injections of morphia are often 
 used to prevent this stage of excitement, but the after 
 effects may be very bad, and we do not therefore recommend 
 its use ; alchohol however seems to improve the action of 
 the heart. It is often reported that sudden fatal syncope 
 has occurred at the very beginning of anaesthesia when 
 the patient had had only a few whiffs. Personally we 
 believe that these cannot all be ascribed to the action of 
 the chloroform, but that a large number of these deaths 
 are due to shock through fear or some other nervous dis- 
 turbance in a sensitive ^Datient. Once we had a death upon 
 the operation table of a patient who had a small empyema, 
 and who died at the moment when the inhaler was about 
 to be placed over his face, and before he had inhaled any 
 chloroform vapour. 
 
 A¥e do not deny that cases of true cardiac syncope occur 
 very suddenly even after very small doses of chloroform, 
 and that in many cases we are powerless to prevent it, but 
 it seems to us that such cases are not very numerous. 
 These cases should warn us to watch the pulse and respira- 
 tion very carefully from the very commencement of giving the 
 
 218 
 
PROPHYLAXIS IN SURGERY 
 
 anaesthetic, and we must liere speak against tlie erroneous 
 opinion that the heart ceases to act only after cessation of 
 the respiration, and that it is sufficient therefore to watch 
 the respiration only. The pulse must be watched from the 
 beginning, and at the same time observation of the respira- 
 tion must not be omitted. 
 
 Deep anaesthesia is recognized by the complete absence of 
 the corneal and conjunctival reflexes and by diminution in 
 the size of the pupils, which at the commencement of 
 anaesthesia undergo'some dilatation. The deeper the narcosis 
 at the commencement of the operation, the less chloroform 
 will be required for prolonged operations. But this is the 
 moment when the anaesthetist cannot be too cautious, and 
 when he must give his full attention to the slightest 
 change noticed in the patient, even in the colour of the 
 skin. If the pulse gets worse or ceases altogether, the 
 operation must be interrupted and attemj^ts must be made 
 to restore the action of the heart. One should see that the 
 respiratory tract is free, and should push forward the lower 
 jaw, or still better, should draw forward the tongue and 
 apply massage to the heart by the Koenig-Maass method. In 
 this way it has often been possible to bring the patient back 
 to life, though the heart has ceased to beat for some time. 
 
 As to respiratory difficulties, it is always possible to 
 remove these ; indeed, it is generally possible in cases of 
 cardiac syncope which end fatally to keej) the respiration 
 going artificially for some time after the heart has ceased 
 to beat. Above all we must keep the respiratory tract free 
 from any obstruction. Among the various methods of 
 artificial respiration Schtiller's is the best. In this method 
 the right and left arches of the ribs are grasped one in 
 each hand, and are forcibly drawn upwards and outwards, 
 and then pressed downwards again towards the abdominal 
 cavity. At the same time the tongue is drawn forward, which 
 may be done with least injury by pointed bullet forceps ; the 
 upper opening of the larynx must first have been cleared 
 of mucus. By observing these principal precautions we 
 shall be able to reduce the number of deaths from chloro- 
 form, a considerable number of which still occur. According 
 
 219 
 
THE PREVENTION OF DISEASE 
 
 to Gurlt's statistics of 330,429 cases of cliloroform anaesthe- 
 sis, there was one death from cliloroform to every 2,076 
 cases. The future will show whether it is possible to avoid 
 all chloroform fatalities. But deaths will only be prevented 
 if the anaesthetist gives his undivided attention to his 
 important task ; so many cases which are in great part, we 
 think, due to the carelessness of the anaesthetist, may then 
 be prevented. But the main point is that only a medical 
 man should administer chloroform. 
 
 After what has been said we shall not be surprised that 
 in recent years the oldest anaesthetic, namely ether, has 
 come again to the front as a powerful competitor of chloro- 
 form. Gurlt's statistics of 1893 showed that only one case 
 of death was recorded in about 16,000 cases of anaesthesia 
 by ether ; but in last year's report the proportion of deaths 
 to cases was 1 to 6,112, now that we are acquainted also 
 with the indirect effects of ether. Ether has an unfavour- 
 able effect upon the respiratory passages, and among its 
 after effects is pneumonia, which in weakly patients readily 
 proves fatal. The great advantage of ether over chloro- 
 form is that the danger to the heart appears to be far less, 
 and it is the unexpected sudden failure of the heart which 
 we have chiefly to fear with chloroform, and which we are 
 quite unable to prevent. An unpleasant symptom of ether 
 is the secretion of a large amount of saliva and mucus, and 
 this leads to unpleasant respiratory difficulties much more 
 frequently than when chloroform is used, and the employment 
 of ether in phthisical patients, in catarrh of the respiratory 
 passages, and in the young, seems contra-indicated. The 
 question as to which anaesthetic is the least dangerous when 
 we consider also the after effects is not yet settled, and will 
 probably not be settled for many years to come, and mean- 
 while we shall still be obliged to use both. On the whole 
 we can confirm the opinion of Ktimmell, who writes, " In 
 the present state of our knowledge we should use ether 
 only in cases with heart disease, in those who are very 
 weak, and when during anaesthesia conditions of weakness 
 become apparent." One great drawback in our present 
 method of anaesthesia must still be mentioned : we do not 
 
 220 
 
PROPHYLAXIS IN SURGERY 
 
 yet possess any convenient apparatus by which we can 
 measure correctly the amount of chloroform and ether 
 vapour which we are administering to the patient, and 
 cannot therefore determine the exact quantity employed. 
 
 To speak about other mixtures now in use, for in- 
 stance, Billroth's mixture used in Vienna, and the A.C.E. 
 mixture employed in England, would take too long. Neither 
 can we go into the question of other anaesthetics such as 
 bromethyl and pental, which are rarely used in surgical 
 practice. 
 
 Paralysis, which sometimes appears after prolonged 
 anaesthesia, and affects especially the brachial plexus, can 
 probably always be avoided by supporting the upraised 
 arm and by suitable posture. 
 
 The subject being so very important, we will briefly 
 recapitulate the preventive measures to be taken in every 
 case of anaesthesia, and we shall follow in the main the 
 rules so excellently set forth by Klimmell. 
 
 1. Chloroform is generally to be preferred for the anaes- 
 thetic. With patients who are very anaemic or exhausted, 
 who have cardiac disease but are free from any respiratory 
 trouble, ether should be used after the stage of unconscious- 
 ness has been induced by chloroform. "We may also change 
 to ether when prolonged anaesthesia is required and the 
 heart's action is becoming weak under the influence of the 
 chloroform. 
 
 2. The chloroform or ether should be absolutely pure and 
 kept in small dark bottles, BO grammes of chloroform or 
 200 grammes of ether in each, protected from light and heat, 
 and should be used out of the bottle itself. 
 
 3. Great caution is needed when during the anaesthesia 
 injections of morphia are employed ; the combination 
 favours the development of respiratory failure during the 
 later stages of narcosis. On the other hand, it is an 
 advantage, especially in the case of those addicted to 
 alcohol, to administer during chloroform anaesthesia larger 
 or smaller quantities of alcohol. 
 
 4. The kidneys, lungs and heart should be examined 
 before giving an anaesthetic. 
 
 221 
 
THE PREVENTION OF DISEASE 
 
 5. Anaesthesia should be induced in a perfectly quiet 
 room, the j)atient being in the horizontal posture with the 
 head low. All manipulations before the patient is under 
 the influence of the anaesthetic should be avoided. 
 
 6. The anaesthetist should be exclusively occupied with 
 giving the anaesthetic ; he should watch the respiration 
 and pulse throughout the whole time, and should be a 
 qualified medical man. The drop method reduces the 
 dangers and should always be used. The shape of the 
 mask should be such as to admit sufficient air. A fresh 
 lining to the mask should be used for each case. 
 
 In view of the dangers which are inseparable from 
 anaesthetics as we have seen, a great endeavour is made now- 
 adays to restrict the use of anaesthetics as much as possible 
 and to use local anaesthesia instead. Infiltration anaes- 
 thesia, introduced by Schleich, has found many adherents 
 during the last few years ; this very useful method removes 
 all danger of poisoning by the drug, and is much used for 
 minor surgical operations. The method is applicable only 
 to certain cases and cannot be employed where there is 
 inflammation of the structures, and there would be some 
 danger in making a puncture in the area around infective 
 foci. For major operations and in laparotomies, where we 
 can seldom be quite sure beforehand about the ultimate 
 extent of the operation, and where the result depends 
 largely upon a condition of complete relaxation of the 
 abdominal wall, this method can only exceptionalljT" be used. 
 
 For a number of operations on fingers and toes, such as 
 amputation, the avulsion of an ingrowing toenail, whit- 
 lows, and so on, Oberst's method of regional anaesthesia is 
 simpler and safer. The finger is raised and emptied of its 
 blood, and then tightly ligatured, a quarter to half a 
 syringeful of a one per cent, cocaine solution is injected in 
 four places below the seat of the ligature. Anaesthesia is 
 complete in three to ten minutes. Here too any possibility 
 of danger of cocaine poisoning is almost entirely excluded, 
 though such danger is always present in the simple sub- 
 cutaneous use of cocaine, since there is a great difference in 
 the individual susceptibility of patients towards cocaine. In 
 
 222 
 
PROPHYLAXIS IN SURGEEY 
 
 many cases anaesthesia induced by local cold is sufficient, 
 and for private practice we strongly recommend ethyl- 
 chloride, introduced by Henning of Berlin, and sold in 
 tubes of a convenient size. Its action is very quick, but 
 does not penetrate so deeply as does the ether spray which 
 has been used for years. 
 
 Thus time ever brings with it new methods by which we 
 can lessen or entirely remove the pain of operative pro- 
 cedures. We should not narrowly confine ourselves to one 
 method, but for any given case should select that method 
 which brings in its train the least risk of poisoning and 
 of infection. And we are grateful for every new method 
 designed to relieve pain, though we do not always go quite 
 so far as the inventor of the method, who often is blinded 
 by his enthusiasm. For nowhere so much as in the field of 
 medicine do we require a calm unbiassed judgement. 
 
 The second great danger in every operation is infection. 
 Here also fortunately we are now in safer times than 
 during the stormy period of antiseptics which menaced the 
 patient's already weakened constitution. We have learnt 
 that there are dangers in the immoderate use of antidotes in 
 the form of antiseptics, and have outlived the time of the 
 carbolic spray and strong solutions of corrosive sublimate. 
 We cannot do altogether without antiseptics, especially for 
 wounds which are already infected, but we should endeavour 
 to restrict their use more and more, and most surgeons 
 today are of opinion that we could altogether dispense with 
 the use of antiseptics if we could make sure that there was 
 no infection present before the operation. Under such 
 conditions asepsis would be justified. With our present 
 exact methods of investigation and the advances made in 
 bacteriological research, the requirements for aseptic opera- 
 tions have enormously increased, and we are very apt 
 nowadays to lose ourselves in a minute attention to details 
 to the exclusion of the wider aspects of the subject. 
 Exact inquiry is esential, but if the demands which it makes 
 continue to increase as at present, from gloves to a mask 
 for the face and a bandage for the head, it will be at the 
 cost of the dexterity of the operator, and will tend to 
 
 223 
 
THE PEEVENTION OF DISEASE 
 
 foster a certain over-anxiety and pessimism wliich in tlie 
 interests of the patient should be avoided. 
 
 Tlie question of wound infection and antiseptics will be ' 
 detailed later, and we need liere mention only those pre- 
 cautionary measures which should be generally followed in 
 every operation. The patient runs some risk both from the 
 operator himself and from his assistants, and it is therefore 
 essential that no one should assist except those whom 
 the operator can thoroughly trust. The main principle 
 should be to have as few hands as possible engaged in the 
 operation and in the handling of the instruments used. We 
 have not yet learned how to make our hands perfectly free 
 from germs, and the surgeon and his assistants, at any rate 
 at major operations, should avoid touching any infectious 
 things or wounds. There are a great number of methods 
 for sterilizing the hands, but for practical purposes Fllr- 
 bringer's method remains the best : after previous thorough 
 cleansing with soap and brush, alcohol is used to remove 
 any fat, and afterwards a solution of corrosive sublimate 
 (one in a thousand). The hands should be carefully kej)t, as 
 it has been proved experimentally how much more difficult 
 it is to disinfect rough and cracked hands. It has been 
 shown that it is impossible to keep the hands sterile during 
 a long operation, and gloves were therefore introduced, but 
 have not yet been universally adopted, owing to certain 
 disadvantages. As to instruments, we are now in the 
 happy position to be able to sterilize by steam instru- 
 ments and ligatures, when made of silk or of metal, and 
 surgeons are therefore gradually giving up the use of catgut 
 ligatures and other materials which cannot be thus 
 sterilized. 
 
 A further source of danger in operations arises from the 
 surrounding air, which should be free from dust and so far 
 as is possible free from germs. Good ventilation is there- 
 fore essential, and infectious wounds should not be dressed 
 in the operating room when this can be avoided. The 
 room should be so constructed that there are no corners, 
 and that every part of it can be thoroughly washed out, 
 and there should be an adjoining room for sterilizing and 
 
 224 
 
PROPHYLAXIS IN SURGERY 
 
 bathing. It is absolutely essential that the patient should 
 have a bath immediately before the operation, and that the 
 part which is to be operated upon and the hands of the 
 operator should be made sterile, so far as it is in our 
 power. 
 
 We have considered only those precautions which are most 
 important on the whole ; but there are numerous minor 
 details which every operator will observe who claims that 
 he works aseptically, and these can only be learned in 
 course of time by careful study. 
 
 Whoever is not in a position to carry out all these rules, 
 as is generally the case in private practice, should follow all 
 the instructions laid down for the antiseptic treatment. 
 
 After the operation come the critical days when the 
 pulse, the temperature and the general condition of the 
 patient must be watched, and any deviation from the 
 normal course at once reported, so that suitable treatment 
 may be adopted and so that no symptom be unnoticed and 
 allowed to get worse. One should always bear in mind the 
 rule that it is better to change a dressing too often than 
 to expose the patient to the risk of a spreading suppuration 
 of the wound. 
 
 Esmarch's bloodless method, introduced for operations 
 upon the extremities, is an excellent method for preventing 
 the exhaustion which follows severe loss of blood during 
 operations ; indeed haemorrhage during such operations may 
 be altogether avoided by this method. In major operations 
 on the abdomen or trunk haemorrhage may be severe, and 
 to prevent serious consequences we make use of the simple 
 method of the subcutaneous injection of saline solution, which 
 answers extremely well in these cases. Many surgeons 
 employ these injections as a prophylactic in all cases where 
 much haemorrhage is likely to occur. A similar result can 
 be obtained by rectal injections of large quantities of fluid. 
 
 Often too in surgery we perform operations which may 
 be termed preventive, for instance operations for recurrent 
 attacks of appendicitis and for reducible herniae. The 
 indications for these operations are not easy to determine, 
 and we must carefully weigh both the probability- and signifi- 
 
 225 Q 
 
THE PREVENTION OF DISEASE 
 
 Cance of unpleasant and serious symptoms which may arise 
 and also the possible risks of the operation. A thorough 
 knowledge of the latter and the possibility of reducing 
 them to a minimum by preventive measures will enable us 
 to proceed with an operation and carry the case to a 
 successful issue instead of avoiding the operation from a fear 
 of the consequences. In general, for the cases just 
 mentioned, the rule now is to operate for recurrent appen- 
 dicitis in the interval between the attacks, and not wait 
 till some subsequent attack causes perforation of the 
 appendix and a dangerous peritonitis is set up. 
 
 The radical operation for reducible hernia is evidently a 
 preventive operation. The operation should be performed 
 as early as possible. It can be easily done during childhood 
 and the results are more likely to be permanent than when 
 the operation is performed in adult life. 
 
 To return to Esmarch's bloodless method, which is of 
 extreme importance so far as the patient is concerned, 
 for the less the haemorrhage the sooner will the patient 
 recover from the results of the operation. This method has 
 advantages too from the surgeon's point of view, the 
 exposed surfaces are free from blood and enable him to see 
 clearly what he is doing and to operate as safely and 
 calmly as on the dead body. 
 
 Whenever it is feasible, we recommend that the limb be 
 made bloodless by suspension, and that subsequent digital 
 compression of the large arteries of the limb be employed. 
 The subsequent haemorrhage is then apt to be much less 
 than when compression has been exercised by means of an 
 indiarubber band. The general oozing may at times be 
 very troublesome when the tourniquet is removed. These 
 cases are best treated by general pressure upon the bleeding 
 surfaces for some minutes rather than by the application at 
 once of numerous ligatures. The pressure stops some of the 
 haemorrhage, and any haemorrhage persisting should as 
 far as possible be stopped by torsion of the bleeding vessels, 
 so that very few ligatures need be applied, for the ligature 
 after all must be regarded as a foreign body in the wound. 
 
 226 
 
PROPHYLAXIS IN SURGERY 
 
 II. PREVENTIVE MEASURES IN THE TREATMENT OF 
 WOUNDS. 
 
 Since the human race has existed man has in his passage 
 from the cradle to the grave always been exposed to the 
 risk of injuries and wounds, and has been obliged to treat 
 them. Even skulls from prehistoric graves have been 
 found which show the marks of trephining. We know 
 that thousands of years ago the Indians and Egyptians 
 practised surgery with great skill, and that today we 
 still carry out their methods for certain plastic operations 
 upon the face. The greatest step forward which surgery 
 has taken during the last twenty years is closely related to 
 the question of the treatment of wounds. After Lister 
 conceived the idea that all inflammations, suppuration and 
 decomposition attendant upon wounds, were traceable to 
 the entrance of micro-organisms into the wound, he intro- 
 duced his antiseptic method, which in a brief space of time 
 spread over the entire civilized world. 
 
 Although favourable results followed this treatment, such 
 as had never before entered our thoughts, and opened up 
 new realms to surgery, yet certain disadvantages appeared 
 too which everywhere surgeons strove to remove. Among 
 German surgeons who worked at introducing improve- 
 ments in the treatment of wounds, and at j)ei'fecting this 
 method, the names Von Bergmann, Bruns, Neuber, Volk- 
 mann, Bardeleben and Maass are familiar to us, and the 
 antiseptic period passed into the aseptic j)eriod. We have 
 intentionally avoided saying that the one has displaced 
 the other, because we are of opinion that asepsis does 
 not exclude antisepsis, but that each is a complement of 
 the other. In his textbook of Antiseptic Surgery, when 
 treating of the practicability of the aseptic treatment of 
 wounds, Watson Cheyne writes : " The method is theo- 
 retically correct, and can be successfully carried out by 
 skilled bacteriologists, but the risks of error are so great 
 that an ordinary surgeon, who has not had a prolonged 
 bacteriological training, meets with so many difficulties 
 
 227 
 
THE PREVENTION OF DISEASE 
 
 that the results cannot compare with those attained by- 
 antisepsis." 
 
 When we call to mind the conditions which existed in 
 our surgical wards before Lister's time, we shall realize the 
 immense changes brought about in a short space of time 
 by antisejDsis. In those days it was a rare exception to 
 find an amputation stump, or a compound fracture, heal- 
 ing without inflammation and suppuration. Indeed even 
 slight unimportant injuries were frequently attacked by- 
 erysipelas, hospital gangrene, tetanus or fatal septi- 
 caemia. Volkmann has openly stated that he was on the 
 point of closing his wards because he was powerless to do 
 anything more against these infective diseases of wounds, 
 yet a few years later he was able to report 129 amputations 
 with only one death from wound infection. In Nussbaum's 
 surgical wards at Munich, every case of compound frac- 
 ture ended fatally, and eighty per cent, of all cases of 
 wounds and ulcers became a prey to hospital gangrene ; 
 yet shortly afterwards, without making any other alter- 
 ations except the introduction of the antiseptic method, 
 Nussbaum's results were as brilliant as those obtained by 
 surgeons at Halle. "When a method is known to have 
 brought about such enormous results, the reasons which 
 would induce us to abandon that method must be very 
 cogent, or we must be in a position to substitute for this 
 method a still better one. As to the former it should 
 be remembered that the antiseptic substances we employ 
 are very different one from another, and that a slight 
 increase in the effect produced may suffice seriously to 
 injure the organism. Yet this slight excess can never 
 beforehand be definitely determined, for different people 
 show a marked difference in their susceptibility to these 
 substances, and the amount which will produce symptoms 
 of jDoisoning varies much with individuals. Nevertheless 
 our experience during the last twenty years has taught us 
 clearly how far we may in general venture in the use of 
 antiseptics, and we are able at the present day to use anti- 
 septics of a strength which only in rarest cases lead to any 
 ill effects. Practical experience in this matter is the best 
 
 228 
 
PROPHYLAXIS IN SURGERY 
 
 guide, while theory which aims at removing one danger 
 only brings in its train other dangers. To pursue this 
 course would be to give up the beneficent action of nar- 
 cotics, to dispense with the good effects of mercury and of 
 potassium iodide, and lastly even to renounce the use of 
 salicylic acid. Today we use antiseptics only when we 
 cannot secure conditions of asepsis, as often occurs in 
 private practice, or when inflammation or suppuration 
 already exists, and we cannot look upon antiseptics as in- 
 jurious when we see the good results obtained by their use. 
 We can truly affirm today that we possess a method by 
 which, with an ever diminishing number of exceptions, we 
 can prevent these infective diseases from attacking wounds 
 and extensive injuries, and have removed what was a 
 source of terror to surgeons in former years. 
 
 The correct use of asepsis and antisepsis is not the only 
 measure we adopt in the preventive treatment of wounds, 
 but a number of other points also require attention. Before 
 we attempt to close a wound by stitches, all haemorrhage 
 must be stopped. Here again the principle should be to 
 employ the simplest method and to stop haemorrhage by 
 compression, except when the vessel is large and would 
 be apt to open again. The ligature in unfavourable 
 conditions is a source of some irritation, and may act as a 
 foreign body and delay the rapid healing of the wound. 
 Sutures should be very carefully placed, especially when 
 we wish to avoid scars, as on the face, and the edges of the 
 wound must be carefully approximated. This, together 
 with a very careful handling of the injured tissues, 
 which must not be mechanically or chemically injured by 
 strong antiseptics, will prevent exudation if the wound is 
 recent. When exudation cannot be prevented, as in the 
 case of wounds impregnated with mud from the street, it is 
 better not to try to obtain primary union by suturing. 
 When the wound is large, and there are recesses and 
 pockets in which blood and exudation products may 
 accumulate, these cavities must be emptied, and the sides 
 kept together by stitches, or they must be plugged. 
 Plugging, especially, may be regarded as a sovereign 
 
 229 
 
THE PRE^rENTION OF DISEASE 
 
 remedy against the dangers of infection which always 
 threaten a wound cavity, as after extirpation of the rectum, 
 which cannot be kept perfectly clean, and it should also 
 be used in recent wounds which for other reasons cannot 
 be safely disinfected. Sutures should not be too close 
 together, otherwise the nutrition of the wound edges is 
 interfered with ; indeed even gangrene of the part may 
 be caused by sutures which are too tightly drawn. A task 
 which confronts the surgeon as frequently as does the treat- 
 ment of recent wounds, is the treatment of wounds which 
 are already infected, so that they may heal aseptically. 
 When we remember that in the case of most wounds we 
 cannot know whether the wound became infected at the 
 moment it was inflicted, the question naturally arises, 
 " How long after the infliction of a wound is it still 
 possible to make the wound aseptic, and which methods are 
 of value ? " 
 
 In the year 189-4, Schimmelbusch gave an account of his 
 recent experiments upon the infection of wounds, and the 
 result was to influence us greatly in our treatment of 
 wounds. His inoculations of mice and guineapigs with 
 cultures of anthrax and streptococci jaelded astonishing 
 results, and the great differences observed in the reaction 
 to the virus shown by the various animals, made him 
 feel that he was not justified in applying the conclu- 
 sions to man. He mentions the difficulty of getting a 
 virus whose degree of virulence is constant, quite apart 
 from the consideration of the varying susceptibility of 
 individual animals to the virus, so that we might almost 
 get the impression that each animal had its own special 
 exciting causes of suppuration. Most remarkable of all 
 was the rapid absorption of bacteria, which made it impos- 
 sible to disinfect the wound and save the animal, though 
 antiseptics were immediately afterwards applied to the 
 wound which had been infected with anthrax or strepto- 
 cocci. Fortunately this rapid absorption and virulence of 
 the bacteria occurs only in recent bleeding wounds, and 
 then only when the poison has been inserted in the recesses 
 of the wound. 
 
 230 
 
PROPHYLAXIS IN SURGERY 
 
 Further tlie risk of infection of recent wounds diminishes 
 from day to day as the wound gets older ; and wounds 
 which are from twenty-four to forty-eight hours old are 
 very resistant to bacteria, and can only seldom and with 
 difficulty be infected. These results were later confirmed 
 by a number of investigators, who mostly worked with 
 very virulent cultures, till Henle's researches made with 
 less virulent pus cocci, showed that it was possible to 
 sterilize wounds with a corrosive sublimate solution of a 
 strength of one in a thousand, three hours, and in some 
 cases even eight hours, after they had been infected. Mess- 
 ner's experiments showed that with one single exception, 
 gangrene or fatal sepsis supervened when the infected 
 wounds were treated aseptically, while in all cases which 
 were treated antiseptically the infection remained localized. 
 We see then how widely individual results differ even with 
 the most careful and exact investigators, and must there- 
 fore avoid drawing definite conclusions from these results. 
 Nevertheless all authorities agree that the main principles 
 of asepsis as carried out today in the treatment of infected 
 and noninfected wounds in general are correct. 
 
 The after treatment and a watchful care of the patient 
 are part of the surgeon's work. Rest is one of the most 
 important conditions for the healing of a wound. For a 
 wound on the lower extremities it is therefore advisable 
 that the patient should be kept lying down ; in this way 
 we secure for the injured limb the most favourable condi- 
 tions for a good circulation, and this plays an important 
 part in the healing of wounds. For wounds of the upper 
 extremities we should prevent obstruction to the circula- 
 tion and the accumulation of exudations by placing the 
 patient in a suitable posture, keeping the limb raised, and 
 thus aiding the return of the venous blood. According to 
 our present views, the dressing should be kept dry, and it 
 is therefore necessary to change the dressing when it is 
 seen to be soaked through with blood and exudation. The 
 dressing must also be changed if it becomes at all displaced, 
 or if there is pain, because an uncomplicated wound if 
 properly treated ought to give rise to no pain. Obviously 
 
 231 
 
THE PREVENTION OF DISEASE 
 
 too tlie dressing must be changed immediately if there is 
 any disturbance in the general condition of the patient or 
 any rise of temperature. If all these precautions have been 
 carefully observed, we can then with a good conscience 
 view any disturbance which may arise in the healing 
 process, though such disturbance is fortunately most rare 
 nowadays, and we shall still be in the position to take 
 adequate measures to prevent greater mischief and those 
 devastating infectious diseases of earlier times. 
 
 Buchner has called attention to one matter in which we 
 still fail : we do not avail ourselves sufficiently of nature's 
 means of defence provided against infective processes. The 
 blood is the most important of these, owing to its absorptive 
 and bactericidal properties. To further absorption and the 
 healing process, 'a large quantity of blood is required by 
 the injured part, and a stronger local circulation, so that 
 the tissues may be bathed with more blood in a given time 
 than is usual. How this may practically be accomplished 
 will be described later. 
 
 The rules laid down for the correct treatment of wounds 
 were drawn up in accordance with results obtained in the 
 treatment of compound fractures. In his well known work 
 on the treatment of compound fractures, which prepared 
 the way for the antiseptic treatment of wounds, Volkmann 
 taught that in a compound fracture, with the exception 
 of fractures caused by puncture, the wound should be 
 thoroughly laid open and all recesses be followed up ; in 
 brief, he advocated the so-called "incision method" of treat- 
 ing compound fractures. The method was adopted by 
 most STirgeons and practised without modifications till 
 the results obtained by Von Bergmann in the Eusso- 
 Turkish war were made known. In the severe injuries 
 treated during this war Von Bergmann avoided wherever 
 possible making any examination of the wound : he simply 
 dressed the wound and at once put the limb in a plaster 
 of Paris bandage. The results were brilliant. They 
 tended to introduce a more expectant method of treatment 
 for compound fractures met with in civil life. And then 
 our highly esteemed teacher, Maass, taught as the result 
 
 232 
 
PROPHYLAXIS IN SURGERY 
 
 of experience gained from injuries inflicted in various 
 severe railway accidents, that equally good results could 
 be obtained in the treatment of compound fractures when 
 incisions were not used, and the surface around the wound 
 was thoroughly disinfected and the wound was merely 
 dressed antiseptically and only touched so far as was 
 necessary to remove loose pieces of bone and tissue, 
 Maass started with the correct assumption that the excit- 
 ing causes of these infective diseases of wounds were not 
 present everywhere. There are indeed micro-organisms in 
 the mud which may get into the wound, but these micro- 
 organisms are not pathogenic. And as early as the year 
 1885 Maass was able to describe forty-five cases of com- 
 pound fracture with only three deaths, and in these three 
 cases death was not in any way connected with the treat- 
 ment of the wound. All other cases treated by this con- 
 servative method healed without any of them becoming 
 affected by a wound infection. Similar good results were 
 recorded in other hospitals, and thus the conservative 
 method was introduced. Not only compound fractures but 
 all other wounds should so far as is possible be treated con- 
 servatively. This is especially true of gunshot injuries, 
 where prophylactic measures in examining the wound are of 
 the utmost importance. Examination with finger or probe 
 should be performed as little as possible, and every opera- 
 tive procedure is wrong, even though the bullet may be 
 felt directly below the skin, and under no circumstances 
 should we disturb this subcutaneous lesion. 
 
 When the soft parts are extensively injured and the 
 wound possibly dirty there is still no direct reason for 
 operating in all cases. If the wound is so situated that 
 the exudation can easily flow out, simple irrigation is 
 sufficient, with antiseptic dressing of the wound and fixa- 
 tion of the limb. Operation should only be resorted to 
 when it is feared that the bone or soft parts will cause 
 retention of secretion or the patient becomes feverish. 
 
 233 
 
THE PREVENTION OF DISEASE 
 
 III. PROPHYLAXIS IN THE TREATMENT OF INFLAM- 
 MATORY PROCESSES. 
 
 Pain is one of tlie cardinal symptoms of inflammation, 
 and is the symptom which makes the patient most uneasy 
 and induces him to seek for medical aid. We have already?- 
 stated elsewhere that the endeavour to relieve pain is one 
 of the noblest aims of the physician, and we state it again 
 here because the cessation of pain in inflammatory pro- 
 cesses is in general an indication that the process is at a 
 standstill or is retrogressing. To effect this, the essential 
 requirement at the commencement of every inflammatory 
 process is rest. By the term " rest " we mean medically 
 much more than is denoted by it in ordinary life, and it 
 includes a number of means all designed to procure those 
 conditions which are required for the cure of the diseased 
 part. First among these is a suitable posture. The great- 
 est pleasure for the physician when called for the first 
 time to a patient who is suffering much, is to be able at 
 once and possibly bj^ some simple device to rid him of his 
 pain or at least to alleviate it. In this respect doctors 
 often err greatly, especially in treating surgical cases. 
 Students hear mostly very little about this matter, and yet 
 it is important they should know that the affected knee 
 can be most efficiently put at rest by placing it so that it 
 is slightly flexed, with a support behind the knee which 
 does not press upon the vessels of the popliteal space ; and 
 that the most comfortable position for the hip joint is, 
 according to the degree of the local disease, either slight 
 flexion or abduction or a combination of these two. If the 
 limb itself is affected it should be so placed that the 
 circulation is unimpeded ; to prevent venous obstruction 
 the distal end should be at a higher level than the proxi- 
 mal, and it may be necessary to assist the venous circu- 
 lation still further by bandaging the whole limb. These 
 mechanical aids are far more efficacious than the icebag 
 and compress, whose chief value consists in their subjective 
 influence upon the patient. It is necessary to individualize 
 for special cases. Thus, for the head, when there is anaemia, 
 
 234 
 
PROPHYLAXIS IN SURGERY 
 
 of tlie brain, general!}^ indicated by great pallor of tbe face, 
 we should select the horizontal position for the body and 
 head, or even let the head be slightly lower than the body ; 
 while if the vessels of the brain and membranes are con- 
 gested and the colour of the face is bluish, we should see 
 that the head and upper part of the body are maintained 
 upright. Unless these points are observed icebags and 
 other medical applications will be of no avail. These are 
 the main principles upon which all further measures to 
 remove inflammation and prevent its spread must be based. 
 In general we may say that it is possible to remove inflam- 
 mation in the majority of cases when it has not passed 
 beyond the first stage, but often unfortunately we do not 
 see these inflammator}^ processes till there is some amount 
 of infiltration or deep suppuration. 
 
 Before all else it is then essential to prevent a spread of 
 the inflammation and to utilize all the resources available 
 in the organism. The diseased area is, as we know, to a 
 certain extent cut off from the general circulation of the 
 body by a bulwark in the form of thrombi and by the 
 reaction of the surrounding healthy structures. This pro- 
 tecting wall gives way the moment the pressure within 
 the affected area becomes too great, the boundary line is 
 passed and the body must again work at forming a fresh 
 protective bulwark. But with the giving way of the 
 boundary wall there is the possibility of a general infec- 
 tion with its often fatal consequences, and this we must 
 endeavour to prevent in every possible way. This is best 
 done by incisions, which relieve the tension and at the 
 same time provide a way of escape for the accumulating 
 pathological secretions. It is evident, as previously stated, 
 that our methods of treatment must be based upon phj^si- 
 cal laws and be aided by the powers given by nature if we 
 are to combat successfully the many injurious influences 
 brought to bear upon the body. 
 
 Free incisions are needed for well marked suppurative 
 inflammation, but in making them it must be remembered 
 that we wish also ultimately to restore the functions of 
 the diseased part. The incisions should therefore always 
 
 235 
 
THE PREVENTION OF DISEASE 
 
 be made in the longitudinal axis of the trunk or limb ; 
 they should be parallel to one another and placed so as to 
 avoid vessels and nerves. In this way we obtain smooth 
 and non-adherent scars and we shall not interfere with the 
 functions of the limb. "When, as often happens in the 
 country, cases are brought for treatment only after the 
 process has advanced far, with extensive loss of skin, we 
 should as soon as the wound is clean cover the exposed 
 surface by Thiersch grafts or by grafting with pieces of 
 skin, either stalked or unstalked, and thus prevent contrac- 
 tions which would interfere with the free use of the limb. 
 
 Incisions alone are not enough ; a free outlet for the 
 pus must also be provided, and the means to be adopted 
 have already been mentioned, namely, plugging, drainage, 
 and irrigation with weak antiseptic solutions. 
 
 One other point requires mention. When the products 
 of inflammation are within a rigid walled cavity, an 
 operation should be undertaken. For empyema of the 
 frontal sinus we trephine the frontal bone ; for empyema 
 of the pleura we resect one or more ribs ; for acute infec- 
 tive osteo-myelitis we chisel open the long bone in its 
 entire length in order that the diseased marrow may 
 escape. All this is prophylactic treatment, and by these 
 timely operations we save the patient from chronic disease 
 or even from death. 
 
 By carrying out this treatment from the commence- 
 ment we are nowadays in the happy position of being 
 able in a very large majority of cases to prevent a process 
 which is still local from spreading and setting up a general 
 infection. The case is otherwise with specific inflamma- 
 tions, but these cannot here be described as our object is 
 to give a sketch of preventive treatment from the general 
 standpoint, for every method of treatment is in a sense 
 prophylactic. For instance, in commencing tuberculosis of 
 a joint, we endeavour to put the joint at rest, to remove all 
 strain upon it, and by extension to keep the two articular 
 surfaces from touching one another ; our object is to pre- 
 vent destruction of the joint, to cure it quickly, and to 
 restore its function. 
 
 236 
 
PROPHYLAXIS IN SURGERY 
 
 Thanks to this conservative tendency in surgery, excisions 
 in early childhood, which so much crippled the joint, have 
 almost ceased to be performed. This conservative method 
 should always be kept in mind and all operations avoided 
 which would impair the function of the part. Therefore we 
 welcome Bier's " stasis method " for tuberculous joints as a 
 great step forward, and we make use of nature by venous 
 hypersemia to carry on the struggle against the invaders 
 with success. And the results of the hot air treatment of 
 chronic inflammations of joints seem to be brought about by 
 arterial hyperaemia, which enables absorption and regenera- 
 tion by the blood to go on more vigorously and for a longer 
 time. This is in close accord with the views of Buchner, 
 who considers that practical methods in the future will 
 rely more and more upon effects produced through the 
 circulation. 
 
 B. Special Prophylaxis 
 
 I. PROPHYLAXIS IN THE TREATMENT OF FRACTURES 
 
 Prophylactic treatment in the strict sense of the word 
 is not applicable to fractures and dislocations, but in speak- 
 ing about the general etiology of fractures we shall find 
 that the mode of life and occupation exercise an important 
 influence upon individual predisposition to fractures and 
 expose certain individuals more or less to the danger of 
 sustaining fractures. Moreover we consider that the 
 principles and rules which should be our guide in the 
 treatment of fractures and dislocations, especially when 
 dressing them for the first time, belong to prophylaxis. 
 
 Above all we should aim from the very first at restoring 
 the part to its normal function, and this will only be pos- 
 sible if we have a due appreciation of the errors which may 
 be made in treating fractures. It matters very much 
 whether the treatment of a simple fracture of the malle- 
 olus leaves the patient after a short time with a movable 
 ankle and able to walk as well as he could before the 
 fracture, or whether it leaves him a cripple for life with a 
 foot fixed in the valgus position. We -need scarcely point 
 
 237 
 
THE PREVENTION OF DISEASE 
 
 out that this is not a rare occurrence after a simple 
 fracture. Every experienced surgeon has had many such 
 cases brought to his notice where the bad result could only 
 be ascribed to bad treatment. In no other cases is it so 
 all-important that the first splints or bandages should in 
 every way be very exactly applied if we are not afterwards 
 to see patients walking about crippled who might with 
 better treatment have been completely restored. When a 
 fracture near a joint has united in bad position, it is 
 generally impossible to put things right even by a further 
 operation. Nowadays too, thanks to laws about acci- 
 dents, no workman would care to undergo an operation 
 which promised to improve his condition and would at the 
 same time reduce his allowance. It would seem too that 
 the laws against doctors for mal praxis are to be more 
 stringent, and for this reason greater caution should be 
 exercised. In the following paragraphs we shall consider 
 more in detail the etiology of fractures and dislocations 
 and of predisposing causes, some of which depend upon 
 external conditions, others upon the condition and nature 
 of the bone, and thus we shall learn what are the mistakes 
 which may lead to bad results. 
 
 Among the various kinds of injury caused by accidents 
 and requiring surgical treatment, fractures are the most 
 common. Statistics from the Reports of the London 
 Hospital, extending over a period of a few years, showed 
 that among 307,352 injuries reported, 45,781 were fractures, 
 that is a percentage of 14-9, so that fractures constituted a 
 seventh part of all accidents treated there. 
 
 Age has an important influence upon fractures. In 
 childhood fractures of the bones of the forearm are the 
 most common ; next come fractures of the humerus, 
 especially of its lower articular end, and fractures of the 
 clavicle. In adult life fractures of the upper limb are less 
 common than fractures of the lower limb ; fractures of the 
 ribs, almost unknown in childhood, are comparatively 
 common in adult life ; and fractures of the patella and 
 olecranon are most common during adult life, though very 
 rare in childhood. Finally, in old age, fractures of the 
 
 238 
 
PROPHYLAXIS IN SURGERY 
 
 lower limb are the most common, especially fracture of the 
 neck of the femur. Fractures of the radius, ribs and upper 
 extremity of the humerus are also common in old age. For 
 diagnostic purposes, the differences in the various periods of 
 life are important, especially when the signs of the fracture 
 are not very evident. As an example, consider the case of 
 a person advanced in years, who falls and complains of 
 severe pain in the region of the hip joint. The signs of 
 fracture may not be evident, yet we may with tolerable 
 certainty assume that it is a case of fracture of the neck 
 of the femur, and it will always be best to act upon this 
 assumption rather than have this fact forced upon us later 
 to our surprise. Nevertheless, fractures of the neck of the 
 femur in youth are not quite so rare as is generally thought 
 to be the case. It would seem that often they have not been 
 diagnosed, and the result is most serious for the patient. 
 
 There are great differences in the degree of brittleness of 
 the various bones of the skeleton, and the bones of some 
 individuals are much more apt to fracture than the bones 
 of others. The firmness of the osseous structure varies extra- 
 ordinarily in different individuals as well as in the various 
 bones of the same individual, and even at different parts of 
 one and the same bone. In general we can distinguish 
 between predisposing causes and accidental causes of frac- 
 tures, and the former are especially interesting to us in so 
 far as we are able to take precautionary measures against 
 them. Apart from the physiological condition of the bone 
 itself, evidenced by its degree of firmness and elasticity or 
 dependent upon the position and function of that particular 
 bone, a great factor in the causation of fractures is to be 
 found in the individual's mode of life and occupation ; and 
 certain fractures have therefore been termed " workmen's 
 fractures." The season of the year also has some influence, 
 especially in large towns, where workpeople have to go 
 long distances to their work ; and there is a marked 
 increase in the number of fractures when the roads are 
 bad and covered with snow and ice. Certain pathological 
 conditions of the bone itself will also predispose to fracture. 
 
 The statistics mentioned above have shown us that the 
 
 239 
 
THE PREVENTION OF DISEASE 
 
 greatest number of fractures, about 43-8 per cent, of all 
 fractures, occur during the middle period of adult life — 
 between the ages of 30 and 60. This is explained by the 
 fact that people at this age are most exposed to those 
 accidental causes of fractures met with in workshops, 
 factories, in building, and in agriculture. This will be 
 more fully dealt with in the chapter on prophylaxis against 
 accidents, and we now pass on to consider pathological pre- 
 disposition to fractures. To this group belong all those 
 diseases of bone which produce an abnormal brittleness of 
 the osseous substance, so that a very slight force, indeed 
 the mere contraction of a muscle, sufEces to fracture the 
 bone. The practical importance of knowing this etiological 
 factor is evident, because often attention is first drawn to 
 the existence of disease of the bone by the occurrence of a 
 fracture without adequate external cause. 
 
 Great interest is attached to the brittleness of bones 
 produced by osseous atrophy, and mostly seen in old people, 
 and we cannot explain the frequent occurrence of fractures 
 in very old people otherwise than through the excessive 
 brittleness of their bones. It is therefore our duty to draw 
 the attention of the relatives of aged people to this danger. 
 It once happened to us when performing artificial respira- 
 tion on an old man of seventy to hear a rib snap with 
 a loud crack, though no great force was being used. 
 When a bone has not been used for a long time, in con- 
 sequence of some chronic inflammation of a bone or joint, 
 or from paralysis, by which the limb has been rendered 
 more or less completely useless for years, great caution 
 must be exercised when the patient gets about again, since 
 the slightest external cause, even a clumsy movement, may 
 suffice to fracture the bone. Such patients must very 
 slowly and gradually accustom their bones again to bear 
 the weight of the body. Atrophy of bone with excessive 
 brittleness after long disuse is not at all uncommon in 
 youth. Bruns relates that in a case of hip disease, which 
 was cured after several years, the femur broke in the lower 
 third when a careful attempt was made at passive move- 
 ment of the hip joint. 
 
 240 
 
PROPHYLAXIS IN SURGERY 
 
 There are, too, several diseases of the central nervous 
 system, chronic diseases of the spinal cord and of the brain, 
 in which the bones become very brittle. This condition of 
 the bones should be constantly borne in mind, that the 
 patients may be guarded or at least warned against these 
 possible dangers which threaten them. In tabes dorsalis 
 Charcot found the primary cause of fracture to be a nutri- 
 tional disturbance of the osseous tissue ; but spontaneous 
 fractures occur even more frequently in general paralysis. 
 It is well known that spontaneous fractures are not at all 
 uncommon in lunatic asylums, and when shortly after 
 death an autopsy is made on the body of such patients, 
 we find an abnormal degree of softness of the bones, 
 and they have a thin layer of compact osseous tissue 
 and dark coloured marrow, while the cancellous tissue 
 consists of a few wide meshes filled with thick fluid blood. 
 In most of the cases, unfortunately the external exciting 
 cause of the fracture is so slight that it is scarcely possible 
 to guard patients against it. The case is very different 
 when the brittleness of the bone is a consequence of osteo- 
 myelitis with necrosis of bone. Here it is always possible 
 to determine what cavities exist by careful examination 
 and by a probe, or even by the Rontgen rays, and we can 
 thus determine how much bone remains, and provide the 
 patient with an apparatus for supporting the bone if there 
 is any danger of possible fracture. 
 
 In childhood the commonest predisposing cause of green- 
 stick and complete fractures is rickets, and this explains 
 the great frequency of fracture at this age. Greenstick 
 fractures are particularly common, more common than is 
 generally believed, and many such fractures are overlooked. 
 This fact is not surprising when we remember the nature 
 of the rickety process, the abnormal growth of intermediary 
 cartilage and of periosteum, and the formation of imper- 
 fectly calcified soft osseous tissue instead of the normal bony 
 structure. All of these conditions are particularly favour- 
 able to the occurrence of greenstick fracture, in which only 
 one side of the bone is fractured, while the other side of the 
 bone is bent. The slightest external violence is often enough 
 
 241 E 
 
THE PREVENTION OE DISEASE 
 
 to cause a greenstick fracture, and a careless dragging by the 
 arm or a fall on level ground may fracture the bone. There- 
 fore this angular bending occurs generally at typical places 
 and in typical directions for the different bones. In the leg 
 it is generally in the lower third, and the curve of the angle 
 is directed outwards, or more rarely forwards or inwards ; in 
 the thigh it is outwards ; in the forearm, outwards ; in the 
 upper arm, inwards. From the nature of the case it follows 
 that these fractures are long in uniting in consequence of 
 the defective formation of callus, and we should remember 
 that the union of the fractured ends may be hastened by 
 treating the rickets. When speaking later about deformi- 
 ties we shall have an opportunity of mentioning the pro- 
 phylactic measures needed for the treatment of rickets, and 
 will merely state here that the early treatment and preven- 
 tion of rickets is the best prophylaxis against these frac- 
 tures. It is of importance to diagnose these greenstick 
 fractures correctly, that we may correct the displacement 
 at once. Indeed it is often possible at the same time to 
 remove the rachitic curvature if the fracture is situated 
 near the curve or even at the curve itself. 
 
 Among constitutional diseases syphilis was formerly 
 thought to be a frequent cause of spontaneous fracture, but 
 nowadays it is thought that spontaneous fracture as the 
 result of syphilis is very rare, when the extraordinary 
 frequency of syphilis is borne in mind. The many cases of 
 fracture occurring with syphilis in remoter times are prob- 
 ably referable to local gummatous affections of bones, which 
 led to spontaneous fracture when the bony structure was 
 extensively involved. On the other hand, there is more 
 reason for regarding congenital syphilis as the primary 
 cause of fractures which occur before birth, during birth, 
 or soon after birth. In addition to the local treatment of 
 the fracture itself, anti-syphilitic remedies are here of great 
 importance. 
 
 To complete this subject it is necessary to mention that a 
 certain brittleness of the bones is a consequence of scurvy, 
 and that a number of cases have been published of spon- 
 taneous fracture occurring in carcinoma and in sarcoma of 
 
 242 
 
PROPHYLAXIS IN SURGERY 
 
 bone. Here, as well as in cases of cysts and enchondromata 
 of bones, it is essential to make an early diagnosis, that tbe 
 operative procednres, wliicli are required in some cases, may 
 be crowned with, success. The Eontgen ray illumination 
 is a valuable aid in the diagnosis of affections of bones, and 
 it would seem that early diagnosis and operation enable our 
 treatment to be more conservative than formerly it was, 
 and cases of sarcoma of bone for which resection has been 
 performed instead of an amputation and without recurrence 
 have been much more numerous of late years. Especially 
 is this so when compared with former years, when in every 
 case of sarcoma of bone the affected limb was simply 
 amputated. 
 
 There is still another form of brittleness of bone, the 
 anatomical cause of which is still obscure, and which is 
 therefore termed idiopathic. Here there exists a strong 
 predisposition to fracture without any apparent cause, and 
 in some cases the only aetiological factor is heredity, which 
 may be traced through several generations. When this 
 hereditary predisposition is known to exist, the attention 
 of the members of that family should be drawn to- the 
 danger. No other prophylactic measure is practicable, as 
 the nature of the nutritional disturbance in the osseous 
 structures, which is probably the cause of the fracture, is 
 wholly unknown. 
 
 We have separated the predisposing causes from the 
 accidental cause, and now will briefly consider the latter. 
 
 All possible kinds of force may produce a fracture when- 
 ever the force applied is sufficient to overcome the elasticity 
 and firmness of the osseous structure. One of the most 
 frequent causes is a fall on the level ground or from, a 
 height, or it may be a push, a blow, or being run over by a 
 vehicle, so that in the daily events of life there are always 
 risks of meeting with an accident which will cause a frac- 
 ture. There are a number of occupations, such as slating 
 roofs, which are specially dangerous, and these will be 
 spoken of later. We cannot guard men against the 
 accidental causes which are incident to daily life. 
 
 A few important points will next be considered in con- 
 
 243 
 
THE PREVENTION OF DISEASE 
 
 nexion witli the making of the diagnosis and the first 
 application of the splints, for upon these the successful 
 union of the fracture and restoration of the function of the 
 limb will depend. 
 
 The examination of the injured person who is suspected 
 of having sustained a fracture must first be most thorough, 
 for such an examination only will enable us to judge of the 
 prognosis and to decide upon the treatment which is 
 required. And here the old rule cannot be too strongly- 
 emphasized — first the history of the case should be obtained, 
 then an inspection be made, and lastly we proceed to 
 manual examination. The importance of the exact history 
 of the case is self evident after what has been said above 
 about predisposing causes of fractures, and it will often give 
 us valuable information. It will tell us how the fracture 
 was caused, whether by mere muscular action or by direct or 
 indirect external violence ; and we can find out exactly the 
 kind and degree of the external violence and the direction 
 in which this force acted. In inspection the chief rule is to 
 compare the two sides of the body that we may obtain a 
 correct estimate of the deformity present. Before inspect- 
 ing the legs we must see that so far as possible the two 
 are in exactly similar positions, and must note the position 
 of the pelvis ; and in the case of the upper limbs the two 
 shoulders should be at the same level. We cannot go into 
 every detail, there are so many deviations from the normal ; 
 for instance, increased or decreased length of limb, abnormal 
 curvature, rotation, or widening, which can only be accu- 
 rately and correctly seen by one who has had much practice 
 in observing the normal form. Correct observation is the 
 first essential in making an examination to determine the 
 diagnosis ; the indications for subsequent therapeutic 
 measures and a successful result depend largely upon it. 
 
 By inspection we determine one of the three cardinal 
 signs, namely, the abnormal curvature or angular deform- 
 ity present ; manual examination gives us information 
 about the other two cardinal signs, crepitus and abnormal 
 mobility. The difficulty in diagnosis arises when these 
 three signs are absent, as is often the case, and we can then 
 
 244 
 
PROPHYLAXIS IN SURGERY 
 
 merely assume the probability of tlie existence of a fracture 
 by the presence of the characteristic pain of a fracture and 
 extravasation of blood, along with the history of the kind 
 of violence sustained. In doubtful cases it is safest to act 
 as previously recommended, and in the interests of the 
 patient to assume that a fracture exists, rather than to 
 exclude that possibility because the signs are obscure. A 
 fracture which has not been diagnosed and treated as such 
 may cause most serious and permanent loss of function ; 
 while a contusion or distortion which has been treated as a 
 fracture will be none the worse for the treatment. 
 
 In the Rontgen rays we possess nowadays a valuable aid 
 to diagnosis, but many doctors, especially those in the 
 country, are unable to avail themselves of this aid, and 
 moreover it would be a pity to apply this method at the 
 expense of our old methods of examination. When the latter 
 fail us we can call the radiograph to our aid, and we may 
 use the radiograph to see whether our therapeutic measures 
 are correct ; for the rest it is wisest to continue to employ 
 our classical methods of examination, and in the interests 
 of the future medical practitioner to retain the valuable 
 faculty for keen observation and judgment. 
 
 In speaking about the treatment of compound fractures 
 Volkmann said, " the first application of the bandage 
 decides the fate of the patient and determines the course 
 which the wound will run " : the first half of this sentence 
 is applicable also to simple fractures. Even when the 
 treatment has been correct, there are nevertheless a number 
 of cases in which some deformity remains after the fracture 
 has united, or in which union fails, yet it must be acknow- 
 ledged that this is sometimes the result of improper 
 treatment. "We are here concerned with finding out what 
 are the sources of error which prevent a perfect union of 
 the fracture, and will therefore consider in detail the most 
 common mistakes in treatment, especially in the application 
 of the first bandages. This is the more necessary because 
 patients with badly united fractures are very apt to hold 
 the surgeon responsible for the deformity. 
 
 The first condition in the treatment of a fracture is to 
 
 245 
 
THE PEEVENTION OE DISEASE 
 
 remove the deformity before applying the splint ; in other 
 words, to fit the broken ends of the bone accurately 
 together. Take as an example the commonest fracture, at 
 the lower end of the radius. If before applying the splint 
 we do not correct both the faulty " bayonet " position and 
 the radial abduction, we shall be sure to obtain an oblique 
 union of the fracture and consequent great limitation of 
 movement. The kind of splint used is of no great import- 
 ance, but it must be exactly applied so as to correct, and in 
 some cases even to over-correct, the deformity. The old 
 rule should be acted upon, and an immovable splint be in 
 general applied only after the swelling of the limb has 
 subsided ; and when for other reasons this course is not 
 possible, the splint should be changed after five to eight 
 days, and any remaining deformity be removed. The 
 application of a plaster of Paris splint immediately after 
 the occurrence of the fracture, especially in fracture of the 
 forearm, brings with it the danger of pressure or of con- 
 striction of the limb, because in all cases of fracture some 
 swelling is certain to supervene. When the plaster of 
 Paris splint is applied one or two days after the occurrence 
 of the fracture, when the swelling is at its height, the 
 bandage becomes loose as the swelling subsides, and the 
 ends readily become displaced. It is therefore advisable 
 to apply the plaster of Paris bandage either not till two or 
 three days after the occurrence of the fracture when the 
 swelling has subsided, or if it must be applied earlier, to 
 change it after eight or ten days. 
 
 These are indeed fundamental rules with which we may 
 assume every surgeon is acquainted, but they are not 
 always carried out, otherwise there would not be so many 
 badly united fractures which, providing there was no 
 complication present, might have united so as to leave no 
 impairment of function. The hospital surgeon who can 
 examine his patients daily, and who daily applies plaster of 
 Paris splints, and has a great deal of practice in making 
 plaster splints fit accurately and well — by no means an 
 easy matter — may under exceptional circumstances depart 
 from the rules given above, but a surgeon in private 
 
 246 
 
PROPHYLAXIS IN SURGERY 
 
 practice will always do well to keep strictly to the rules 
 laid down if he would be spared unpleasant surprises in 
 this direction. 
 
 In this connexion we may say a few words about the 
 so-called " ambulatory " treatment, which has in its time 
 been regarded as a valuable method in the treatment of 
 fractures, but which is not free from certain dangers for the 
 patient. There are many doctors who used this method 
 which was so much praised, and who only afterwards, by 
 experience of such cases, learned the disadvantages inherent 
 in the method. 
 
 We cannot here thoroughly go into the technique of 
 the ambulatory treatment, and must refer the reader to 
 Hoffa's textbook on Fractures and Dislocations, in which 
 the method is minutely described. In many cases the 
 ordinary plaster of Paris splint suffices. It should not be 
 too thickly padded, and it is merely necessary that the 
 splint be to some extent shaped to the natural support- 
 ing points of the extremity to avoid pressure on the 
 projecting parts of the bone and all deformity. Special 
 care should be taken to avoid any pressure upon the 
 peroneal nerve behind the head of the fibula, otherwise 
 paralysis of the nerve is apt to set in, and it is very difficult 
 to cure. If the technique of this ambulatory treatment is 
 completely understood, it may be recommended for fractures 
 with little displacement in the middle or upper third of the 
 leg. On the other hand, we strongly caution the surgeon 
 against its use for fractures of the malleoli, for our experi- 
 ence has shown that the dreaded valgus position often 
 follows its use. And we do not recommend this treatment 
 for fractures of the femur ; even Krause has given up 
 using it. 
 
 We consider a good splint for walking is most useful in 
 the treatment of intra-capsular fractures of the neck of the 
 femur in very old people. In such patients, as we know from 
 experience, bony union does not generally occur. On the 
 other hand, when these old people are confined to bed for a 
 long time, there is the danger that they may get hypostatic 
 pneumonia and pressure sores which may prove fatal. Our 
 
 247 
 
THE PREVENTION OF DISEASE 
 
 rule is therefore to get these patients up as soon as possible. 
 It is best to have a well fitting splint made for them, with 
 a pelvic band, although the same result may be obtained by 
 a bandage which is jDroperly applied. These patients should 
 be early treated with massage and passive movements. 
 
 This brings us to the modern method so much employed 
 in the treatment of fractures at a joint, the so-called physical 
 method, first introduced by Lucas Ohampioniere and made 
 known in Germany by the work of Landerer. Some frac- 
 tures, for instance fractures of the patella or olecranon, 
 may at once be treated by massage after a proper splint 
 has been applied. By this method the cure is hastened 
 and the troublesome after effects, especially the muscular 
 atrophy, are avoided, and the function of the limb is 
 restored much earlier. As a rule, in fractures at a joint, 
 movement of the joint may be commenced towards the end 
 of the second week. 
 
 These three main points must be observed if we are to 
 prevent the joint becoming stiff: the splint must not be 
 kept on the limb longer than is absolutely necessary, the 
 position in which the joint is placed must be changed, and 
 early massage and passive movements must be used. 
 When the nature of the fracture makes it probable that a 
 stiff joint or even anchylosis will be the consequence, we 
 should in applying the first splint place the joint in a 
 position which will least impair the function of the limb. 
 For the hand the best position is slight dorsal flexion, 
 with the forearm midway between pronation and supina- 
 tion ; for the fingers, with the exception of the thumb and 
 little finger, a slight degree of flexion ; for the elbow the 
 forearm should be placed at an acute angle with the upper 
 arm ; for the shoulder, a slight degree of abduction of the 
 arm. For a stiff ankle joint the best position is dorsal 
 flexion at right angles to the leg and a slight degree of 
 varus ; a stiff knee can act best when slightly flexed ; and 
 the best position for a stiff hip joint is slight flexion, to 
 make sitting down easier, and slight abduction of the thigh. 
 These rules should be strictly followed not only for fractures 
 but for all other joint affections ; if they are not followed, 
 
 248 
 
PROPHYLAXIS IN SURGERY 
 
 then when the original trouble has been cured the patient 
 has for the rest of his life to suffer the most serious dis- 
 advantages from the false position of the joint. 
 
 It is not our intention to go into all the details of the 
 treatment of fractures, but as an example we will select 
 two, namely, fracture of the radius and fracture of the 
 malleoli (Pott's fracture), which together make up nearly 
 one half of all fractures, and will point out how restoration 
 of function may be obtained in the shortest time and 
 malunion prevented. 
 
 The first and most important point in the treatment of 
 fracture of the radius is, as with all other fractures, to 
 reduce the fracture properly : this can best be done by 
 strong ulnar flexion combined with palmar flexion, while 
 pressure is made against the projecting piece by the two 
 index fingers so as to bring it in the plane of the rest of 
 the radius. Unfortunately, the great number of fractures 
 which have united with the deformity still present shows 
 that many surgeons do not attempt to correct the deformity 
 or correct it very imperfectly. 
 
 To make sure of the correct position it is sufficient to use 
 the so-called " pistol splint," which should be so padded as 
 to exercise very little pressure upon the site of the fracture 
 itself. By this splint the hand is maintained in strong 
 palmar and ulnar flexion. The fingers should be free ; this 
 is most important for elderly people, in whom stiffness is 
 otherwise apt to remain for weeks and may be very trouble- 
 some to remove. For this reason the splint should reach 
 only as far as the metacarpo-phalangeal joints, in order that 
 the patient may be able to move freely all the finger joints 
 from the very beginning. It is advisable to change the 
 bandage after about six days, to make sure that the fractured 
 bone is in good position, and to correct it if not. About a 
 fortnight after the occurrence of the fracture, if the patient 
 is sensible, massage may be commenced and a spica only 
 applied to the hand ; and every day the muscles of the fore- 
 arm should be kneaded and tapped, and the area over the 
 wrist joint and the callus should be stroked. In this way 
 
 249 
 
THE PREVENTION OF DISEASE 
 
 it is possible to restore the complete use of the hand in the 
 shortest time. 
 
 In a fracture through the malleoli, the external malleolus 
 or fibula is pressed towards the tibia, so that the angle 
 opens outwards while the internal malleolus is displaced 
 slightly downwards below the tibia. This fracture can be 
 reduced by first extending the foot in the longitudinal axis 
 and then bringing it into the position of talipes varus. A 
 plaster of Paris splint should be applied while the foot is in 
 this position, and care should be taken to maintain a slight 
 degree of varus while the bandage is being applied. After 
 five or six days, the bandage should be changed for the 
 same reason as for fracture of the radius, and two weeks 
 after the commencement of the treatment massage and 
 passive movements should be begun and the old splint, 
 which has previously been slit up along both sides, should 
 be reapplied. After about three weeks the patients can go 
 about without difficulty, wearing a laced-up boot. Formerly 
 we dared not even take off the bandage so early, and later 
 on we had to devote our energy to removing the stiffness 
 and the muscular atrophy. 
 
 All that has been said about simple fractures applies also 
 to compound fractures in general, though in the latter the 
 treatment of the wound is of the first importance. We 
 saw in the earlier paragraphs that the kind of treatment 
 adopted for such a wound will decide the entire course of 
 the case, and that a mistake in the antiseptic method may 
 render the result doubtful. The treatment of wounds has 
 already been discussed. The same general principles must 
 be followed in the treatment of the wound in a compound 
 fracture, and infection of the wound must be prevented, as 
 it would lead to the most serious consequences in connexion 
 with the fracture. Here too very much will depend upon 
 the way in which the limb is first dressed ; this must be 
 adapted to suit any operation, large or small, which is 
 necessary, and the physician will be guided by his previous 
 experience in deciding which is the best method. As a 
 rule the conservative method may be followed in the so- 
 called punctured fracture, provided that antiseptic treat- 
 
 260 
 
PROPHYLAXIS IN SURGERY 
 
 ment is possible ; in other cases the wound has to be en- 
 larged to secure a free outlet for secretions ; or the fractured 
 ends of the bone have to be resected in order that good 
 union may be obtained. Certainly our successful results 
 with these fractures today are numerous when compared 
 with those of pre-antiseptic days, and we have made con- 
 siderable progress since Volkmann first laid down the prin- 
 ciples for the treatment of compound fractures. 
 
 These are the most important points, upon the whole, 
 which must be observed if we would prevent faulty union. 
 Very many other points need attention and these are 
 learned only by the experience of many years. We have 
 here merely sketched the fundamental principles upon 
 which every surgeon must act if success is to follow. The 
 more severe the fracture which has to be treated, the more 
 will the surgeon see that the best guarantee for good union 
 and also for true prophylaxis is found in extensive know- 
 ledge and ability. 
 
 PROPHYLAXIS IN THE TREATMENT OF DISLOCATIONS 
 
 Dislocations may be grouped according to their etiology 
 into (1) traumatic, caused by external violence or by 
 muscular action upon a joint which was sound ; (2) con- 
 genital ; (3) spontaneous or inflammatory, which have 
 arisen in the course of certain affections of joints. Trau- 
 matic dislocations interest us most, because they require 
 immediate operative treatment. In this respect they may 
 be compared to strangulated hernia, where every hour of 
 delay in reducing the hernia or in operating has most 
 serious consequences. As a rule, when a simple dislocation 
 is at once reduced, perfect restoration of the normal func- 
 tion of the joint may be expected, and this is therefore 
 one of the most satisfactory operations for the surgeon. 
 But if days or weeks have elapsed since the occurrence 
 of the dislocation, great difficulties stand in the way 
 of its reduction and an operation may even be necessary, 
 and there is less hope of a complete restoration of 
 function. We have but little to say about dislocations. 
 It was recognized much earlier than was the case with 
 
 251 
 
THE PREVENTION OP DISEASE 
 
 fractures, that not much good can be done by fixing the 
 joint for a long time, and gradually the method which 
 combined the simplest possible bandage and early mas- 
 sage and passive movements was introduced, with the 
 object of early restoration of the function of the joint and 
 the prevention of stiffness. 
 
 Just as abnormal brittleness of bones predisposes to 
 fractures, so too will abnormal weakness and relaxation 
 of the ligaments predispose to dislocations. Many people 
 who have once had a dislocation of a joint tend to get a 
 recurrence of the dislocation ; these cases might be termed 
 habitual dislocations, as the slightest external cause brings 
 them about. This is especially the case with the shoulder 
 joint and the temporo-maxillary joint. Such patients must 
 wear a suitable bandage for years to prevent a greater 
 range of movement than that of which the joint is capable 
 without becoming dislocated. By this means it is possible 
 to prevent dislocation, and according to our experience 
 to effect a cure ultimately. 
 
 The diagnosis between dislocation and fracture at the 
 articular end of the bone is generally easy, but in some 
 cases may be very difficult, especially when there is both a 
 fracture and a dislocation. Fracture of the radius affords 
 us a classical example of the difficulty of diagnosis. In the 
 majority of cases before the time of Dupuytren, a fractured 
 radius was taken to be a dislocation of the wrist. Similar 
 mistakes may be made between dislocation of the shoulder 
 joint and fracture of the surgical neck of the humerus, or 
 between a backward dislocation of the elbow and a supra- 
 condylar fracture of the humerus. There is also a difficulty 
 in exact diagnosis when small pieces of bone have been 
 broken off. In complicated cases an exact examination is 
 indispensable, and one should not hesitate to use an anaes- 
 thetic if the examination is not possible otherwise ; the 
 consequences of omitting to make such examination cannot 
 be repaired later. If the surgeon is in doubt about the 
 diagnosis, he should have a skiagram taken with the 
 Rontgen rays in order that the relation between the parts 
 may be made evident. 
 
 262 
 
PROPHYLAXIS IN SURGERY 
 
 In the treatment of dislocations the same principles apply 
 as in the treatment of fractures. Here too we aim at early- 
 restoration of the functions of the limb, and therefore do 
 not keep the part bandaged up for a long time, but prevent 
 atrophy of the muscles by early massage and the application 
 of electricity, and stiffness of the joint by early passive and 
 active movements. The first thing to be done in a fracture 
 is to correct the deformity ; in dislocations too the first 
 step is to reduce the dislocation. The bandage afterwards 
 applied should be as simple as possible and should merely 
 restrain the movements of the affected joint. 
 
 To take as an example the most common dislocation, 
 namely, dislocation of the humerus, which forms about fifty 
 per cent, of all dislocations. It suffices, when the disloca- 
 tion has been reduced, to apply a triangular bandage as an 
 arm sling and a few turns of bandage round the chest. It 
 is best to leave the shoulder quite free so that massage may 
 be carefully employed during the first few days for the 
 extravasation of blood, and electricity may be applied to 
 the brachial plexus. If this is not done, the bruising and 
 tearing of these nerves may lead to serious nutritional 
 changes in the deltoid muscle. After a week, when the 
 rent in the capsule has become closed, a triangular bandage 
 alone as a sling suffices, and light passive movements may 
 be begun ; in the third week, stronger passive movements 
 may be used, one hand being placed upon the shoulder to 
 make sure that the movements are at the joint itself. 
 When the dislocation is complicated by a fracture, the 
 bandage must be more firmly applied and must be worn 
 longer, but it is seldom advisable to wear it longer than a 
 fortnight, for otherwise stiffness of the joint is apt to set 
 in, especially in old people, and it is very difficult to 
 remove. 
 
 If these principles are followed it will be possible in most 
 cases when the dislocation is a simple one to restore per- 
 fectly the functions of the limb. 
 
 253 
 
THE PREVENTION OF DISEASE 
 
 II. PEOPHYLAXIS IN INJURIES THROUGH ACCIDENTS 
 
 The Employers' Liability Act in the German empire 
 opened up a new realm in surgery, and was a strong 
 incentive to etiological and therapeutical study, especially 
 in relation to the inquiry into the after effects of such 
 injuries and the connexion existing between these after 
 effects and the original injury. Any surgeon today may 
 be called upon to give an expert opinion about a patient 
 who has met with an accident, and this compels him to 
 familiarize himself with this new branch of surgical science. 
 This new branch has already produced many offshoots, and 
 there are treatises and textbooks which deal minutely with 
 the diseases and injuries which may follow an accident, and 
 the danger of over specialization cannot be excluded. But 
 this must not deter us from recognizing the great advan- 
 tages which have been the outcome of surgical efforts in 
 this direction. The desire not only that the part should be 
 healed, but also that it might be perfectly restored to its 
 former usefulness, which was first felt by the employers, 
 was afterwards shared by the medical men much more 
 than had been the case formerly. And thus during the 
 last few years we have seen arrangements made in the 
 large cities for first aid in accidents, which are of great 
 value to suffering humanity. Further, we see what a 
 great impulse has been given to the use of mechanical 
 methods of treatment combined with massage. In con- 
 nexion with this, ambulatory methods were introduced for 
 treating fractures of the lower extremity, and by means of 
 other surgical apparatus we are able to protect the injured 
 part while the patient gets the beneficial effects of the 
 movements of the rest of the body at a much earlier period 
 than formerly was the case. The chief good ;^however of 
 this Employers' Liability Act is that the injured workman 
 is compelled at once to seek medical advice and to allow 
 himself to be treated. If he has not complied with these 
 conditions, compensation may later be refused him. The 
 request made by the employers that the injured workman 
 
 should be under their care from the very beginning is only 
 
 254 
 
PROPHYLAXIS IN SUEGERY 
 
 just. The suggestion that it is not good to put these 
 accident cases in a special hospital because it tends to 
 malingering is not to the point, because this tendency 
 among injured persons in general surgical hospitals can by 
 no means be excluded. On the other hand we must not 
 overlook the advantages we possess in the better equipment 
 of these special hospitals with apparatus, and in the better 
 general sanitary arrangements. Our experience too is 
 that the number of cases of malingering in which symptoms 
 are invented which do not exist has not increased in the 
 last few years. Possibly this can in part be explained by 
 the fact that the methods used today for the detection of 
 such malingering make the practice more difficult. Besides 
 we must not undervalue the arrangement which enables 
 the injured person to be watched from the very beginning 
 by the same doctor who treated him immediately after 
 the accident. Indeed it is an excellent precaution against 
 future exaggerations of his complaint, that the patient 
 knows he was carefully examined and his case watched from 
 the very beginning by the doctor who is afterwards called 
 upon to give an opinion as to compensation. It often 
 happens that the surgeon gives an opinion which is asked 
 for when the injured person leaves the hos^Dital, and that 
 the employers' doctor gives a second opinion based upon 
 the condition of the patient at the time when he sees him 
 and without having had personal knowledge of the history 
 of the case. To decide between two opposing opinions, 
 another authority is called in and a final opinion arrived at 
 according to the law, though the patient was not seen or 
 was only once examined. It seems unnecessary to point 
 out who should be the authority recognized. When a 
 skilled surgeon is put at the head of a hospital for these 
 accident cases, there can surely be no serious suspicion 
 against him from the medical point of view. We rejoice 
 in the fact that the law has provided means by which ade- 
 quate medical aid is forthcoming from the very beginning, 
 and that so far as is possible the bad consequences of the 
 accident are prevented, and that the former indifference in 
 the matter has been replaced by excellent arrangements. 
 
 255 
 
THE PREVENTION OF DISEASE 
 
 The prophylaxis for injuries caused by the occupation 
 does not differ essentially from that already mentioned for 
 other injuries, and we should only have to repeat most of 
 what has been already said if we were to go into details. 
 It only remains for us therefore to refer to certain special 
 arrangements which are directly or indirectly due to this 
 law about accidents, and to apply them for the purposes 
 of prophylaxis. 
 
 First, we must consider the causes of such accidents, 
 because only an exact knowledge of these will enable us to 
 prevent them. They are best divided into internal and 
 external causes, of which the former are partly personal 
 but rest also partly upon an unfit condition of health. 
 Among the former are included accidents which are the 
 result of inattention, of carelessness in the working of 
 machines, disregard of well known precautions and so on. 
 To prevent or at any rate to reduce the number of these, 
 it is necessary again and again to draw attention to the 
 dangers, not only by printed rules, but also from time to 
 time verbally ; by fines for infringement of the rules, and 
 by strict supervision to see that the rules are kept by 
 the workmen. They need some training and education to 
 observe these precautions at all times. "We are convinced 
 that when this course is adopted the number of accidents 
 will be diminished ; and that this is possible is shown by the 
 great differences in the frequency of such accidents in the 
 same occupation. 
 
 As to the physical fitness of the workman, it might easily 
 be determined by medical examination whether the work- 
 man's general constitution fits him for the particular work 
 and should enable him to do it without injury to himself. 
 Many a workman is fit to undertake the heaviest work out 
 of doors who could not work in a confined space without 
 injury to his health. It is perhaps only a pious wish to 
 desire the appointment of doctors, especially in large manu- 
 factories, whose aid should not merely be sought when the 
 health has already been endangered, but who would regu- 
 larly from time to time examine the workmen as to their 
 bodily fitness for the work. There is today an humani- 
 
 256 
 
PROPHYLAXIS IN SURGERY 
 
 tarian tendency which might easily be diverted into this 
 channel, just as the aj^pointment of doctors to schools will 
 be generally adopted when the government is convinced of 
 the utility. There are plenty of young doctors, especially 
 in large towns, who would gladly devote their leisure time 
 to this useful work without requiring much remuneration. 
 
 Among external causes of accidents, those which are 
 general come first, such as unfavourable conditions of the 
 weather ; the influence too of holidays and Sundays must 
 not be underestimated, and is most marked in the building 
 trade where a large number of accidents occur on Mondays, 
 and the chief factor at work in this is alcohol. It is super- 
 fluous here to go into details about the injurious effects of 
 the excessive use of alcohol, and we must also, on account 
 of the small space at our disposal in this work, refrain from 
 mentioning the measures which should be taken against 
 this abuse of alcohol. The question has been thoroughly 
 discussed in all its relations by doctors and by the public, 
 and the old o|)position still exists from time to time between 
 the advocates of total abstinence and those who preach a 
 moderate use of alcoholic liquors. But these theoretical 
 considerations are beside the point when we want to help 
 the workman, and it becomes then necessary to supply him 
 with substitutes for the alcohol, by improving his position, 
 by ameliorating the domestic arrangements made for him, 
 by providing public amusements, free baths, libraries and 
 coffee houses. The workman who during the week has to 
 work hard should have opportunities afforded him of getting 
 recreation at no great cost and with ease, so that he may 
 not seek relief in the sorrow-killing but dangerous 
 alcohol. 
 
 Among the special causes of accidents are those which 
 are peculiar to certain trades. The accidents in engineering 
 are different "from those in textile manufactures, and these 
 are both different from those in the building trade, and 
 general statistical tables have been drawn up by the various 
 societies. Very large numbers are dealt with in these 
 tables, and as they contain interesting data about the chief 
 causes of accidents, a few of the numbers will now be given. 
 
 257 s 
 
THE PREVENTION OF DISEASE 
 
 In the year 1898 there were 6,042,618 persons insured by 
 sixty-five trade societies ; 41,746 of these met with acci- 
 dents, that is 6 '91 injured workpeople per 1,000 ; in 
 agricultural pursuits the injured men were 4*06 per 1,000. 
 The causes of these accidents among the men injured are 
 given as follows : dangerous nature of the occupation, 
 44-36 per cent. ; carelessness or inattention, 1649 per cent. ; 
 neglect of precautions, 10"50 per cent. Among the women 
 employed the numbers given are : dangerous nature of the 
 occupation, 18*92 per cent. ; acting against regulations, 
 18"60 per cent. ; carelessness, 16*64 per cent. ; neglect of 
 precautions, 14*19 per cent. The differences in these 
 numbers, especially as to the dangerous nature of the 
 occupation, shows the greatest proportion among men, 
 while the workwomen would seem to be more apt to break 
 rules ; greater supervision is therefore required and should 
 be provided. Neglect of precautions on an average causes 
 about 16 per cent, of the accidents, which is still a high 
 percentage, and might be considerably reduced if not 
 altogether avoided by better arrangements. 
 
 The time of the day also exercises some influence upon the 
 occurrence of accidents. They are most frequent towards 
 the close of the day when bodily fatigue predisposes to 
 them or when the remaining work which has to be done on 
 that day leads to haste and so to want of caution and its 
 consequences. These accidents also can only be prevented 
 by careful supervision and careful regulation of the work. 
 From investigations as to causal connexion between the 
 accident and the injury a number of new facts have been 
 ascertained about etiology, and we will give a few 
 examples, explaining them in so far as they can be met 
 by prophylactic measures. Perfectly healthy, strong and 
 generally quite robust men sometimes sustain a fracture 
 when at work, which is entirely caused by some definite 
 condition of their work. These fractures mostly occur 
 when a heavy load is being moved and some strong or 
 clumsy bodily movement is made ; this cause of fracture 
 is generally met with in men who carry heavy weights 
 upon the shoulder or back. These have nothing in 
 
 268 
 
PROPHYLAXIS IN SURGERY 
 
 common witli spontaneous fractures, where the bones are 
 affected, and would not have otherwise occurred, so we 
 may assume that the heavy weight supported by the body 
 was the essential condition for the occurrence of this frac- 
 ture. It is an evidence that a fracture may be caused 
 entirely by muscular action, and we should always warn 
 these carriers of heavy weights of the danger they run 
 when they make the slightest incautious movement. 
 
 In connexion with the suggestion we made above, that 
 workmen should from time to time be medically examined, 
 the occurrence of spontaneous fractures is instructive, in 
 cases of tuberculosis, syphilis and tabes. We will select 
 two typical cases from Golebiewski's Atlas, which will show 
 us how such fractures are to be prevented. 
 
 In one case a bricklayer thirty-four years of age when 
 lifting a box of lime felt a " crack " in his back. Examina- 
 tion showed the presence of a fractured lumbar vertebra, 
 and the cause was tuberculosis. 
 
 In the second case a plasterer forty-six years of age 
 twisted his ankle when carrying half a sack of plaster on 
 his back and sustained a fracture of the ankle, which pro- 
 duced severe disease of the joint. The diagnosis was a 
 fracture of the malleoli, and the cause was tabes. 
 
 There are numerous similar cases in the literature of 
 accidents. We need only glance through the chapter on 
 this subject in Thiem's handbook, in which well marked 
 local or a general constitutional disease is given as the 
 direct cause of the accident. If these diseases had pre- 
 viously been diagnosed by medical examination these 
 fractures might have been prevented, quite apart from 
 the fact that in cases of advanced disease heavy work 
 should not be permitted. In tuberculosis of bone, which 
 often runs a very chronic course, much may be done by 
 suitable supporting splints and other contrivances to pre- 
 vent complete destruction of the joint and its resulting 
 deformities. In syphilis too the workman would save 
 himself much trouble if he did not purposely conceal the 
 disease so long. This is partly also the consequence of 
 that unfortunate regulation which excludes persons suffer- 
 
 259 
 
THE PREVENTION OF DISEASE 
 
 ing from venereal disease from any help. Yet, when a bone is 
 already affected with tertiary syphilis a small injury often 
 suffices to cause a fracture at that spot, and the workman 
 must be compensated, since he can claim compensation for 
 an accident which has aggravated his previous disease. 
 On the other hand years may have elapsed between the 
 venereal affection and the development of tertiary symp- 
 toms, and it may not be possible to prove the connexion 
 between them. 
 
 It would take too long to give many other examples of 
 cases which prove the importance of the prevention of these 
 accidents by early examination of the workmen before they 
 think they are ill, but we will give one example to show 
 that this is in the interests of the trade societies also. It 
 is well known that differences of opinion may arise about 
 the traumatic origin of herniae, at least every case is 
 critically investigated in this respect because we never 
 know beforehand whether the workman had a hernia 
 before the accident, and it is often very difficult to deter- 
 mine whether the hernia has been acutely produced or not. ' 
 Thiem in his handbook therefore says: "Because of the 
 vexed question about hernia it is the duty of the surgeon 
 who has to examine and to treat accident cases to examine 
 the abdomen in every case of injury, without exception, 
 whatever may be the nature of the injury. In this way 
 many useless contentions are avoided, and we urgently 
 advise the directors of medico-mechanical institutions to 
 examine every patient for hernia upon his admission into 
 the institution. This will also prove that the assertion 
 often made by such patients is incorrect when they state 
 that the hernia was caused by the exercises prescribed." 
 This caution would certainly not have been given had not 
 the experience of Thiem and of all other surgeons shown 
 that workmen avail themselves of every chance to assert 
 that the hernia was caused by an accident and thus claim 
 compensation. If surgeons were appointed to examine the 
 workmen regularly the number of these cases of deception 
 would be considerably reduced. 
 
 The examination and treatment of persons who have 
 
 260 
 
PROPHYLAXIS IN SURGERY 
 
 sustained accidents must be according to the fundamental 
 rules already laid down. The fact that the consequences of an 
 accident must be borne by the society, who value accurately 
 the capacity for work, and whose own interest lies in 
 seeing that the patient has early and adequate treatment, 
 has had very good results, especially in the rendering of 
 first aid. Means of transport for injured persons have 
 marvellously increased during the last few years in large 
 towns, as also has the erection of stations with appliances 
 where the first dressing, which is so important, may be 
 applied by surgeons after a thorough examination has been 
 made, and this should include examination of the whole 
 body. In accident cases many instruments are required, 
 in order that conclusive evidence may be given for 
 the estimation of the compensation. In addition to the 
 ordinary linear measure we need an instrument to measure 
 exactly the range of movements at the joint or the angle 
 of an anchylosed joint or contracted limb ; also callipers to 
 measure the diameters of limbs and a dynamometer to 
 determine the grasp and strength of the hand. These 
 exact measurements are very important but should always 
 be accompanied by a minute description of the local con- 
 dition of the injured part, otherwise they are apt to lead to 
 erroneous conclusions. For example the mere statement 
 that the circumference of the affected limb is reduced or 
 increased tells nothing if we do not add it is caused by 
 oedema, or whether there is muscular atrophy, or whether 
 both conditions are present. We have often opportunities 
 of seeing opinions given where these points are not suffi- 
 ciently regarded and too great stress is placed upon figures 
 which in these cases are of no value. It is these accident 
 cases which should make the young surgeon, here and to a 
 certain extent in all surgical cases, not only make a 
 thorough local examination, but also a general examina- 
 tion, that he may be able to form a correct opinion about 
 the patient. This is to the advantage of the patient, 
 because the sooner a constitutional affection is discovered 
 the sooner is it possible to take adequate precautions. 
 The doctor who does not make this general examination 
 
 261 
 
THE PREVENTION OF DISEASE 
 
 before giving his opinion runs also the risk that a later 
 opinion — and there are generally several opinions — will 
 expose his neglect. Our opinion is that most weight 
 should be laid upon an exact record of the condition 
 directly after the injury ; in this way only, when he is 
 later called upon to decide whether the consequences of 
 the accident coincide with the complaints of the patient, 
 can the surgeon give an unbiassed opinion. 
 
 The after treatment is an important consideration in 
 accidents from which the patient has not recovered by the 
 thirteenth week, or in which the functions have not yet 
 been completely restored. There however we can no 
 longer speak about prophylaxis, and must therefore refrain 
 from entering upon this interesting subject. On the whole 
 our impression is that prophylaxis is somewhat neglected 
 in the treatment of accident cases ; yet it opens up a wide 
 field of work which will soon be fully explored. 
 
 III. PEOPHYLAXIS IN THE TEEATMENT OF DEFOEMITIES 
 
 The oldest records of the history of the art of medicine 
 give us but scanty information about the deformities of 
 the human body. This is due to the widespread custom 
 among ancient races of exposing weakly children or those 
 who showed some defect. But even Galen uses a number 
 of expressions, such as scoliosis, kyphosis, lordosis, and so 
 on, which are still in use today. The first to introduce 
 the term orthopaedics for the art of curing deformities of 
 the body, and incorporated this branch of science into 
 medicine, was Andry (1741). From that time up to the 
 present this branch has been so closely connected with 
 surgery, and so many famous surgeons have worked success- 
 fully at the subject, that we need only mention the names 
 of Heister, Grlisson, Heine, Dupuytren, Pott, Stromeyer 
 and Little, to justify us in treating this subject here. The 
 tendency of orthopaedics during the last few years has also 
 been in the direction of antisepsis and asepsis, and 
 only thus can we safely undertake osteotomies, tenotomies, 
 transplantation of tendons and operations for dislocation 
 
 262 
 
PROPHYLAXIS IN SURGERY 
 
 of the hip. Indeed our most important orthopaedists con- 
 sider that a thorough surgical education is indispensable 
 for successful work in this field. In regard to our prophy- 
 lactic measures, it is important to state that by far the 
 greatest number of cases occur during the first decennium, 
 between the ages of one and ten years. "We quote here a 
 few interesting figures from the statistics given by Hoffa 
 in his work on orthopaedic surgery. Among 67,919 purely 
 surgical cases in the Munich Policlinic, he found 1,449 
 cases of deformity ; that is a percentage of 2 'IS, approxi- 
 mately equally distributed among males and females. 
 Ranged according to age the numbers were : — 
 
 From to 10 years 
 From 10 to 20 j^ears 
 From. 20 to 30 years 
 From 30 to 40 years 
 From 40 to 50 years 
 From 50 to 60 years 
 From GO to 70 years 
 From 70 to 80 years 
 
 The chief point of interest is the constant decrease in the 
 number of cases with increasing years, and this will be no 
 surprise to us when we remember the delicate soft osseous 
 structures of childhood. The inquiry whether the defor- 
 mity was congenital or acquired gave the result that 150 
 cases, that is 11*3 per cent, were congenital; and 1,175 
 cases, that is 88-7 per cent, were acquired. For our pur- 
 pose this great excess of acquired cases over congenital 
 cases is important, because in acquired cases prophylactic 
 measures might have prevented them, while we are power- 
 less to do anything to prevent congenital cases, at least 
 those primary or idiopathic cases the causes of which are 
 inherent in the germ of the embryo. In these the external 
 cause is missing, while secondary congenital deformities 
 may arise through some external injury, although in the 
 latter too an important part is played by pathological 
 conditions, such as adhesions of the amnion, foetal rickets, 
 and disease of the central nervous apparatus. Here we can 
 do nothing apart from strict observance of hygiene during 
 
 263 
 
 
 602 
 
 cases 
 
 = 
 
 41-68 
 
 per 
 
 cent. 
 
 
 481 
 
 cases 
 
 = 
 
 32-32 
 
 per 
 
 cent. 
 
 
 182 
 
 cases 
 
 — 
 
 12-61 
 
 per 
 
 cent. 
 
 
 70 
 
 cases 
 
 = 
 
 4-84 
 
 per 
 
 cent 
 
 
 54 
 
 cases 
 
 = 
 
 3-74 
 
 per 
 
 cent. 
 
 
 30 
 
 cases 
 
 = 
 
 2-08 
 
 per 
 
 cent. 
 
 
 28 
 
 cases 
 
 = 
 
 1-59 
 
 per 
 
 cent 
 
 
 2 
 
 cases 
 
 = 
 
 0-14 
 
 per 
 
 cent 
 
THE PREVENTION OF DISEASE 
 
 pregnancy, or at most the only treatment possible would 
 be to remove early certain pathological growths of the 
 uterus, which take up room and thus may tend to cause 
 deformities. As regards the inheritance of deformity, 
 Hoffa calculates that there was an hereditary predisposition 
 in about 23 per cent, of all cases, and it often occurred that 
 the deformity first showed itself at the same age at which 
 the disease appeared in the parents. There is reason 
 therefore why we should be even more careful with the 
 members of such families, and should guard the children 
 from all those injurious causes which may give rise to the 
 deformity. Above all, preventive measures must be adop- 
 ted as soon as possible after birth when a congenital 
 deformity has been diagnosed, in order that increase of the 
 deformity may be prevented. During the first year of life 
 the soft osseous structures still permit of being moulded, 
 and at this early age we can often accomplish much more 
 than we can later with the most complex apparatus. "We 
 must utter a warning against the use of apparatus or 
 plaster splints which are kept on for weeks, or even months. 
 The most important point is to bear in mind the general 
 bodily health, and by massage and simple manipulations to 
 counteract the deformity. By this method we prevent 
 atrophy which so readily appears when splints are used, 
 and also that troublesome eczema, which may assume 
 dangerous characters in young children and reduce the 
 general strength. The prognosis in deformities depends 
 mainly upon the time when the deformity appeared, and 
 upon the degree of deformity, but it has been observed in 
 cases where there is an hereditary basis that the deformity 
 may increase after a temporary improvement, and caution is 
 especially needed in these cases where the prognosis seems to 
 be made more unfavourable by the hereditary predisposition. 
 Our main object from the commencement of the deformity 
 should be to restore the correct position by appropriate 
 measures, so that the growing osseous structures may be 
 developed according to normal conditions. It is most 
 essential, especially in deformity of the lower extremities, 
 which constitute a large percentage of all deformities, that 
 
 264 
 
PROPHYLAXIS IN SURGERY 
 
 we prepare the deformed feet of the child for its first 
 attempts at walking, in order that the weight of the body- 
 may then help to correct the deformity, instead of still 
 further increasing it. 
 
 Among acquired deformities we shall for the present 
 omit those primary or traumatic cases which are commonly 
 the result of fractures and dislocations, and shall refer to 
 them later. The secondary so-called " weight deformities " 
 are, as their name implies, developed as the result of the 
 effect of the body weight, or of some other pressure and 
 strain. This shows the direction in which we must work 
 if we would reduce the number of cripples, who it has been 
 estimated number in Germany 500,000 approximately. In 
 this treatment of deformities a wide field of usefulness is 
 opened up to the family physician, which is the more 
 hopeful when we remember, as already pointed out, that 
 the prognosis is far better for cases which have been 
 treated early. In most cases unfortunately medical treat- 
 ment is not commenced sufficiently early ; sometimes 
 because the child's relatives have not noticed the deviation 
 of the shape from the normal, sometimes because the 
 anxious mother really takes the child to the doctor at the 
 very beginning, but goes home consoled with the opinion 
 " the child will grow out of it." Here we must state 
 definitely that spontaneous cure of an existing deformity is 
 the rarest occurrence, and must always be regarded as very 
 exceptional. 
 
 To answer the question, how can we best remove these 
 deformities of bones, or better still, how can we prevent 
 them ? it is necessary first to be quite clear as to the way 
 in which they are brought about, and the causes which 
 have been at work. It is not our intention to discuss the 
 theories advanced by Hueter and Volkmann on the one 
 side, and by Julius Wolff on the other, but it is at 
 least certain that these deformities are developed under the 
 action of physical laws, and just as the internal architec- 
 tural structure of normal bones is mathematically accord- 
 ing to the laws of statics, so too the internal structure of 
 pathological forms is in accordance with the same laws, 
 
 265 
 
THE PEEVENTION OF DISEASE 
 
 and this explains to us a large number of cases of patholo- 
 gical changes in bones and joints. And when we see the 
 different mechanical causes which injure the osseous devel- 
 opment in individual cases, we cannot but assume that 
 there are certain predisposing factors at work in causing 
 these deformities. Among such deformities are those met 
 with in men who work constantly with the body in 
 some faulty position. Thus we meet with kyphosis in men 
 who habitually carry heavy weights, where it is caused by 
 the carrying of such weights ; and in bootmakers and 
 weavers, where it is caused by the constant bending 
 forward of the body. Scoliosis is met with in millers and 
 masons, who carry heavy weights upon one shoulder. 
 Genu valgum and flatfoot are seen in bakers and waiters. 
 These deformities due to occupation have been largely 
 ascribed to rickets but without any definite evidence ; 
 and genu valgum and iiatfoot which appear at puberty 
 have been regarded as a special late manifestation of 
 rickets. Occasionally deformity appears in strong, robust 
 looking children, though as a rule these skeletal changes 
 appear in children who are delicate, weakly and anaemic, 
 who suffer from digestive disturbances, are scrofulous, 
 and have grown very fast. The family physician should 
 use his influence with the parents in order that occupa- 
 tions may not be chosen for them which will favour 
 the appearance of deformities such as genu valgum and 
 flatfoot. All occupations which require long continued 
 standing should be forbidden. In anaemic children we 
 must endeavour to raise the nutrition of the entire body, 
 and to increase the formation of proteids. This is 
 best attained by suitable gymnastic exercises combined 
 with massage and hydrotherapy, and the regulation 
 of diet, which for children should contain much milk ; and 
 this is far preferable to the use of iron and arsenic prepara- 
 tions, although in some cases we cannot dispense with the 
 latter. These measures are not enough by themselves, and 
 these children should at school be kept from all influences, 
 such as bad posture in writing and long continued sitting 
 which so frequently lead to deformity. The commonest 
 
 266 
 
PROPHYLAXIS IN SURGERY 
 
 deformity set up is habitual scoliosis, wliicli constitutes 
 about twenty-eight per cent, of all cases of deformity, and 
 in the majority of cases is developed between five and 
 ten years. Eulenburg found that among 1,000 cases of 
 scoliosis, 564 cases appeared between the seventh and tenth 
 years of age ; that is during the years when, with the 
 commencing second dentition, there is a tendency to in- 
 creased development of the entire skeleton. Eulenburg 
 calculates that heredity is a factor in twenty-five per cent. 
 among the 1,000 cases; not that these children are born 
 with scoliosis, but the hereditary factor consists in this, 
 that the children are born with a certain relaxation and 
 lack of resisting power in the constituent parts of the 
 vertebral column, and in this condition deformity vastj 
 later be produced by some slight external cause. The act 
 of writing must be regarded as one of the most important 
 of these causes when combined with the predisposing 
 factors above alluded to, partly constitutional weak- 
 ness, and partly weakness of the bones themselves, the 
 aetiology of which is still unknown. During late years 
 many school desks have been devised to try to remedy the 
 faulty posture assumed by children in writing. But by 
 this we shall not be able to prevent the tired body from 
 again adopting a crooked position. In addition to school 
 hygiene, and this disease has been called sedentary or 
 school disease, preventive measures should aim at prevent- 
 ing any real tiredness. This can be best done by restrict- 
 ing the number of school hours, and above all by adequate 
 intervals between the lessons, during which the relaxed 
 muscles may be again strengthened by exercise in the 
 fresh air. In addition there should be for both sexes, regu- 
 lar gymnastic exercises acting upon the vertebral column, 
 and strengthening the whole muscular system, and espe- 
 cially the muscles of the back. Gymnastic games are 
 especially beneficial, and have gradually spread from 
 Gorlitz to other places. Growing girls should have physi- 
 cal exercise ; for example, playing with balls, swimming 
 and skating. Care of the skin must not be neglected, 
 especially of the back, and neglect to cleanse the skin by 
 
 267 
 
THE PREVENTION OF DISEASE 
 
 friction and baths is still very common among us, but we 
 are endeavouring to remedy this by providing public baths, 
 which put this luxury within the reach of the poorest 
 classes. It is to be hoped that in course of time such 
 institutions will be available free of charge for the mass of 
 the people. 
 
 To see whether these endeavours protect our youth 
 against the injurious effects of school, school doctors will 
 be appointed^ — it is merely a matter of time — and by 
 examining the children several times a year, they will re- 
 cognize commencing deformities, and the necessary steps will 
 be at once taken to prevent them. And when in the future 
 the changes which the doctors recommend are carried out at 
 schools, and the physical health of these children is not 
 sacrificed to their intellectual development, but the two 
 work harmoniously together, then children will later be 
 equal to their future occupations, and their minds will 
 develop better when their physical health is good than when 
 an erroneous method of education has weakened the body. 
 
 Still one other factor in the causation of deformities must 
 be considered, namely rickets, a disease in which a defec- 
 tive deposition of lime salts in growing bones interferes 
 with their proper function. It appears mostly during the 
 second year of life, at the time when active growth of the 
 osseous structures takes place. As a result the bones be- 
 come weak, and deformity of the skeleton is developed. 
 Rickets is the commonest disease in children, and exists all 
 over the world, though it is much rarer in tropical and sub- 
 tropical districts than in northern countries. The disease 
 is produced by unfavourable external conditions, and is met 
 with therefore not only among the people in large towns, 
 but also in the country, where the small close damp rooms 
 are injurious to health. But the chief predisposing cause 
 is the faulty diet of children. Sometimes it is improper 
 diet, which predisposes to rickets by setting up chronic 
 digestive troubles ; sometimes it is insufficient food. Arti- 
 ficial foods are a very great causative factor, especially 
 when they are used as substitutes for milk diet, as often 
 is the case among the lower classes, and cocoa, coffee 
 
 268 
 
PROPHYLAXIS IN SURGERY 
 
 and starcliy foods are given to children. Severe acute 
 diseases are also unfavourable conditions, and congenital 
 syphilis is regarded by many as a causative factor in 
 rickets. 
 
 At present we have no statistics showing the number of 
 cases of deformity in which rickets was a cause, but there 
 is no doubt that rickets plays a large part in the aetiology 
 of deformities. Kassowitz found that among 5,000 cases 
 of rickets nearly every case showed more or less clearly the 
 deformity known as " pigeon breast." Among 1,444 cases 
 mentioned by Ho£fa, there were 39 cases of rachitic 
 kyphosis, that is 2-07 per cent. ; 107 cases of rickety curva- 
 ture of the leg, that is 741 per cent. ; and among the 119 
 cases of genu valgum doubtless a large number had 
 suffered from rickets in youth. Among 859 orthopaedic 
 cases treated by Dollinger there were 72 rickety curvatures 
 of the leg, or 8'4 per cent. According to Gruerin, rachitic 
 scoliosis occurs in 9'7 per cent, of all rickety children. 
 
 To ensure a proper diet for children during the first nine 
 months of life is the best prophylactic measure against 
 rickets which a doctor can take. The child should not be 
 overfed, and the breast should be given in accordance with 
 the well known rules. Unfortunately the artificial feeding 
 of children is becoming more and more common, even 
 among the poorer classes, and we should make every effort 
 to see that children are breast fed, especially when no contra- 
 indication exists. If artificial feeding cannot be avoided, 
 cow's milk is the best substitute for the breast, and should 
 be given mixed with varying proportions of water or of veal 
 broth, according to the condition and age of the infant. 
 All other methods of artificial feeding should be avoided, 
 especially when rickets already exists, and also the addition 
 of much sugar or starch. Special care should be given to 
 the digestive organs, because chronic dyspepsia and 
 intestinal catarrh which have existed for long, either cause 
 rickets or aggravate the disease if it already exists. The 
 distended abdomen of such children points to the meteorism 
 which is never absent in rickets and to the habitual con- 
 stipation. These children should be much out in the fresh 
 
 269 
 
THE PREVENTION OF DISEASE 
 
 air, and to prevent curvature of the spinal column, should 
 not be carried on the arm, but lie on a horsehair mattress. 
 General massage of the body is very useful for these 
 digestive disturbances, when it is combined with washing 
 in cold water and friction. By this method the skin is main- 
 tained in a good condition. Baths may also be used with 
 the addition of brine or of Kreuznach salts, or of some of 
 the well known salts of Orb, Kosen, Stassfurt, or Sodenthal. 
 By these baths a derivative action of the skin is obtained, 
 and the skin should become red if the proper effect is to be 
 obtained. If circumstances permit these children should 
 be sent to a place where there are brine baths, or still 
 better where there are sea baths. Associations exist to 
 provide such a holiday for the poorer children, and this is 
 spreading from year to year, though much more still 
 remains to be done in this direction. Homes for cripples, 
 which have been established during the last decade, are 
 also most useful ; but these cripples are to a certain extent 
 cut off from the rest of the world, and they are apt to feel 
 that they are looked at askance ; and this gradually leads 
 to a bitterness in their character. 
 
 To prevent such deformities by carrying out the general 
 principles sketched above is the most grateful task of the 
 surgeon, especially when we remember that in spite of 
 great advances made in the last few years and of the intro- 
 duction of mechano- therapy, a well marked deformity often 
 takes years to cure, and it may even be impossible to restore 
 perfectly the normal form of the body. 
 
 IV. PEOPHYLAXIS IN THE TKEATMENT OE TUMOUES 
 
 Cohnheim's sentence, " If there is one chapter in our 
 science which is still veiled in darkness it is that of the 
 aetiology of tumours," is still true today, and we are still 
 unable to say what is the real cause of carcinoma and other 
 tumours, though much work has been done in this subject. 
 Yet it is a consolation that we have learned certain of the 
 jiredisposing causes of carcinoma which are constantly 
 met with, and have therefore caused us to attach much 
 
 270 
 
PROPHYLAXIS IN SURGERY 
 
 importance to them. "We mean the mechanical and chemical 
 injuries connected with certain occupations. The best 
 known are the tar cancer and chimney sweepers' cancer 
 among workmen at the tar and paraffin industries and 
 chimney sweepers. We will give a few other striking 
 instances of the aetiological significance of irritation 
 leading to chronic inflammation upon the occurrence of 
 carcinoma. Bottini mentions 100 cases of cancer of the 
 tongue which he had observed (including three cases in 
 women) which were all caused by smoking and chewing of 
 tobacco. H. Zinker found gall stones in 84-5 per cent., and 
 Birch-Hirschfeld in 91-7 per cent, of cases of primary carci- 
 noma of the gall bladder, and these stones are known to 
 give rise to irritation and inflammation. 
 
 If we glance through the statistics of cancer of the 
 breast hj Winiwarter and Oldekop we find that in 125 out 
 of 934 cases some trauma had occurred — that is in 13-4 per 
 cent, of the cases. Unfortunately the many sources of 
 irritation, especially of internal organs, can only be pre- 
 vented if we remove early enough the condition, which we 
 know may in course of time lead to the development of a 
 malignant growth. 
 
 Every form of benign tissue-hyperplasia, such as con- 
 genital naevus, papilloma, atheroma, adenoma, gumma, 
 may, if exposed to constant mechanical or chemical irrita- 
 tion, pass over into a carcinoma, though we cannot say the 
 exact time when the change began; scars too of very 
 various origin are a favourable soil for malignant tumours. 
 According to Rapock 182 out of 399 cases of carcinoma of 
 the skin arose from warts. It is these occasional causes 
 which we must oppose with all the means at our disposal. 
 We must advise the removal of benign tumours, especially 
 those which show even the very least tendency to increased 
 growth or which are situated in places where they are 
 exposed to constant irritation. We must warn against the 
 scratching of warts, and against cutting them with septic 
 knives, and should see that sharp pieces of teeth and bad 
 teeth are removed. In chronic states of irritation of the 
 mucous membranes we must forbid smoking and chewing of 
 
 271 
 
THE PREVENTION OF DISEASE 
 
 tobacco, and above all the abuse of alcohol, which experi- 
 ence has shown ns gives rise to carcinoma of the oesophagus 
 and of the stomach. 
 
 "We must point out the dangers of the pressure by corsets, 
 which are a cause of mammary cancer and of obstruction in 
 the portal circulation, and may tend to the formation of 
 gall stones, the causal significance of which in the develop- 
 ment of malignant tumours has been mentioned above. 
 Chronic eczema of the skin should be carefully treated, and 
 workmen in tar and paraffin factories and chimney sweeps 
 should be warned of the danger which threatens them. It 
 has been shown that congenital phimosis tends to the 
 development of cancer, and early operation should be recom- 
 mended. An endeavour should also be made to heal old 
 ulcers of the leg, which often afford a favourable opportunity 
 for the development of carcinoma. 
 
 "When we review these occasional causes the question 
 rises in our minds, How is it to be explained that the 
 number of cases of malignant tumours is small compared 
 with the frequency of the occurrence of the irritations and 
 injurious effects mentioned above ? This is a problem 
 which the theories of Virchow, Cohnheim, Waldeyer, 
 Grawitz and Klebs have not yet solved. This is not the 
 place to discuss these theories, yet we must refer to one 
 factor which has perhaps hitherto not received sufficient 
 attention — the heredity of carcinoma, or rather the disposi- 
 tion to it. To give a few statistics, according to Winiwarter 
 6 per cent, of the cases of carcinoma are hereditary ; accord- 
 ing to Brautigam, 8*5 j)6r cent. ; according to PfeiJffer, 9"3 
 per cent. ; and according to Ziel, 11 per cent. In Ziemssen's 
 "Handbook of Pathology and Therapeutics" 192 out of 1,137 
 cases had a family history of cancer. And though we con- 
 fess that the heredity cannot always be proved in a family 
 and that little weight can be placed upon the statements of 
 patients when medical information is not forthcoming, yet 
 we cannot but regard heredity as an aetiological factor, and 
 in families where there is this hereditary taint the greatest 
 care should be taken to avoid all the injurious conditions 
 and occasional causes described above. 
 
 272 
 
PROPHYLAXIS IN SURGERY 
 
 While we know so little about the real cause of tumours, 
 we shall not be able to do much to prevent them in spite of 
 all our efforts. In the present state of our knowledge we 
 can only successfully combat the disease by removing every 
 benign tumour as soon as possible, since it is possible a 
 benign tumour may become malignant, though it is 
 impossible to tell when the change began or what caused 
 it. The next question that arises is whether it is possible 
 today to remove a malignant tumour so completely by 
 operation, and without danger to life, that we may feel 
 sure it will not spread or recur. 
 
 To answer this question we take the statistics of cases 
 in which cure is assumed to have resulted when, as 
 Volkmann teaches, no reourrence has appeared within 
 three years. Although we know that occasionally recur- 
 rence has been seen after five to ten years, yet this is after 
 all so rare that for practical purposes and in dealing with 
 large figures, an interval of three years may be taken to 
 denote probable cure. "We select for this purpose that part 
 of the body which is most accessible and has therefore been 
 most thoroughly worked out, the female breast. How 
 widespread carcinoma of the breast is, may be judged 
 from the following figures taken from Heimann. Of 1,234 
 operations on the breast, 1,110 were for carcinoma, and 
 only 124 for other tumours. 
 
 The essential conditions for a perfect cure are an early 
 operation and the removal of all the diseased tissue. The 
 history of mammary amputation is extremely interesting 
 in this respect, and figures prove that the number of cases 
 cured by the operation has increased according as investi- 
 gations have advanced showing us the path along which it 
 spreads and enabling us to remove this diseased tract. The 
 stages have roughly speaking been the following : extir- 
 pation of the tumour itself ; amputation of the breast ; 
 clearing out of the axilla ; removal of the pectoralis major 
 muscle. At the Congress of Surgeons in 1883, Kiister 
 pointed out the importance of always clearing out the 
 axilla and introduced the method. After further experi- 
 ence Heidenhain's book appeared in 1889, and he recom- 
 
 273 T 
 
THE PREVENTION OF DISEASE 
 
 mended that in some cases the pectoralis major should also 
 be removed ; his researches showed the path along which 
 mammary cancer spreads, and that local recurrence pro- 
 ceeded in most cases from cancer cells which had been 
 conveyed by lymphatic vessels into the muscle itself. 
 Following his suggestion, a number of others, for example 
 Helferich, Rotter and Halsted have carried out this method 
 of breast amputation, and their results, when compared 
 with those previously published by the best operators, 
 testify to the excellence of the method. That what we 
 have most to fear is local recurrence is proved by numer- 
 ous records of earlier years. Those of Hans Schmidt 
 show that among 95 cases of recurrence, 71 were 
 local, that is 744 per cent ; and Rotter found 30 such 
 local recurrences among 34 cases, that is 88-23 per 
 cent. Statistics collected by S. Gross show that on an 
 average the best results of former years give 66*8 per cent, 
 cases of local recurrence, while the average among the 
 results of Halsted, Rotter, Cheyne and Helferich give only 
 30*3 per cent., or less than half the former. Another 
 important point to consider is whether the greater extent 
 of the operation has increased the danger of it. In regard 
 to this, recent years show very favourable results, and in 
 125 consecutive cases published by Weir, and 76 by 
 Halsted and May only one case of death occurred, and 
 this was ascribed to the ether, while Dennis had one 
 fatal result among 74 cases and this patient suffered 
 from haemophilia. It is obvious that with extensive 
 tumours there are limits to successful operation. We 
 confess that it is hopeless to think of operation for a " cancer 
 en cuirasse," neither would a judicious surgeon operate 
 when there were already signs of pleuritic irritation. For 
 these inoperable cases there remains the possibility of 
 attempting a cure by injections of bacterial virus, although 
 the results are not very satisfactory. Friedrich writes 
 about these attempts which he carried out under Thiersch : 
 " With streptococci and mixed culture sterilizations and 
 filtrates, cure was not obtained when these were injected 
 into the tissues of the tumour, whether carcinoma or 
 
 274 
 
PROPHYLAXIS IN SURGERY 
 
 sarcoma." When however both doctor and patient are 
 convinced of the hopelessness of any operation, the patient 
 may be advised to try this method. It is these hopeless 
 cases, where operation is impossible because of the extent of 
 the local growth, which point again to the importance of 
 early operation for snch cases. In general we may say 
 that the earlier the tumour is removed the less extensive 
 will be the operation and the greater the chance of a cure. 
 We must therefore make a diagnosis early, and there are 
 many cases in which this is possible. One symptom should 
 be specially borne in mind, which is important in malig- 
 nant tumours ; this is haemorrhage, and it appears com- 
 paratively early. In every case of haemorrhage from the 
 rectum or vagina, we should ascertain by palpation 
 whether there is any special cause for it, and we must not 
 hesitate to make a vaginal examination, even though it 
 possibly turns out to be only menorrhagia or haemorrhage 
 from haemorrhoids. In haemorrhage from the stomach 
 too one should avail oneself of every possible means of 
 diagnosis to avoid a mistake in this difEcult matter of the 
 differential diagnosis between simple ulcer of the stomach 
 and carcinoma. 
 
 A second symptom to which great weight should be 
 attached is emaciation, which is often so marked in com- 
 parison with the small size of the tumour that we cannot 
 but assume that serious nutritional changes are present, 
 and above all a change in the condition of the blood 
 though up till now no such change in the blood has been 
 detected. This loss of flesh is the more remarkable when 
 there has been no loss of blood and when the digestive 
 organs apparently still work well, and when we remember 
 how commonly haemorrhages exist for years in women 
 without leading to any real disturbance of nutrition. On 
 the other hand, emaciation with malignant tumours may 
 be regarded as the precursor of cachexia which with 
 certainty appears when the tumour has not been removed. 
 If the tumours are situated near the surface or upon an 
 osseous structure, as is the case with most sarcomata, then 
 it is palpable and more easily accessible, yet nevertheless it 
 
 275 
 
THE PREVENTION OF DISEASE 
 
 may present great difficulties in diagnosis. In the 
 Rontgen rays we possess an additional means of diagnosis, 
 yet here mnch depends upon the correct interpretation 
 of the photograph, and it will need some years of ex- 
 perience before we can interpret skiagrams correctly and 
 thus reduce the number of errors. The difficulties which 
 depend on the obscurity of the origin of tumours have 
 stimulated our most eminent inquirers to renewed research, 
 and we cherish the hope that these great endeavours will 
 prove successful in throwing some light upon the subject. 
 
 276 
 
Prophylaxis in the Diseases of Women 
 
 BY 
 
 DR. 0. SCHAEFFER 
 
 OF THE UNIVEESITY OF HEIDELBEEG 
 
 277 
 
Prophylaxis in the Diseases of Women 
 
 When we consider tlie prevention of the diseases of women 
 from the standpoint of their aetiology, we are led in 
 almost every case out of the narrow range of gynaecology 
 into the wide field of general internal pathology — far more 
 indeed than is the case when these diseases are considered 
 with regard to their symptoms and pathological anatomy. 
 When the diseases of women are considered aetiologically, 
 the close connexion which exists between the sexual system 
 and the whole organism becomes more clear : the latter 
 appears no longer so definitely controlled by the former, 
 but the two seem rather to exercise a peculiar mutual 
 influence upon one another, such as we meet with in the 
 case of no other subordinate organ. 
 
 Briefly I might express it thus : not only in consequence 
 of the influence of the sexual system, but also because of 
 the sexual functions, there arise through the action of the 
 central nervous system of ill developed individuals disturb- 
 ances of the whole organism, which in a " vicious circle " 
 react on the organs of generation. 
 
 Among these disturbances, for example, I would put first 
 the anomalies of menstruation and their associated pheno- 
 mena, such as chlorosis, anaemia, gastro-intestinal disturb- 
 ances, anomalies of micturition, diseases of the skin and 
 anomalies of perspiration, hystero-neurasthenic attacks and 
 other neuroses. Next I would place those conditions of 
 relaxation and of congestion of the pelvic and abdominal 
 organs which have been produced, not by primary local 
 infective inflammations, but by disturbances in the innerva- 
 tion of all the contractile elements of the generative organs 
 
 279 
 
THE PREVENTION OF DISEASE 
 
 and of their ligamentous and subperitoneal connexions in 
 the pelvis, principally therefore of the muscular tissues 
 including the muscular fibres of the blood vessels. This 
 " want of tone" leads in part to the production of descent 
 and of prolapse of the uterus, of the vaginal walls with 
 the bladder and rectum, and of the ovaries, and further 
 to general enteroptosis. It leads also to retroversion and 
 flexion of the uterus, and sometimes to chronic hyperaemia, 
 and thus to vascular and lymphatic engorgement of all the 
 abdominal viscera ; and when there is at the same time a 
 want of tone of the abdominal wall, it gives rise to disten- 
 sion of the intestines. Remoter results of this hyperaemia 
 are various inflammatory conditions not produced by any 
 primary infection : these are certain forms of chronic 
 metritis, cystic degeneration of the ovaries, and possibly 
 also the formation of fibroids and glandular cysts. 
 
 Almost without exception we find in such individuals 
 other signs also of general neurasthenia and of irregularities 
 of metabolism, which usually appear first at puberty or 
 which become much more marked at that period. It is 
 therefore clear that the influence is mutual and not one- 
 sided. And it is here that "preventive treatment" has a 
 wide field, which is recognized often neither by the public 
 nor by the physician, and this preventive treatment is of 
 value not only for the patient herself but also for her off- 
 spring. Prophylaxis is especially useful in these cases, because 
 these slowly progressive functional disorders lead at last to 
 structural changes, and thus make it almost impossible to 
 restore by treatment the normal condition of the organs. 
 
 Taking the pathology as the basis of classification, we will 
 consider the preventive treatment of the diseases of women 
 and of their sequelse under five heads — ■ 
 
 I. Abnormalities of growth and arrests in development. 
 II. Changes in form and in position. 
 
 III. Inflammations and disturbances in nutrition. 
 
 IV. Injuries. 
 
 V. New growths. 
 VI. Gynaeological operations and procedures. 
 
 280 
 
PROPHYLAXIS IN THE DISEASES OF WOMEN 
 
 In each chapter will be set forth in order the preventive 
 treatment of — 
 
 (a) The primary cause or predisposition to the disease. 
 (&) The exciting cause. 
 
 (c) The sequelse, including complications arising out of 
 pregnancy. 
 
 (d) The results of typical errors in the treatment of the 
 disease. 
 
 I. Abnormalities of Formation and Arrests 
 in Development 
 
 In so far as the defects in development are congenital, 
 their aetiology lies in the yet obscure region of general 
 teratology, and of this we only know that it includes 
 several utterly different causes. In the first place there 
 are diseased ova analogous to degenerate spermatozoa and 
 due to poisoning by lead, mercury, alcohol and morphine. 
 Further diseased conditions of the decidua, primary or 
 secondary, may at the same time give rise to disease in the 
 foetus and produce abnormalities in growth or inflammatory 
 adhesions. Congenital malformations may also be caused 
 by general as well as by local infective disorders such as 
 influenza, tuberculosis, syphilis, and gonorrhoea. Disturb- 
 ances in nutrition are probably also produced by the toxins 
 of these diseases, by pyrexia and by obstruction to the 
 circulation, as in disappearance of the liquor amnii in the 
 first six months and adhesions between the embryo and the 
 membranes, and subchorionic haematomata. The more 
 chronic these influences and the longer they have been at 
 work, the more likely is it that the child will live but will 
 be deformed. But under what special circumstances these 
 causes act upon the embryo so as to produce deformity is 
 still entirely beyond our knowledge. 
 
 In the female generative organs deformities are very 
 often met with ; on the whole malformations are most 
 frequent. The abnormalities of the uterus and of the 
 Fallopian tubes in children who are otherwise healthy must 
 
 281 
 
THE PEEVENTION OF DISEASE 
 
 arise from a simple arrest in development of both, or of 
 one of the ducts of Miiller, and thus are produced the 
 uterus bicornis and unicornis. Here preventive treatment 
 is limited, and it can only be suggested that mothers and 
 those who will become mothers should be healthy, and 
 especially that all chronic disorders of the sexual organs 
 should be treated. The same holds good for the father. 
 Those who have tuberculous disease of the genital organs 
 should not marry. 
 
 But far more important to the physician is the preven- 
 tive treatment in cases where congenital malformations 
 already exist. And this will depend upon the period of 
 life reached : at birth, at puberty, before marriage, after 
 marriage, during the first pregnancy, during labour, and 
 with regard to the question of subsequent pregnancies. 
 
 1. In complete absence of uterus and vagina it is generally 
 advisable not to marry ; so too when there is a rudimentary 
 vagina, because coitus will increase the molimina menstru- 
 alia if the ovaries are present. The continuance of 
 menstruation may be prevented by removal of the ovaries. 
 Unhappiness in marriage may result from the incapacity 
 to fulfil the physical functions, and in such cases the 
 construction of a vagina-like cul-de-sac is followed with 
 partial success. 
 
 2. In atresia vaginae with a well formed uterus and 
 ovaries, a vaginal passage should be made. The same holds 
 good for diaphragmatic or cord-like atresia of the cervix, 
 vagina, hymen, or vulva ; and this should be done partly to 
 prevent sterility and partly to prevent the difficulties 
 connected with menstruation and with childbirth. 
 
 3. In cases of pseiido-heriifiaphrodism an attempt to deter- 
 mine the sex should I'be made, but this is often not possible 
 till puberty with its; well marked sexual inclinations. "We 
 may be guided by\ the knowledge that most pseudo- 
 hermaphrodites havei been, proved to be males, and several 
 of them have been capable of procreating, and this is the 
 more likely to be the case the better the genital protuber- 
 ance is developed afid when the catheter shows that a 
 cul-de-sac exists in jbhe posterior wall of the urethra. In 
 
 282 
 
PROPHYLAXIS IN THE DISEASES OP WOMEN 
 
 female pseiiclo-liermaplirodites atresia of the vagina is 
 always found. 
 
 4. Congenital recto-vaginal or recto- vulval fistulae should 
 be treated early so that, apart from the considerations of 
 cleanliness, no infection of the genital canal from this 
 source shall arise during childbirth. 
 
 5. Of more frequent practical importance is the preventive 
 treatment in cases of uterus unicornis and bicornis and 
 septa in the vagina and uterus, considered in relation to 
 generative processes. 
 
 If in weakly individuals amenorrhoea exists as a compli- 
 cation of this malformation, marriage should be avoided ; 
 conception very rarely occurs. In the married, septa should 
 be divided to prevent difficulties in childbirth. Such may 
 arise too from a hymen stretched tensely across the orifice. 
 If conception has taken place, we must act according to the 
 rules given in the section on Obstetrics. 
 
 6. In regard to the presence of a third ovary, it must be 
 mentioned that if oophorectomy is undertaken as preventive 
 treatment for menorrhagia from a fibroid or other cause, 
 the possibility of a third ovary must be borne in mind so 
 that no failure may result. 
 
 Far more successful are the measures which preventive 
 treatment can bring to bear upon the abnormalities of 
 formation during childhood and at puberty. 
 
 Preventive treatment in the infantile condition of the 
 genital organs should aim, before marriage, at improve- 
 ment of the entire general constitution ; local treatment 
 should generally be resorted to only after marriage. The 
 general treatment should not be restricted to combating 
 the chlorosis and anaemia, or to allaying a chronic dyspepsia, 
 but should embrace a regime which will raise the tone of 
 and strengthen the entire physical and mental life. 
 Hysteria and neurasthenia, dyspepsia and chlorosis should 
 be overcome by a well regulated mode of life, regular and 
 not too fatiguing work, eight to ten hours of sleep and 
 early retiring to bed, five meals a day of easily digested 
 food, moderate exercise calculated to strengthen the muscles, 
 every morning bathing with cool water of 80° F., 70° F., 
 
 283 
 
THE PREVENTION OF DISEASE 
 
 or 65° F,, according to the state of nutrition, the avoidance 
 of mental exertion and of amusements which excite the 
 imagination and burden the memory. In place of these, 
 the wholesome mental influence of a simple family and 
 home life, the avoidance of all wine, beer, tea, coffee and 
 spices, while chocolate and sweetmeats should only be 
 allowed exceptionally as dainties. The choice of recreations 
 and amusements should be restricted to simple ones which 
 do not excite the senses and the imagination, while the 
 desire for work and the sense of duty and training in self 
 control should be aroused — in short, the causes of effemin- 
 acy, of eccentricity, and of hysterical attacks should be 
 removed. In general such patients are deficient in bodily 
 heat, and therefore it is a mistake to use strong measures 
 to try and fortify them against cold, or to dress young 
 and delicate children in clothing insufHciently warm. 
 
 Hydropathy may be of value if we select applications 
 which are not too stimulating. So too general and special 
 massage of the abdomen and the thighs. In the summer 
 at least six weeks stay in the country, or better at the 
 seaside, or at some elevated district with pine forests. 
 Along with this drugs should be given. Firstly those 
 containing iron, such as haemalbumin, pilula ferri, ferratin, 
 liquor ferri manganatis saccharatus, haemol and haemo- 
 gallol, Blaud's pill, and per rectum alkarnose is the best 
 form. Then stomachics and tonics such as tinctura cin- 
 chonae, nutrol, chloralbacrd, acidum hydrochloricum dilutum 
 and liquor arsenicalis. For very neurotic anaemic girls the 
 Weir-Mitchell and Playfair treatment is suitable. Special 
 treatment is needed for certain definite symptoms such as 
 dysmenorrhoea, scanty menstruation and amenorrhoea, or 
 menorrhagia with anaemia. It is a question essentially of 
 regulation of the blood supply, and can be accomplished by 
 the general measures before mentioned, be the case one of 
 scanty menstrual flow or of menorrhagia. As additional 
 treatment for delayed or scanty menstruation must be men- 
 tioned foot baths hefore the cessation of the period. The 
 footbath may be ordinary hot footbaths reaching to above 
 the ankles, or a footbath in which the feet are immersed 
 
 284 
 
PROPHYLAXIS IN THE DISEASES OF WOMEN 
 
 alternately in water of 65° F. and of 104° F., with or with- 
 out the addition of salt or mustard ; then massage or water 
 compresses on the lower extremities and abdomen, warm 
 hip baths and warm full baths, and mustard leaves upon 
 the inner surface of the thighs. For dysmenorrhoea the 
 same line of treatment is required with hot fomentations 
 and enemata. For habitual menorrhagia the treatment 
 before the period should comprise a cold water compress on 
 the abdomen and mustard leaves over the hepatic region, 
 and during the intermenstrual period the above mentioned 
 general treatment. 
 
 Remedies in addition to iron and tonics which act well 
 in all these cases by regulating the blood supply are 
 ergotin, stypticin, which is also a sedative, and especially 
 in cases of menorrhagia the fluid extract of hydrastis 
 given several days before the expected period. The same 
 result may be quickly and effectually attained by a pro- 
 longed use of calcium hypophosphite or of sodium iodide 
 in increasing doses, or the rectal or subcutaneous injection 
 of a 2 per cent, gelatin emulsion, or a 3 per cent, solution 
 of sugar. 
 
 In the married, local preventive treatment is more 
 important and may be recommended without hesitation : 
 hot vaginal douches of salt and water or of infusions or 
 mucilaginous sedatives, the patient being in the dorsal 
 position. For dysmenorrhoea with scanty menstrual flow, 
 dilatation and stretching of the cervix by plugging or by 
 tents, several times and always at least one week before the 
 menstrual period, with strict asepsis and with after treat- 
 ment according to the directions already given. 
 
 I have repeatedly seen sterility quickly cured by this 
 treatment ; with the cessation of dysmenorrhoea, the 
 vaginismus simultaneously disappears. 
 
 Menorrhagia and the tendency to early miscarriage, 
 which is apparently combined with this condition, may be 
 cured by curetting, after dilatation of the cervix, if the 
 disease has already existed a long time, or by the internal 
 application of steam (atmocausis). If all other methods 
 have failed, the latter may be used in the unmarried also 
 
 285 
 
THE PREVENTION OE DISEASE 
 
 ■for severe and otherwise incurable dysmenorrlioea, the 
 cervical canal should be suflficiently dilated and protected 
 from the hot tube by some material which is a bad con- 
 ductor of heat, such as gauze ; the temperature must not be 
 higher than 105° C. (220° F.) and the steaming must not 
 exceed a quarter of a minute. 
 
 By these hot vaginal irrigations and by the use of 
 tampons to produce dilatation an increased flow of blood 
 is first of all established, whereby the organ is increased in 
 size, as can be shown by palpation, and its form and con- 
 sistence become more normal, the sharp angle of flexion 
 which otherwise would gradually become firm and hard 
 disappears, the body of the uterus comes to lie more in a 
 line with the cervix, the wall of the cervix becomes softer 
 and the os uteri remains wider. In this way several factors 
 which tend to sterility are removed, and the endometrium 
 doubtless undergoes changes since its functions are im- 
 proved. Direct experiments to prove this are wanting. 
 
 It must be briefly stated that preventive treatment 
 against sterility should extend to the male and should be 
 directed, on the one hand, against neurasthenic conditions, 
 and, on the other hand, against malformations of the penis 
 such as epispadias and hypospadias, and inflammatory or 
 traumatic strictures and prostatic enlargements. 
 
 II. Changes in the Form and Position of the 
 Generative Organs 
 
 It is desirable here to distinguish four groups ; symptoms 
 connected with the uterus are generally the most promi- 
 nent, as the uterus forms the largest part of the generative 
 organs. 
 
 1. Herniae. 2. Descent or prolapse, 3. Inversion of the 
 uterus. 4. Pathological malpositions, versions and flexions 
 of the uterus. The pathological malpositions are displace- 
 ments forwards, backwards or to either side of a uterus 
 which is normal in form and in its inclination to the pelvic 
 axis ; whereas in " versions " the uterine axis is inclined to the 
 
 286 
 
PROPHYLAXIS IN THE DISEASES OF WOMEN 
 
 pelvic axis at an abnormal angle, generally backwards ; 
 and in "flexions" an abnormal angle of flexion exists 
 between the body of the uterus and the cervix, thus the 
 relation between the component parts of the uterus is 
 changed. 
 
 1. PREVENTIVE TREATMENT IN HERNIAE 
 
 is that of herniae in general, especially the avoidance of 
 everything that will permanently weaken the abdominal 
 walls and tend to increase the intra-abdominal pressure. 
 
 For our purpose we must keep separate three groups ; 
 {a) in which parts of the generative organs form the hernial 
 contents, for instance a horn of a uterus bicornis or a uterine 
 appendage in an inguinal hernia ; (&) in which some part of 
 the generative organs forms the hernial sac, as in ovariocele 
 and enterocele vaginalis and hernia labialis ; (c) repro- 
 ductive processes are the exciting cause of a hernia in some 
 other region, as in umbilical, inguinal and femoral herniae, 
 which are predisposed to by pregnancy, or caused by partu- 
 rition, or result from the removal of tumours by abdominal 
 section. Of these group h belongs to the inversions or 
 prolapse of vagina ; and the labial herniae belong aetiologic- 
 ally to group c. It is rare to find parts of the generative 
 organs as hernial contents, and in these cases malformations 
 generally play a part, as in pseudo-hermaphrodism and 
 uterus bicornis ; indeed the tendency to hernia may exist 
 from birth together with a tendency to prolapse of the 
 uterus and vagina and rectum. It requires then only some 
 exciting cause to force a passage through the hernial orifice. 
 Such predisposition may be reduced by systematic moderate 
 exercise of the abdominal muscles, regular action of the 
 bowels and urinary bladder, and especially by massage and 
 suitable gymnastic exercises. 
 
 In some cases the complete formation of the hernia will 
 lead to troublesome and dangerous consequences, as when 
 an abnormally short round ligament draws the ovary or 
 uterine cornu into the hernial orifice. The menstrual 
 troubles may then become unendurable ; and when impreg- 
 
 287 
 
THE PREA^ENTION OF DISEASE 
 
 nation has taken place the ovum may become lodged in the 
 hernial sac or the herniated uterine cornu, instances of 
 both of which have been seen by the author. This may be 
 prevented by timely closure of the hernial orifice, generally 
 an inguinal one, with or without removal of the hernial 
 contents. If some freely movable part is concerned, reduc- 
 tion of the hernia must be followed by use of a truss to 
 prevent the troubles and dangers mentioned above. 
 
 As every increase of intra-abdominal pressure predisposes 
 to hernia, so especially will pregnancy and tumours of the 
 ovary or uterus. Pregnancy predisposes chiefly by frequent 
 recurrence or by the presence of hydramnion or of twins, 
 when there exists some corresponding predisposition or when 
 prophylactic treatment has been neglected. This prophy- 
 lactic treatment consists of suitable exercises of the abdom- 
 inal muscles, support of the abdomen by a suitable belt 
 or bandage when the uterus or tumour approaches the 
 umbilicus, or the removal of the tumour before this. 
 
 Preventive treatment is most important during the 
 puerperal period : a uniform compression of the abdomen 
 by a bandage which may be aided by pressure by a weight, 
 but the weight pressure must never be employed alone, as 
 one so often sees, because the intestines are thereby forced 
 to the sides and the abdomen is pressed flat. A gentle 
 aperient may be given on the third day, and if the abdo- 
 minal wall is flaccid, and disease of the generative organs 
 can be excluded, massage of the abdomen may be performed, 
 not only to stimulate the action of the intestines and the 
 circulation of the blood, but also to raise the muscular tone 
 of the abdominal wall and reflexly to increase the blood 
 flow to the mammary glands. Suckling is an important 
 regulator of the involution of the pelvic organs and of the 
 abdominal wall ; it must be emphasized that too little 
 patience is in this matter generally evinced by the mother 
 and by the nurse, and also by the doctors. Sometimes it is 
 possible only after several weeks to bring about a regular 
 and sufflcient milk supply. On the day this was written 
 there came to the writer a woman, thirty-two years of age, 
 who had been delivered of her third child by forceps seven 
 
 288 
 
PROPHYLAXIS IN THE DISEASES OF WOMEN 
 
 weeks before, and who at my urgent request — she was 
 engaged in business and had not nursed her first two 
 children — had for four weeks perseveringly tried to increase 
 the flow of milk, and in consequence the milk had increased 
 to a sufficient quantity. But usuall}^ the attempt is given 
 up after a few days, through impatience. In addition to 
 abdominal ma,ssage, somatose and plasmon, which consist 
 of the proteids of milk, may be recommended for this pur- 
 pose, though the author has found them useful in increasing 
 the flow of milk also. 
 
 For meteorism of the intestines, bitters, oil of peppermint 
 and mucilaginous or peppermint enemata are of service. 
 
 If the hernial orifice is already large, it is desirable 
 immediately after delivery to apply a truss, and for this 
 purpose the English truss is better than the G-erman one, 
 even during pregnancy. During pregnancy the uterus 
 usually impedes the passage for the intestine, even though 
 the hernial canal is dilated ; in the puerperal period, on 
 the other hand, the wide opening is suddenly uncovered and 
 exposed to the full abdominal pressure. Confinement to 
 bed for too long during the puerperium is as injurious to 
 the patient as getting up too early, because the muscles 
 become relaxed ; on an average ten to twelve days is most 
 suitable. Heavy lifting and hard work should be alto- 
 gether forbidden, and systematic exercise of the abdominal 
 muscles must be recommended. Very thin patients should 
 be fed to develop a thicker panniculus adiposus. 
 
 The same holds good for the care of the abdominal wall 
 before and after abdominal sections. From carefully com- 
 piled statistics obtained by examination of patients who 
 had previously undergone an abdominal section, Abel has 
 drawn the conclusion that the subsequent formation of 
 herniae in such patients is generally the fault of the oper- 
 ator, and is due to inexact sutures, pressure necrosis, sub- 
 cutaneous abscesses, or the inclusion of fat lobules between 
 the wound surfaces. While acknowledging the correctness 
 of much of Abel's work, yet there are cases which have 
 already in them a predisposition to the formation of herniae, 
 and in these deficient tone of the abdominal muscles plays 
 
 289 u 
 
THE PREVENTION OF DISEASE 
 
 the chief part. Therefore exercise of these muscles and 
 careful suturing must be used, but too many ligatures 
 should not be employed. 
 
 2. THE PEEYENTIVE TEEATMENT OP PKOLAPSE OP 
 THE INTEENAL GENEEATIVE OEGANS 
 
 Here too we must distinguish between the preventive 
 treatment of the primary cause or predisposition to the 
 descent, of the exciting cause, and of the sequelae. 
 
 With regard to the primary cause, the prolapse may be 
 congenital ; this is very rare. I found one such case in 
 the Munich Frauenklinik, in a child with a lumbo-sacral 
 meningocele ; a second case I saw in the Heidelberg Frau- 
 enklinik. In literature I knew then of only one case by 
 Qviesling ; several others have since been published, and 
 some with spina bifida as in the case mentioned above. 
 The causal connexion which possibly exists between the 
 spina bifida and the incomplete prolapse produced by exces- 
 sive hypertrophy of the cervix was first pointed out by 
 Winkel ; in other similar cases there is, as a matter of fact, 
 a congenital prolapse of the whole uterus. 
 
 I mention this aetiological possibility here because it is 
 not at all improbable that disturbances of the central 
 nervous system, especially of the lumbar part of the spinal 
 cord, are the immediate cause of the appearance of these 
 lumbo-sacral symptoms in all relaxed conditions — muscular 
 as well as vasomotor — of the ligamentous and fascial struc- 
 tures of the pelvis, of which prolapse of the uterus and 
 vagina represents the final stage. To treat these specially 
 is beyond our knowledge and our skill. Here too we fall 
 back upon the treatment of the general neurasthenia, and 
 upon prevention of over stretching of the elastic liga- 
 mentous structures, and upon the restoration so far as 
 possible of the former elasticity after any severe stretching. 
 This stretching may occur in pregnancy, or after the cervix 
 has been drawn down for operations, or it may follow heavy 
 lifting or sudden violent falls upon the buttocks. 
 
 The general neurasthenia which here shows itself locally 
 as a disturbance in innervation, in the form of diminished 
 
 290 
 
PROPHYLAXIS IN THE DISEASES OF WOMEN 
 
 tone of all tlie elastic elements, including those of the vessel 
 walls, is to be treated by the measures already given under 
 "Infantile conditions of the Generative Organs," and under 
 " Herniae," for improving the tone and vigour of the body. 
 By these measures we remove too the symptoms which are 
 in part concomitant, in part reflex. 
 
 The knowledge that a relaxed condition of the pelvic 
 floor allows of the completion of a prolapse which had 
 commenced through the yielding of the ligaments and of 
 the subserous parietal pelvic tissues, suggested the idea of 
 using gynaecological massage and resistance exercises to 
 raise the tone of the pelvic floor. The results have unfor- 
 tunately not been encouraging, yet as adjuncts these 
 methods need not be despised. 
 
 The first result of relaxation of the ligaments is retro- 
 version of the uterus ; and this may appear even in J^'oung 
 girls, but most freqiiently begins at the first or second 
 confinement when there is a corresponding predisposition to 
 it. When once the uterine axis comes to lie in the same 
 direction as the vaginal axis, especially when there is a 
 ruptured perineum or the legs are rather wide apart and 
 the body is bent forward — then a sudden increase of 
 abdominal pressure, as in heavy lifting or a sudden violent 
 fall, suffices to bring the uterus to the vulva, giving rise to 
 acute prolapse. In the posture described, the musculature 
 of the perineum together with its fasciae is relaxed. If 
 then the physician discovers a retroversion of the uterus or 
 a defective perineum, he should prescribe suitable pre- 
 cautionary measures and advise immediate plastic repair of 
 the perineum. 
 
 Retroversion brings with it, not only the risk of prolapse 
 of the uterus, but is indeed the first stage to it ; in most 
 cases however this fortunately leads only to a slight degree 
 of descent so long as the functions of the pelvic floor are 
 normal. It may be suddenly lost by too early and severe 
 abdominal pressure in labour, or by too long continued 
 impaction of the head, or by too sudden stretching by lever- 
 age and traction with forceps. If the head has only jus- 
 passed the OS and the perineum is still undilated and extract 
 
 291 
 
THE PREVENTION OF DISEASE 
 
 tion is indicated, it is best first to introduce a large-sized 
 dilatable indiarubber bag, or if there is not time enongb 
 for this — and it takes some minutes — then make a deep 
 lateral perineal incision through the sphincter vaginae and 
 levator ani of one side, and immediately after delivery bring 
 together the edges of this incision after careful cleansing 
 by deep catgut sutures. 
 
 The most appropriate time for preventive treatment of 
 retroversion and of descent of the uterus is during the 
 puerperium, because on the one hand at this time the 
 foundation for subinvolution of the uterus and ligaments is 
 most frequently laid, and on the other hand the genitalia 
 are most plastic at this time and can, as it were, be better 
 moulded by suitable treatment. We must remember that 
 it is by no means most common for these processes of 
 descent to start from the uterus, but rather that the first 
 stage of it belongs to the vagina. Descent of the anterior 
 vaginal wall is the most frequent ; and is followed by 
 descent of the adjacent part of the bladder, and the uterus 
 is then drawn down. Prolapse of the vagina thus leads to 
 cystocele ; and prolapse of the posterior vaginal wall to 
 rectocele. Prolapse of the posterior wall may bring about 
 a prolapse of the organs contained in the pouch of Douglas, 
 and may give rise to serious obstetric complications, and 
 these should therefore be replaced beforehand or removed. 
 
 All these processes of descent may easily be prevented 
 during the puerperal period by the use of pessaries. These 
 should be introduced at the end of the first week with the 
 strictest aseptic precautions. Broad rimmed smooth 
 celluloid or vulcanite pessaries should be used, never porous 
 elastic indiarubber rings, which might injure the delicate 
 hyperaemic mucus membrane or by absorption of lochial 
 discharge become a nidus for bacteria. The shape should 
 be oval, and slightly concave towards the symphysis ; or 
 when there is a tendency to retroflexion, the S shaped or 
 Hodge pessary with a very broad bar for the posterior 
 vaginal vault may be employed. 
 
 In such cases the perineum often sinks down and the 
 vagina threatens to prolapse ; they should then be sup- 
 
 292 
 
PROPHYLAXIS IN THE DISEASES OF WOMEN 
 
 ported during involution by a T bandage, firmly applied. 
 When a tendency to retroversion of the uterus is known to 
 exist, the patient should be kept in the lateral position as 
 much as possible during the j)uerperium. Too early getting 
 up, that is before the fourteenth day, or too long a confine- 
 ment to bed, that is after the third week, and too early 
 hard work and heavy lifting should be forbidden. 
 
 The patient should be seen once a week till the next 
 menstruation, so that as the involution of the vagina pro- 
 ceeds smaller pessaries may be substituted. The round 
 Meyer ring pessaries are of no use because of their form, 
 since, according to my observations, they produce eversion of 
 the lips of the os of the soft puerperal uterus ; then the 
 cervix sinks into the ring, and there arises a dragging on 
 the cervico- vaginal muscular fibres, which pass on the one 
 hand to the vaginal wall, and on the other hand radiate 
 fan-like into the lips of the os uteri ; and hence the 
 eversion occurs. There are no purely circular or oblique 
 muscle fibres to offer a more effective resistance than the 
 elastic fibres are able to do. "We must therefore not only 
 with the puerperal uterus but with every relaxed uterus, 
 especially when there exists lateral laceration of the os, be 
 very cautious in the use of perfectly circular and thick 
 brimmed pessaries with small lumen ; oval pessaries are 
 better. The most rational treatment is a fixation opera- 
 tion and a perineorraphy. 
 
 The vasomotor tone may be improved by the administra- 
 tion of ergot and by hot vaginal douches several times 
 daily, or by irrigations with cold and hot water alternately 
 (60° to 70° F. and 108° to 115° F.). Gynaecological mas- 
 sage acts quickly, but cannot be used till after the lying-in 
 period. The combination of pressure and heat by a vaginal 
 "thermophore" is useful; the temperature of the sodium 
 acetate contained in it reamins constant for hours. 
 
 Prolapse of the vagina wall alone occurring after labour 
 is not seldom combined with incontinence of urine, and is 
 most successfully treated so as to prevent further prolapse 
 by astringent tampons, such as glycerine of tannic acid or 
 a ten per cent, solution of aluminium acetate. A third 
 
 293 
 
THE PREVENTION OF DISEASE 
 
 preventive measure in the piierperium is the suturing of a 
 rupture of the perineum directly after the third stage of 
 labour. The sooner and the more exactly the sutures are 
 inserted, the more likely is primary union to occur. The 
 surfaces should be properly fitted one to the other ; this is 
 especially important in the frequent lateral tears. The 
 vaginal rent must be sutured in its whole length, otherwise 
 the healing of the perineal wound may be prevented by 
 the penetration of lochial discharge. The deep catgut 
 sutures must pass deeply below the wound, but they should 
 be only few in number so that there may not be too much 
 material to be absorbed. The points of entry and of exit of 
 the stitches should lie near the edge of the wound, but the 
 needle should pass far into the neighbouring tissues. 
 
 The after-treatment must not be too active. The. wound 
 should be sprinkled with an antiseptic jDOwdei — I prefer 
 airol or nosophen — or some airol paste, which softens on the 
 skin, should be carefully applied. With due cleanliness 
 and when the lochia are normal, catgut or silk is as good a 
 material for sutures as celluloid thread, silkworm gut or 
 silver wire. Non-absorbable sutures should be removed at 
 the end of the first week. 
 
 If primary union fail, or the physician is not called to 
 the patient till the second or third day, it is advisable to 
 wait, and the plastic perineal operation should be under- 
 taken six or eight weeks after the confinement. Secondary 
 suturing of the granulating surfaces after paring is 
 generally more or less unsuccessful. Sometimes a small 
 abscess may then form, which in favourable cases opens at a 
 spot between the vaginal and perineal sutures, but which, 
 should it become larger, may cause troublesome fistulae 
 (recto- vaginal or perineo- vaginal). 
 
 Long continued infective inflammations and frequently 
 recurring pregnancies bring about conditions in weakly 
 patients exactly similar to those caiised by puerperal sub- 
 involution : immediately after normal childbirth the anterior 
 lip of the OS uteri may be felt immediately within the 
 vagina. Through long continued infective inflammations 
 the vessel walls gradually lose their tone ; this occurs both 
 
 294 
 
PROPHYLAXIS IN THE DISEASES OP AVOMEN 
 
 in the uterus wliicli has been thickened by metritis and in 
 the ligaments. It occurs also in the vagina in which there 
 is chronic hyperaemia. The prevention or early cure of all 
 infective inflammations of the vagina, of endometritis, of 
 erosions and of eversion, is a cardinal point in the preven- 
 tion of prolapse. 
 
 In a similar manner by muscular and vasomotor dis- 
 turbances in innervation perverted sexual habits (mastur- 
 bation and onanism) will tend to cause retroversion and 
 descent of the uterus. Here also the appearance of the 
 injurious reaction which follows frequent congestion is 
 dependent upon the state of the general neurotic condition 
 of the individual. Finally, we recognize a purely mechanical 
 displacement of the uterus either upwards or downwards by 
 tumours. The simple downward displacement of a uterus 
 may lead to total prolapse, if at the same time it becomes 
 retroflexed and gravid, and in enlarging has become incar- 
 cerated below the promontory. In both cases it should be 
 replaced ; either the uterus or the tumour should be pushed 
 upwards and forwards out of the pelvis, and a pessary 
 inserted. If there are peritoneal adhesions which make 
 replacement impossible, then all preventive measures are 
 in vain and radical treatment should be resorted to. 
 
 In the last sentences we have already passed over to the 
 preventive treatment of the sequelae of prolapse. Simple 
 descent of the uterus predisposes to miscarriage when the 
 walls are relaxed or the os is everted. It can be prevented 
 by immediate insertion of an oval pessary which should be 
 worn to the fifth month of pregnancy. Plastic operations 
 for the eversion of the os are contra-indicated during 
 pregnancy, because operations on the cervix readily cause 
 miscarriage. But colporrhaphy and perineal operations 
 may be carried out. After such an operation at the sixth 
 month I have observed slight labour pains for a few days, 
 but then all went well. The parts become so readily 
 dilated again that it is better to postpone the operation till 
 after the puerperal period, or till after lactation. 
 
 The results of a simple prolapse are apparent in all the 
 organs concerned. They are excoriation and catarrhal 
 
 295 
 
THE PREVENTION OE DISEASE 
 
 inflammation of the mucous membrane of the vagina, erosion 
 and eversion of the li]3S of the os uteri, oedema and gradual 
 hypertrophy of the cervix, the formation of pouches in the 
 bladder and rectum with catarrh through stagnation of 
 the urine and faeces, the formation of calculi, circulatory 
 disturbances, as in the formation of haemorrhoids, even 
 gangrene of the prolapsed parts, kinking of the urethra 
 and ureters with secondary hydronephrosis, entero-kolpo- 
 cele, and peritoneal adhesions of the uterus to the organs in 
 Douglas' pouch which has also descended — and as a conse- 
 quence sterility. All these troubles, some of them very 
 serious, may be prevented by early radical cure of the 
 prolapse. The commencing formation of adhesions should 
 be met by replacement of the uterus. If firmer adhesions 
 are present, they are stretched or broken down by massage 
 and subsequent plugging of the posterior cul-de-sac. 
 Lastly, a few words about the harmful results of unsuitable 
 treatment of prolapse. Concerning the use of pessaries, 
 I would refer to what has been said above about the action 
 which round thick-brimmed rings exercise in producing 
 eversion when the uterus is relaxed. The lumen of the 
 pessary must be wide enough to allow the vaginal part of 
 the cervix to lie easily within it, otherwise strangulation 
 of the cervix and pressure ulcers will occur. To avoid 
 excoriations and ulcerations of the vaginal mucous mem- 
 brane the instrument should be removed for a few days 
 every three months, or after the climacteric even oftener. 
 Ulceration may lead to incrustation of the pessary, and to 
 the formation of granulations and even to fistulae. For 
 washing out the vagina it is best to use lukewarm normal 
 saline solution, and this should be done in the recumbent 
 posture, daily if there is leucorrhoea, otherwise once a week 
 or at least several times after every period. As soon as the 
 discharge becomes irritating or foetid, the pessary must be 
 removed and the vagina irrigated with a weak solution of 
 potassium permanganate. 
 
 The pessary must not tensely stretch the vaginal walls, 
 and the lower bar must not lie so as to be visible at the 
 vulva ; pain, a sensation of great pressure, incontinence or 
 
 296 
 
PROPHYLAXIS IN THE DISEASES OP WOMEN 
 
 retention of urine, and catarrh of the vagina would 
 result. 
 
 If the vaginal part of the cervix is too short, it slips out 
 of the pessary and pressure effects readily arise. In such 
 cases a Hodge S-shaped pessary should be used, and the 
 upper bar should be directed backwards, to stretch the j^arts 
 transversely and obliterate the folds of Douglas' pouch. If 
 scar tissue in the vaginal vault, left by parametritis or by 
 lacerations, or if too short an anterior vaginal wall prevents 
 a correct position of the ring, then pieces of vaginal 
 mucous membrane must be excised by oval incisions, and 
 stitched parallel to the longer diameter of the oval, in such 
 a way that in place of this shortening an increase in length 
 is obtained. 
 
 "When the ring is imperfectly or not at all retained in 
 consequence of a defective perineum, or of too wide and lax 
 a vagina, a plastic operation should be performed. If 
 operation is refused, or if the patient is old, Schultze's 
 sledge pessary should be introduced, reversed in such a way 
 that the anterior curve looks towards the posterior vaginal 
 vault and the vaginal part of the cervix is carried up by 
 that segment. When the perineum is intact, the vagina 
 very wide, and the prolapse constantly recurs, E. Martin's 
 modification of Zangerle's stemmed pessary, which rests 
 upon the levator ani muscle, is useful. So too is Hewitt's 
 cradle or clamp pessary. The old stemmed pessary on the 
 other hand is very bad, as it causes troublesome ulcers. 
 As a last resource, the oval hollow egg-shaped vulcanite 
 pessaries (generally No, 2 and 3) brought into use again by 
 Breisky, with a T bandage, are to be recommended ; these 
 must be removed by forceps when they have to be cleaned. 
 
 When hypertrophy of the cervix or tumours are present 
 pessaries must on no account be used. 
 
 With regard to hysteropexy in women capable of child- 
 bearing, vaginal fixation or vesical fixation is dangerous, and 
 this is true even if their most recent modifications are used, 
 which are intended to avoid adhesions being formed too high 
 up or too extensively, since their extent can never be deter- 
 mined beforehand. For very serious disturbances have been 
 
 297 
 
THE PEEVENTION OF DISEASE 
 
 observed during pregnancy and childbirth through the 
 failure of the anterior uterine wall to expand, and the con- 
 sequent overstretching of the posterior wall ; and in order 
 to render delivery possible, it has been necessary to make 
 an incision through the whole anterior uterine wall, or 
 even perform a Caesarian section. Similar disturbances in 
 cases of ventrifixation of the fundus uteri have occasionally 
 been reported. 
 
 3. THE PREVENTIVE TREATMENT OF INVERSION 
 OF THE UTERUS 
 
 This depends intimately upon aetiology. It may be caused 
 by relaxation of the dilated cervix with very strong con- 
 tractions of the body of the uterus, and the presence of 
 adhesions between the body which is being expelled from 
 the uterus and the fundus, as in fibromyoma or adherent 
 placenta. It may also be due to relaxation of the body 
 of the uterus and forcible expression of the placenta by 
 Crede's method, or to strong traction on the umbilical cord ; 
 or it may occur in precipitate labour. 
 
 Fibrous polypi should be removed when they begin to 
 cause dilatation of the os uteri. When a placenta is really 
 adherent it should be removed by the hand, with strict 
 antiseptic precautions, Crede's expression of the placenta 
 should be made only during a pain ; forcible traction should 
 never be made on the umbilical cord. In threatened pre- 
 cipitate labour the patient should be placed in the lateral 
 posture and forbidden to make any bearing down efforts, 
 and a sedative may be given. 
 
 Treatment to prevent the results which may follow 
 inversion consists essentially in immediate replacement of 
 the uterus, for the longer we wait the more difficult does it 
 become. The best method is to dilate the vagina and use 
 massage and cold injections, and to administer ergot after 
 replacement. A funnel-shaped piece of peritoneum is 
 carried down by the inverted uterus, and unless the uterus 
 is soon replaced peritoneal adhesions form which later can 
 be overcome only with difficulty, if at all. 
 
 It must be borne in mind that an error in diagnosis 
 
 298 
 
PROPHYLAXIS IN THE DISEASES OF WOMEN 
 
 between au inverted uterus and a polypus has led to the 
 removal of the uterus in mistake for a polypus. 
 
 During replacement counter-pressure should be made on 
 the abdomen to prevent a rupture of the vagina. 
 
 4. THE PREVENTIVE TREATMENT IN DISPLACEMENTS, 
 VERSIONS AND FLEXIONS OF THE UTERUS 
 
 These three forms, which have been already defined, may 
 occur combined one with another and with change in the 
 position in the level of the uterus, as in prolapse. 
 
 (a) With regard to displacements of the uterus, aetiology 
 teaches that inflammatory exudations, as in parametritis 
 and perimetritis, cause displacements in a definite direction ; 
 first indeed in one direction by the presence of the exudation, 
 and later in the opposite direction by contraction of this 
 newly formed fibrous tissue ; and this leads to fixation. 
 The same result may follow appendicitis. 
 
 The displaced uterus generally remains movable when 
 the displacement is due to a tumour, whether it be a tumour 
 of the uterus, of a neighbouring organ, or simply an habi- 
 tually overfilled bladder or rectum, or a hydrosalpinx 
 or pyosalpinx. A congenital inequality of the ligaments of 
 the uterus is unimportant. Among tumours of the pouch 
 of Douglas, extra-uterine gestation is specially important. 
 
 The preventive treatment to be adopted is that described 
 under " Inflammations " and under " Tumours." Commen- 
 cing adhesions should be early removed by massage to pre- 
 vent an abnormal fixation of the uterus. 
 
 During the years of school care should be taken to 
 prevent girls getting into the harmful habit of neglecting 
 to empty the urinary bladder, from mistaken ideas of 
 propriety. So also with regard to habitual constipation, 
 the rule of a fixed hour for the evacuation of the bowels 
 from childhood onwards is the best way of inducing regu- 
 larity of the bowels, especially in chlorotic girls. 
 
 The further development of ectopic gestation may be 
 prevented in the early months by the injection into the 
 tumour of small doses of morphine hydrochloride, or it may 
 be removed. 
 
 299 
 
THE PREVENTION OF DISEASE 
 
 (6) By pathological auteflexions of the uterus we mean 
 those only which are permanent; they are accompanied 
 generally by very slight mobility of the body of the uterus. 
 
 "We have already spoken of the initial stage in the 
 anteflexed infantile uterus. The diminished mobility 
 may be the result of the position of the uterus in the 
 pelvic cavity, or of the relation of the body to the cervix. 
 When the anteflexion has not been produced by any 
 limitation of movement by fixation, it has been caused by 
 a rigidity of the " flexion angle," as a result of the form- 
 ation of inflammatory fibrous tissue. 
 
 In another variety the cause is to be found external to 
 the uterus, most frequently indeed in the cord-like indura- 
 ations left by parametritic and perimetritic exudations. 
 These may fasten the body of the uterus to the bladder and 
 anterior pelvic wall in front, or may fix the cervix to the 
 posterior wall behind — the latter being the more frequent. 
 If an adhesion draws back the posterior part of the uterus 
 near the internal os, anteflexion is produced. This may 
 also be produced by fixation of the cervix of the uterus 
 anteriorly, but this is very rare. 
 
 Tumours produce anteversion and anteflexion in various 
 ways; as by pressure from above and behind when the 
 tumour is connected with some other organ, as with an 
 ovarian cyst, or by a fibroid in the anterior wall of the 
 uterus which may simulate a flexion ; but the diagnosis 
 can be established by passing a uterine sound. Submucous 
 polypi may also cause anteversion. Fibroids in the anterior 
 wall may, according as they are situated in the cervix or 
 in the body of the uterus, produce either anteversion or 
 anteflexion. 
 
 Increased weight of the uterus, as in metritis or early 
 pregnancy may cause a bending forward and lowering of 
 the body of the uterus. From what has been said, it is 
 clear that the preventive treatment should aim at the pre- 
 vention or the early cure of inflammations of the vagina 
 and uterus, and also of the pelvic connective tissue, of the 
 adnexa and of the pelvic peritoneum. 
 
 Once the acute inflammatory stage has passed, it becomes 
 
 300 
 
PROPHYLAXIS IN THE DISEASES OF WOMEN 
 
 necessary to remove adhesions by massage or later by in- 
 cisions to set free the adherent organs, or by forcible break- 
 ing down of the adhesions and subsequent plugging with 
 glycerine gauze. Compression by firm plugging of the 
 vagina with moistened cotton wool pledgets or with a shot 
 bag and the application of bags of sand or of shot to the 
 abdomen are useful. 
 
 By these measures too the various sequelae of anteflexion 
 are prevented, such as dysmenorrhoea, sterility, constipation, 
 tenesmus, and bladder troubles. Whether removal of the 
 tumour is indicated depends upon its nature, and upon the 
 severity of the symptoms produced by the anteflexion. 
 
 (c) The preventive treatment of retroversion and retro- 
 flexion of the uterus depends in most cases upon the removal 
 of the neurotic disposition, the local effect of which has been 
 to lower the muscular and vasomotor tone of the pelvic 
 organs and their ligaments, and thus to produce descent and 
 prolapse. In speaking about the latter we have already 
 enumerated the general and special preventive measures 
 to be taken, as we believe retroversion of the uterus to be 
 the" first stage of descent. 
 
 Congenital retroversions are very rare ; but the predis- 
 position to these may be congenital, and leads to puerile 
 retroversion and retroflexion at puberty, when the body of 
 the uterus becomes heavier relatively to the cervix. With 
 such predisposition, an habitually overfilled urinary bladder, 
 early excessive abdominal straining and the dorsal position 
 in the puerperal period act as exciting causes producing 
 retroversion and later retroflexion of the uterus. The 
 recognition of this predisposition affords the indication for 
 the avoidance of these causes. The puerperium is too 
 the most favourable moment for the prevention or cure of 
 these anomalies in position, seeing that retroversion of the 
 uterus is produced by the same causes which produce pro- 
 lapse. We employ the same treatment for these as for de- 
 scent of the uterus. Here too subinvolution of the uterus 
 plays an important part, partly because of the increased 
 strain upon the ligaments, and partly because of the engorge- 
 ment of blood and the consequent diminution of elasticity of 
 
 301 
 
THE PREVENTION OF DISEASE 
 
 the ligaments. Regarding the use of pessaries, I must add 
 that the object to be attained is not the complete forward 
 replacement of the uterus, but rather the support of the 
 posterior cul-de-sac and relief of the strain on the ligaments. 
 
 The puerperal processes however act also in another wa}?-, 
 the most important of all : this is by giving rise to inflam- 
 mations, either alone or in combination with injuries of the 
 vaginal vault, and stretching, dragging and secondary 
 relaxation of the generative organs. The inflammation itself 
 next weakens the ligaments. The neck of the uterus may 
 be pulled forward by inflammatory indurations, or the body 
 of the uterus may be firmly fixed in Douglas' pouch by 
 perimetritic bands. Apart from these primary inflammatory 
 processes, secondary adhesions may be formed on the pos- 
 terior surface of the retroverted uterus. These adhesions 
 hold the uterus and thus make the flexion permanent. 
 
 Just as the weight of the puerperal or gravid uterus or 
 the enlarged uterus in metritis may induce retroversion, 
 and the adhesion between the uterus and the intestine may 
 hold down a uterus which otherwise would be mobile, so 
 heavy tumours may act in the same way, whether they are 
 situated in the uterus itself or in the adnexa or in neigh- 
 bouring organs. 
 
 The preventive treatment is similar to that for ante- 
 flexion of the uterus. 
 
 All troubles and morbid conditions which appear first in 
 later life and cause chronic hyperaemia and permanent 
 laxity of the ligaments produce retroversion of the uterus. 
 
 To this class belong all chronic disorders of metabolism 
 and dyscrasias, general neuropathic conditions with local 
 disorders in innervation and perverted habits. Cases of 
 simple retroversion also, in which the author has observed 
 spasmodic flexions, belong to this group. Preventive treat- 
 ment should be directed against these conditions, according to 
 the details already given under " Infantile Condition of the 
 G-enerative Organs," " Hernise," and " Prolapse." 
 
 Of practical importance is the preventive treatment of the 
 sequelae of retroversion and retroflexion of the uterus, which 
 are essentially of a nervous type. The controversy whether 
 
 302 
 
PEOPHYLAXIS IN THE DISEASES OF WOMEN 
 
 these are piirely reflex or whether they are accidental con- 
 comitants of a hysterical nature may perhaps be decided 
 by the fact, that according to what has been afore stated, 
 simple retroversion and retroflexion of the uterus almost 
 always arises from a general neuropathic condition, so that 
 the requisite predisposition for the development of these 
 nervous reflexes is present. That such reflexes exist has 
 been proved as a matter of fact by earlier observations, and 
 also by recent ones by the author which are free from 
 objections. For instance in some cases a cough can be caused, 
 " tussis uterina," by touching the posterior fornix with the 
 sound through a speculum. In the uterus itself, spasmodic 
 phenomena may be noticed by palpation if sufficient patience 
 and care are exercised . Thus a functional retroflexion may 
 arise temporarily from a simple retroversion. 
 
 The swelling of the mucous membrane which appears in 
 course of time and finally causes chronic metritis is likewise 
 the result of a vasomotor disorder of innervation. Its symp- 
 toms are menorrhagia and dj'-smenorrhoea ; the dysmenor- 
 rhoea is produced by spasmodic flexion which has been 
 already mentioned, and but seldom by any actual mechanical 
 stenosis due to the flexion. 
 
 It is not possible to look upon sterility as the conse- 
 quence of an ordinary retroversion and retroflexion of the 
 uterus without any inflammatory complication ; and apart 
 from complications the cause may be found in a lowering of 
 the general health combined with a morbid condition of the 
 nervous sj^stem. 
 
 For all these symptoms general treatment to raise the 
 tone of the body is required. For commencing endometritis 
 and metritis the special treatment given under those 
 headings is needed. The adhesions described as occurring 
 between the uterus and the pouch of Douglas may be pre- 
 vented by early replacement of the organ, by plugging and 
 by massage, and similar treatment may be employed for 
 the troubles connected with micturition and defaecation. 
 
 Special care must be observed in cases of retroflexion 
 which are complicated by pregnancy. Although in most 
 cases spontaneous replacement occurs in the second or third 
 
 303 
 
THE PREVENTION OF DISEASE 
 
 month, yet when this fails to take place serious and even 
 dangerous symptoms may arise. In neuropathic patients, 
 excessive vomiting may occur, and difficulty of micturition 
 which may lead to gangrene of the bladder wall. These 
 are the results of retroflexion of the incarcerated gravid 
 uterus. The replacement of the uterus in the second or 
 third month and the wearing of a pessary till the fifth 
 month will prevent this. 
 
 For other complications and sequelae reference must be 
 made to what has been said under " Prolapse." 
 
 In conclusion I must mention elevation and torsion of the 
 uterus, both of which as a rule are combined with other 
 pathological displacements. They are caused by tumours 
 or inflammatory adhesions or by the distension of some 
 neighbouring organ. Pathological rotation of the uterus, 
 especially that caused by tumours, may bring about 
 very serious circulatory disturbances and necrosis of the 
 uterine wall, or even a tearing of the tissues. Such 
 occurrences should be prevented by a radical operation, or 
 if this is refused by the use of a closely fitting abdominal 
 belt. 
 
 III. Disturbances in Nutrition and 
 
 Inflammations 
 
 (a) The preventive treatment in disorders of nutrition and 
 of circulation. 
 
 Vascular engorgement in consequence of vasomotor dis- 
 turbances has been frequently mentioned in the foregoing 
 pages, and we found it generally associated with changes 
 in form and in position of the internal generative organs. 
 These changes owe their origin to a similar loss of tone of 
 the elastic elements in the walls of the organs and their 
 ligaments. In its further course such hyperaemia leads 
 on to inflammation, not infective in origin yet the 
 abnormal secretion of mucus is well adapted to serve as a 
 nidus for bacteria ; yeast cells and amoebae have also been 
 found. 
 
 A definite set of symptoms arises from this source : 
 
 304 - 
 
PROPHYLAXIS IN THE DISEASES OF WOMEN 
 
 pruritus of the vulva, vaginismus and dysmenorrhoea. In 
 more severe cases there may also be tenesmus of the rectum 
 and bladder, and uterine colic. 
 
 Preventive measures consist chiefly in general tonic 
 treatment, as already described under " The Infantile Con- 
 dition," " Herniae " and " Prolapse." 
 
 An aetiological factor which is of great and frequent 
 importance, closely connected with neurotic conditions and 
 hysteria, in this group of disorders is the existence of per- 
 verted sexual habits, such as masturbation and onanism, 
 and sexual over-stimulation. On the other hand these morbid 
 conditions may be associated with impotence in the male. 
 Pruritus and vaginismus, as well as neuralgia of the 
 posterior vaginal vault, have in many cases been readily 
 proved to have a causal connexion therewith. These two 
 factors constitute a vicious circle. In a girl thus predisposed 
 we must insist upon her performing household duties 
 which shall fully occupy her time, and upon the avoidance 
 of all such things as tend to stimulate the sensual nature 
 and the imagination, such as lectures, balls and the theatre. 
 When nearing maturity such girls should be under the 
 care of a sensible mother, and not in a girls' boarding 
 school, very few indeed of which are in a position to give 
 to each individual girl the special training she requires, and 
 which afford scope for numerous follies that injure both 
 body and mind. An occupation in which mental work pre- 
 ponderates is useless. We must note that masturbation is 
 sometimes seen in quite young children. It is sometimes 
 caused by the irritation of thread worms, and these should 
 be looked for and treated ; in other cases it is due to vesical 
 calculi, or to fissures in the region of the clitoris or hymen. 
 These fissures often give rise to vaginismus, analogous to 
 the tenesmus of the anus caused by anal fissures. They 
 are most quickly cured by dabbing with ichthyol. 
 
 Pruritis of the vulva is often caused by diabetes. 
 
 Vulvitis is caused too by want of cleanliness, especially 
 when leucorrhoea exists or marked enlargement of the 
 labia and clitoris. Cleanliness, bathing with lotions which 
 are antiseptic and astringent, such as lead lotion, powdering 
 
 305 X 
 
THE PREVENTION OF DISEASE 
 
 with salicylic acid and talc, or bismiitli and talc, will 
 prevent the inflammation becoming worse. "When there is 
 a tendency to the formation of boils, the eruption may be 
 checked by the immediate use of Unna's mercurial carbolic 
 plaster upon the tender spots which are just becoming red. 
 Lotions of sodium carbonate may be used for folliculitis. 
 
 With regard to vaginismus, we must not forget that it 
 may be hysterical in origin and arise from a fixed dread 
 of connexion. In other cases there is inflammatory 
 hypertrophy of the hymen. A pretended or an actual 
 excision of the hjmien and the orifice of the urethra, 
 followed by the passage of a speculum, will convince the 
 patient that the vagina can now be easily entered, and 
 vaginismus will then be less likely to recur. "We must 
 remove also all other contributing factors, such as fissures 
 and perverted habits. 
 
 The same holds good for neuroses affecting the upj)er 
 part of the vagina. 
 
 Varicose veins are not seldom met with in the broad 
 ligaments and in the nymphae. The latter condition as 
 well as the troublesome sequelae, such as the rupture of the 
 varicose veins and the formation of haematoma of the 
 vulva and thrombosis, may be prevented during pregnancy 
 by compression with a T bandage witha dressing steeped in 
 astringent lotion ; and the external genitals should be kept 
 scrupulously clean. 
 
 By the bursting of varicose veins of the broad ligament 
 an intraperitoneal haematoma or a haematoma of the 
 broad ligament may arise, and for this reason they should 
 not be neglected. By way of prevention hot mucilaginous 
 vaginal and rectal injections should be given, the regular 
 evacuation of the bowels should be ensured, and compression 
 be applied by j)lugging, as by a bag of shot in the vagina 
 and also upon the abdomen, and cautious bimanual 
 massage. The patient should afterwards rest for an hour 
 in the recumbent position. 
 
 The so-called neuralgia of the ovary has nothing to do 
 with the ovaries, and but seldom with the adjacent nerve 
 plexuses ; but is generally neuralgia of the nerves passing 
 
 306 
 
PROPHYLAXIS IN THE DISEASES OF WOMEN 
 
 througli the recti muscles towards tlie hypogastriiim, or 
 neuralgia of the posterior vaginal vault and of Douglas' 
 pouch and the adjacent part of the rectum. If the pain 
 radiates downwards, it is felt according to my observations 
 in the region of the coccyx and anus; apart from this there 
 is also a true coccygodynia. For all these conditions, pre- 
 ventive treatment consists in the treatment of the general 
 neurasthenia and of the local congestions caused by it. 
 Only very seldom do we find actual periostitis or dislocation 
 in coccygodynia. 
 
 The congestive inflammations of the vagina, uterus and 
 ovaries, and the dysmenorrhoea associated with these, have 
 already been dealt with. 
 
 (b) The preventive treatment of inflanimations and their 
 sequelae. 
 
 There is, as mentioned above, an inflammation of the 
 generative organs, which is not infective in origin. The 
 exciting cause of infective inflammations is infection with 
 microbes, among which gonococci, staphylococci and 
 streptococci play by far the most important part. Their 
 entry is brought about by sexual connexion or by labour, 
 by operations, by foreign bodies, by injuries, or by trans- 
 ference from other organs as in the case of tuberculosis, 
 and of the bacterium coli. As already stated, the presence 
 of bacteria in the secretions of the uterus and the presence 
 of the yeast fungus must not always be regarded as the 
 cause of the inflammation. These organisms have settled 
 there because the secretions had become pathological, or 
 because the entrance of the vagina and the cervical canal 
 had received injuries and been dilated. The primary cause 
 is to be found in the congestion, hyperaemia and engorge- 
 ment as often mentioned above, as the result of disorders in 
 innervation and conditions of relaxation of the pelvic and 
 abdominal organs. In accordance with this, these in- 
 flammations do not finally disappear until the tone of the 
 general and local innervation has been raised. 
 
 And conversely the cause of the congestive hyperaemia 
 and engorgement may originally have been infective in- 
 flammations, which were cured when the bacteria had died 
 
 307 
 
THE PREVENTION OF DISEASE 
 
 out or had lost their virulence and which left behind a 
 diminished contractility of all the elastic tissue elements, 
 including those of the vessels. These infective inflamma- 
 tions may have occurred even in early childhood from 
 scarlatina, measles or gonorrhoea. 
 
 It is very important then to avoid the introduction of 
 infective germs into the internal genitalia, because these 
 organisms readily make their way along the mucous mem- 
 brane of the Fallopian tubes to the pelvic peritoneum, or 
 pass through the uterine wall to the parametrium and 
 spread to the ovary. If they have entered the vagina, 
 they should be removed before they pass the internal os. 
 "When the acute infective inflammation has subsided care 
 must be taken that no congestion of the organs and liga- 
 mentous apparatus remains or loss of elasticity — and on the 
 other hand that no contractions and adhesions exist to 
 produce permanent displacement of the uterus. 
 
 1. GONOREHOEA 
 
 is the most frequent cause of infective inflammations of the 
 genitalia. It should be remembered that 
 
 (a) In recent acute infection the internal os uteri and 
 afterwards the uterine orifices of the Fallopian tubes are able 
 for a long time to resist the further passage of the infection, 
 and hence acute infection vary rarely leads directly to 
 salpingitis or perimetritis. 
 
 (&) That chronic gonorrhoea is the form in which it 
 appears most often in married life, and is caused by latent 
 gleet in the male ; and in spite of or possibly by reason of 
 its very slowly progressive course it at last reaches the 
 serous membrane. 
 
 The preventive treatment of gonorrhoea belongs to the 
 section on Venereal Disorders. But so far as gynaecology is 
 concerned, and in order that the patient innocently exposed 
 to this infection may be relieved, the husband must be cured 
 of his gonorrhoea or gleet, and coitus should be avoided till 
 he is cured, and again later after any alcoholic or venereal 
 excess. In other words all over-stimulation reacts upon 
 the cocci concealed in the deep crypts, and this fact is the 
 
 308 
 
PROPHYLAXIS IN THE DISEASES OF WOMEN 
 
 more important because it is doubtful wliether such cases 
 are ever completely cured. Antigonorrlioeal applications in 
 the form of pastilles, of vaginal suppositories, or as douches 
 or as insufflation are useful if used both before and after 
 coitus, but they are not absolutely certain, and tend to pre- 
 vent conception. All local treatment at such times acts 
 injuriously upon the nervous system especially in those 
 with a neuropathic predisposition. Cold irrigations should 
 be altogether avoided as they cause metritis, parametritis 
 and oSphoritis by disturbance of the circulation. 
 
 "When infection has taken place treatment is essential 
 to prevent its extension to the internal os uteri : vaginal 
 douching five times daily with solutions of silver salts 
 and under very slight pressure — such as a 5 per cent. 
 solution of protargol, a 5 to 10 per cent, solution of 
 argonin, a 5 per cent, solution of argentamin in cases 
 where treatment of the deeper structures is required, 6 to 
 20 per cent, solution of silver nitrate as an astringent for 
 after treatment, a 5 per cent, solution of largin which is a 
 powerful antiseptic to the gonococcus though with very 
 slight action upon the nutritive medium. The vulva must 
 be scrupulously cleansed to prevent reinfection and urethri- 
 tis, or cystitis, or inflammation of Bartholin's glands. 
 
 If cervicitis appears the cervical canal should be dilated 
 after disinfection with protargol, and the uterine cavity 
 treated by cleansing, douching, plugging, and the use of 
 pencils or ointments (from ^ to 10 per cent, of protargol), 
 while the patient remains at absolute rest in bed. Finally, 
 treatment should be continued for several weeks longer 
 with potassium permanganate, and lastly with astringents 
 to remove the oedematous condition which is left behind : a 
 2 to 5 per cent, solution of aluminium acetate or a 2 to 3 
 per cent, of bismuth subnitrate may be employed. 
 
 If for other reasons this thorough treatment cannot be 
 carried out vaginal douches should be ordered ; they may 
 consist of a 5 per cent, solution of protargol, or 5 to 20 per 
 cent, solution of silver nitrate or potassium permanganate, 
 or a 1 in 2,000 or 4,000 solution of corrosive sublimate. 
 The vagina should be wiped out and plugged several times 
 
 309 
 
THE PREVENTION OF DISEASE 
 
 a week with a 10 per cent, protargol gauze, or the patient 
 should herself a23ply 10 per cent, protargol glj^cerine plugs. 
 The cervix should not be treated. 
 
 With a pyosalpinx, bilateral as a rule in cases of 
 gonorrhoea, extension to the peritoneum must be pre- 
 vented. Simple salpingitis can be cured by sedative treat- 
 ment, mercury and rest in bed, before a pyosalpinx forms. 
 An operation for removal of the tube is indicated when 
 suppuration threatens. Even after recovery from the 
 perimetritis the danger of subsequent attacks is great, and 
 for this reason the parts should be removed; they have 
 already become useless. Otherwise the only preventive 
 treatment possible is to lead a very regular life, and avoid 
 colds and cold feet. For attacks of pain however slight 
 apply an ice bag or at least cold compresses, and the patient 
 must rest in bed. By preventing the inflammation of the 
 uterus from becoming chronic we prevent also the joint 
 affections which may gradually and insidiously through 
 the circulation affect all the joints. 
 
 2. ACUTE SEPSIS 
 
 is prevented by strict asepsis and antisepsis at operations. 
 When an abscess is to be opened in or near the abdominal 
 cavity, the suppurative focus should be caref uU}'' isolated bj'- 
 gauze pads before the incision into the abscess is made. 
 Should the pus nevertheless escape into the abdominal 
 cavity it should be carefully mopjDed out and the peritoneum 
 drained with iodoform gauze or itrol gauze brought out 
 through the vagina or the lower angle of the abdominal 
 wound. The germs contained in old cases of salpingitis 
 have but slight virulence or are dead. Infected wounds 
 should be disinfected as thoroughly as possible and should 
 be daily dressed with iodoform or itrol gauze. Immediate 
 treatment is the surest way of preventing the extension of 
 the sepsis to the parametrium, the peritoneum or to the 
 lymph or blood stream. 
 
 The prevention of puerperal sepsis is dealt with under 
 the hygiene of parturition, to which the reader is 
 referred. 
 
 310 
 
PROPHYLAXIS IN THE DISEASES OP WOMEX 
 
 3. ACUTE INFLAMMATIONS OF THE GENITALIA 
 
 These are vulvitis, colpitis, endometritis, parametritis 
 and perimetritis, and ooplioritis. They are mostly of 
 gonorrhoeal or of septic origin : besides streptococci, we 
 find staphylococci, bacterium coli and pneiimococci as the 
 exciting cause. Cases of colpitis and of endometritis of 
 this nature are occasionally caused by wearing a pessary 
 for too long a time, or by the use of dirty or rough 
 pessaries, by curetting or use of the uterine sound without 
 previously sterilizing the instruments, and even by rough 
 exploration with infected fingers. From what has been 
 said it is obvious that the preventive treatment consists in 
 strict asepsis and antisepsis. And further these inflamma- 
 tions may appear as complications in general acute 
 infections diseases, as scarlatina, measles, smallpox, typhoid 
 fever, cholera, and influenza, and in these preventive treat- 
 ment should aim at removing the congestion which has been 
 left by the acute disease. 
 
 Finally in colds accompanied hy suppression of the 
 menses we may meet, not only with acute cystitis and 
 metritis, buV also with parametritis and oophoritis. 
 Immediate confinement to bed, the production of dia- 
 phoresis, cold abdominal compresses or an ice bag, local 
 blood letting, mild purgation, and hot vaginal douches are 
 indicated for this as well as for all other acute inflamma- 
 tions of the genitalia. 
 
 Acute vulvitis often originates in slight injuries and 
 fissures which have not been kept clean. Cauterization 
 and subsequent treatment with aluminium acetate will 
 prevent the formation of ulcers and abscesses. 
 
 4. CEEYICAL CATAERH AND ITS SEQUELAE, EYEESION 
 AND EROSION 
 
 Preventive treatment consists in the removal of circula- 
 tory disturbances and of displacements, and the removal of 
 scar tissue from the os uteri (laceration scars). The scar 
 tissue should be excised and the raw surfaces united by 
 catgut sutures. 
 
 311 
 
THE PREVENTION Or DISEASE 
 
 Erosions, especially'- old erosions of papilloid form, have 
 sometimes been observed to nndergo cancerous degenera- 
 tion. To avoid this danger it is wise to remove the diseased 
 mucous membrane by excision according to Scbroeder's 
 metliod, by wliich the cervical wall including tbat of tbe 
 vaginal portion of tbe cervix is reduced to one half its 
 thickness. Catgut sutures are then passed from the 
 internal os to the external os, and after turning over the 
 flaps are tied so that tlie line of the former external os is 
 now applied to the internal os. 
 
 For the treatment of eversion produced b}'' unsuitable 
 pessaries when the walls of the cervix are relaxed and there 
 are no lacerations of the os see under " Prolapse." 
 
 5, PEEVENTIVE TREATMENT IN CHRONIC ENDOMETRITIS 
 AND METRITIS OF THE BODY OF THE UTERUS 
 
 The longer these chronic catarrhal inflammations have 
 existed, with over secretion of mucus and pus, the more 
 readily do they bring about structural changes in the 
 endometrium and in the uterine wall. The sooner the 
 treatment is commenced, the more easily and the more 
 completely will the affected parts be restored to their 
 normal condition. 
 
 Endometi^itis should not be regarded with indifference, 
 and to look upon everj^ discharge as a condition which 
 presumabl}^ need not be treated or is quite irrelevant is 
 indifference which cannot be justified ; it causes an un- 
 necessary loss of secretion, of blood and of the patient's 
 strength, and predisposes to puerperal fever, and later 
 affords a favourable site for carcinoma and a number of 
 other morbid conditions. 
 
 Chronic metritis may follow every acute form of metritis 
 and also puerj^eral infective processes. Very often it is 
 the immediate result of a simple non-infective condition of 
 congestion and of relaxation, and for this reason is always 
 met with in retroversion and descent of the uterus. 
 Hence too it is the sequela of all processes which cause 
 frequent congestion such as masturbation, excessive sexual 
 intercourse, cold and irritating vaginal douches, suppression 
 
 312 
 
PROPHYLAXIS IN THE DISEASES OP WOMEN 
 
 of the menses and colds. Subinvolution of the uterus 
 also is likely to give rise to metritis, especially when the 
 subinvolution occurs after miscarriage, or after failure to 
 suckle the infant though there is sufficient milk in the 
 breasts ; these occasional determining causes bring about 
 the result probably because a neuropathic predisposition 
 already exists. 
 
 Upon the soil thus provided by chronic endometritis, 
 erosions and eversions may develop, and solitary or 
 multiple adenomatous new growths (polypi) may form. 
 Preventive treatment should concern itself with the avoid- 
 ance or speedy removal of all infection on the one hand, 
 and on the other hand with the removal of general and local 
 disturbances in innervation as has already been stated. 
 
 And further we must see that simple catarrhal endo- 
 metritis does not become haemorrhagic or purulent, and so 
 lay the foundation for structural changes and for adeno- 
 matous growths. 
 
 A free outlet for the secretion must be provided, and may 
 necessitate a dilating of the cervical canal ; the vagina 
 should be washed out several times a day with lukewarm 
 or hot normal saline solution, the patient being in the 
 recumbent posture. Astringents and antiseptics are 
 generally added without much discrimination. Astringents 
 are suitable for erosion and eversion, though cauterization 
 through the speculum is more effectual, and for vaginitis. 
 Antiseptics are best for infective or septic inflammations — 
 but long continued applications and strong irritating anti- 
 septics should be avoided. Hot douches excite contraction 
 of the uterus and thus tend to expel the secretion. This 
 may be assisted by the administration of ergot ; or by the 
 use of stypticin and hydrastis immediately before the 
 commencement of the period we may act upon the 
 vasomotor system in monorrhagia. During the first stage 
 of metritis, that of hyperaemia, cotton wool pledgets 
 soaked in glycerine and placed in the vagina produce 
 depletion and stimulate the uterus to contract, and this 
 may be combined with compression by means of bags of 
 shot in the vagina and on the abdomen. 
 
 313 
 
THE PREVENTION OF DISEASE 
 
 During the menstrual period there is diminished power 
 of resistance against injurious processes, and these must 
 therefore be especially avoided at this time. Among them 
 must be mentioned colds and cold feet, errors in diet, con- 
 stipation, habitual overfilling of the bladder, long journeys 
 by rail or by coach, river bathing, balls, heavy lifting, over- 
 exertion, sexual stimulation. In those who are thus pre- 
 disposed, proper precautions should be taken after mis- 
 carriage and during the puerperium : two weeks' rest in 
 bed, then the administration of ergot, the use of cold water 
 compresses and abdominal massage, and if possible the child 
 should be suckled ; hot vaginal injections and the insertion 
 of a pessary in the second week are also of value. These 
 measures prevent dysmenorrhoea ; they are aided by timely 
 scarification of the vaginal cervix and removal of two or 
 three tablespoonfuls of blood, or by wedge shaped excisions 
 from the vaginal cervix. If the process has already become 
 chronic then after dilatation a change of conditions is 
 brought about by cauterizing once or twice a week with a 
 sound wrapped round with cotton wool dipped in a five per 
 cent, solution of zinc chloride. Stronger and more frequent 
 cauterization is contra indicated by reason of the possibility 
 of the formation of scar tissue and adhesions. 
 
 But the infective agent must also be combated, in 
 suitable cases, by iodoform, or by silver salts in the form of 
 pencils or ointments. Abel recommejids plugging the uterus 
 with iodoform gauze. For the purpose of " biological dis- 
 placement " Landau introduced yeast cultures. The plug 
 at the same time stimulates contraction. 
 
 When once swelling of the mucous membrane is present, 
 the possibility of further development may be prevented by 
 curetting, after dilatation of the cervix and the subsequent 
 application of liquor ferri perchloridi or tinctura iodi 
 twice daily by means of a sound after the uterus has been 
 washed out, or steam may be applied at a temperature of 
 220° F. for not more than a quarter to half a minute. The 
 author has found the latter process very useful in obstinate 
 cases with metritis, but it must never be used while the 
 patient is allowed to go about, and in some patients it 
 
 314 
 
PEOPHYLAXIS IN THE DISEASES OF WOMEN 
 
 must be performed under an anaesthetic and always after 
 dilatation and measurement of the uterus to avoid perfora- 
 tion of tlie uterine wall. The organ contracts vigorouslj'- 
 under the action of the steam, and in order to avoid local 
 effects by the heated metal the apparatus should be slowly 
 rotated and moved about. The method must not be used 
 by any one who is not skilled in gynaecology. My own 
 experience is that it not only checks haemorrhage and 
 suppuration, purposes for which it was introduced, but that 
 it acts as an alterative unlike any other treatment. 
 
 G. PREVENTIVE TREATMENT IN CHRONIC 
 PARAMETRITIS 
 
 In cases which have developed out of an acute para- 
 metritis and which are characterized by contraction of the 
 residual products and the formation of scar tissue, or by 
 slowness in the absorption of the exudation products, 
 associated with small abscesses which cannot properly dis- 
 charge their contents, we must endeavour as soon as the fever 
 and pain have ceased, to remove the residual products of the 
 parametritis, in order that no firm fibrous bauds may 
 arise, for these are difficult to treat and lead to dis- 
 placement, flexions and strain upon the pelvic organs. 
 Treatment should consist of massage, aided by hot vaginal 
 douches and by plugging, which is best performed by a 
 dilatable iudiarubber bag. 
 
 The long dela}^ in the absorption of exudations and the 
 loss of strength produced by the suppuration must be met 
 by measures which tend to promote absorption, such as 
 the introduction of tampons with glycerine, iodine and 
 potassium iodide, combined with compression by means of 
 bags of shot placed in the vagina and on the abdomen, and hot 
 vaginal and rectal injections at a temperature of 90° F. to 
 100° F.; a few litres may be administered several times 
 daily the patient being recumbent. Massage may be used 
 but with caution, and hot sand baths and saline baths may 
 be given, and the patient should have a nutritious diet. 
 Should pyrexia occur the treatment must be discontinued 
 .and cold water compresses must be applied to the abdomen. 
 
 315 
 
THE PREVENTION OE DISEASE 
 
 Intra-nterine treatment must never be used. Care should 
 be taken that the bowels are freely open. 
 
 There is too an atrophic form of parametritis, which is 
 produced by over stimulation of the genital nerves and long- 
 continued loss by over secretion ; this is due to frequent 
 pregnancies with lactation in the intervals, and to sexual 
 excesses. It consists of a fibrosis of the connective tissues 
 following upon a periphlebitis which starts in the liga- 
 ments and ultimately involves the whole genital tract. 
 Preventive treatment should be directed against these 
 injurious causes, especially against masturbation. The 
 further progress of the fibrosis may be prevented by hot 
 vaginal douches, the use of the vaginal thermophore, and 
 hip baths, massage, intra-uterine stimulation by tents, the 
 use of intra-uterine tampons and irrigation with a solution 
 of sodium carbonate. 
 
 Apart from infection we find a traumatic non-infective con- 
 traction of the parametrium after laceration occurring during 
 labour or after injuries caused by a sudden fall or by heavy 
 lifting. The injury often does not obviously involve the 
 vagina. But if such contractions are diagnosed it is well 
 to stretch them early, or to excise the scars and stitch the 
 parts in such a wsij that the contracted part in the 
 vaginal vault may be widened. 
 
 7. PEEVENTIVE TEEATMENT IN CHRONIC OOPHORITIS 
 
 The chronic form which is derived from the acute form 
 of oophoritis, whether gonorrhoeal or septic, arises through 
 infection by the Ij^mphatics, or more frequently by the 
 direct extension of a salpingitis. This condition is in- 
 separable from perimetritis involving the tube and ovary 
 and will be considered subsequently. 
 
 It is otherwise with fibrosis of the ovary, which finally 
 leads to complete destruction of all the follicles by the 
 formation of fibrous tissue. Preventive treatment consists 
 in the avoidance of all that would lead to congestion ; there 
 should be sexual abstinence, a discontinuance of pernicious 
 habits and over stimulation ; the bowels must be regularly 
 evacuated, hot vaginal and rectal injections, or hot and cold 
 
 316 
 
PROPHYLAXIS IN THE DISEASES OE WOMEN 
 
 vaginal douches at temperatures of 60° F. and 90° F. 
 alternately, treatment by compression, and at night a 
 cold water compress may be employed. 
 
 8. PEEVENTIVE TREATMENT IN CHRONIC PERIMETRITIS 
 WITH SALPINGITIS AND OOPHORITIS, AND PELVIC 
 PERITONITIS. 
 
 Prophylaxis consists on the one hand in treatment of 
 the corresponding acute inflammation or of the primary 
 focus, whether a metritis, a parametritis, an oophoritis, or 
 a salpingitis, generally septic or gonorrhoeal in origin, and 
 on the other hand in checking the further extension of the 
 primary focus of infection. 
 
 This is best effected by active measures : such as an 
 ice bag, a cold water compress, and the local abstrac- 
 tion of blood. Lukewarm mucilaginous or saline irrigation 
 of the vagina under slight pressure should be employed, 
 together with the application of substances which are 
 antiseptic and tend to cause absorption by the blood and 
 lymph channels. Care should be taken that the skin, 
 kidneys and bowels act freely in order to get rid of the 
 toxine. A nourishing diet is important, and later on 
 stimulation of the heart by alcohol and by friction. 
 
 "When the acute stage is over, the slow transition into a 
 chronic stage must be prevented by energetic treatment 
 to promote absorption, such as mud baths, hot sand baths, 
 saline baths, vaginal and abdominal compression, vaginal 
 thermophore and tampons, with glycerine, iodine and 
 potassium iodide, hot vaginal douches, and a nourishing 
 diet. Later, massage may be used, partly to hasten absorp- 
 tion, partly to prevent displacement and fixation of the 
 uterus and ovaries. 
 
 If a localized pelvic peritonitis has been formed by the 
 adhesion of a coil of intestine across the pouch of Douglas, 
 rest is needed to prevent a general peritonitis. The intes- 
 tine is placed at rest by tinctura opii, or if there is pro- 
 fuse diarrhoea by extract of opium with bismuth subnitrate. 
 In this condition any interference with the internal 
 genitalia is contra-indicated. 
 
 317 
 
THE PREVENTION OE DISEASE 
 
 (xoiiorrlioeal pelvic peritonitis is a23t to recur, and there- 
 iore to prevent these recurrent attacks of fever whicli 
 confine the patient to bed for weeks at a time, it msij he 
 advisable to perform a vaginal or suprapubic hyster- 
 ectomy. 
 
 AVhen encapsuled intraperitoneal abscesses form, it is 
 most important to provide a safe and free outlet for the 
 pus. Perforation of the rectum brings with it the risk of 
 decomposition, a passage for the pus should therefore be 
 made through the vagina. Should it open into the bladder 
 an ascending pyelonephritis may be set up, and to prevent 
 this it may be necessary to make a temporary vesical 
 fistula by a suprapubic cystotomy or by an incision 
 through the vaginal wall. 
 
 9. PEEVENTITE TREATMENT IN TUBERCULOSIS OF THE 
 
 GENITALIA 
 
 The agent is the tubercle bacillus, and its entry is 
 favoured by a general predisj)Osition. There seems how- 
 ever to be also a local predisposition to it after gonorrhoeal 
 or septic infection or mixed infection, and also when 
 fissures appear in the epithelium of the vagina or vulva. 
 Such fissures make it easy for primary tuberculosis of the 
 genitals to be produced by coitus, or by examination with 
 an infected finger, or by infected linen and similar oc- 
 casional exciting causes. 
 
 Secondary tuberculosis is more frequent, and arises through 
 the circulation, as from tuberculous disease of the intes- 
 tines, lungs or kidneys. Infection may pass to the genera- 
 tive organs by the lymph path, or by infection of a 
 Fallopian tube from the peritoneum, which is the most 
 frequent of all. It may be caused by contact with a 
 tuberculous intestine. 
 
 Preventive treatment consists in part in the prevention 
 of the occasional causes mentioned above and in part in the 
 early removal of inflammations occurring in other regions. 
 It is essential to raise the general tone of the body. In 
 primary tuberculous disease of the genitalia removal of the 
 
 318 
 
PROPHYLAXIS IN THE DISEASES OF WOMEN 
 
 tuberculous focus is indicated as a prophylactic measure to 
 avoid a general infection of the body. This holds good also 
 for solitary ulcers of the vulva or bladder. If the ulcer is 
 vesical excision is carried out by the suprapubic operation, 
 and iodoform gauze tampons are used. Some writers have 
 recently recommended tuberculin R for these cases. In 
 tuberculosis of the peritoneum opening the abdomen often 
 suffices to check the progress of the disease, and according 
 to Lohlein opening the peritpneum through the vagina 
 answers the same purpose. 
 
 10. PREVENTIVE TREATMENT IN CYSTITIS REGARDED 
 FROM THE STANDPOINT OF GYNAECOLOGY. 
 
 Vesical catarrh may be caused, not only by the introduc- 
 tion of infectious germs into the bladder, but also by injuries 
 and by disturbances of the circulation ; both these causes 
 must therefore be borne in mind. The most frequent ex- 
 citing cause is catheterization, by which slight injuries 
 may be inflicted at the neck of the bladder, as may also 
 be caused by calculi and other foreign bodies. The most 
 frequent predisposing cause is cold, which produces a dis- 
 turbance of the circulation. Pathogenic germs are at all 
 times present in the urethra, and bacteria, especially the 
 bacterium coli, get into the bladder in spite of the most 
 careful sterilization of the catheter and cleansing of the 
 urethra. The difficulty of micturition which necessitated 
 the use of the catheter arises often from some cause such 
 as paresis or bruising, which induced at the same time 
 disturbances of the circulation, so that it is not even 
 necessary that the catheter should first produce some 
 fissure or abrasion in order that decomposition of the urine 
 may occur upon the soil produced by a congested vesical 
 mucous membrane. These primary circulatory disturb- 
 ances of the bladder wall must be removed by wet com- 
 presses, hot spirit fomentations on the abdomen, hot com- 
 presses over the symphysis and urethra, wet compresses 
 around the lower limbs or of the whole body. We do 
 not recommend any active treatment with antiseptics, 
 because the frequent passage of the catheter is apt to 
 
 319 
 
THE PREVENTION OF DISEASE 
 
 produce excoriation of the uretliral mucous membrane, 
 and thus provide a suitable nidus for germs. 
 
 Alterations in the bladder wall may arise too from 
 inflammatory processes in the connective tissue, such as 
 parametritis and perimetritis, which lead to exudation and 
 to suppuration. Silk ligatures and elastic ligatures which 
 have wandered into the bladder and tumours may also 
 cause disease of the bladder wall. It can be seen by the 
 cystoscope that each perforation is preceded by hyperaemia 
 and local swelling of the wall. 
 
 Secondary vesical catarrh is readily produced when 
 bacteria have been present in the urine for any length of 
 time, whether as the result of kidney disease, such as 
 tuberculosis, or of general sepsis. Washing out with 
 boracic acid lotion and the administration of salol are the 
 most effective preventive measures. 
 
 Pathogenic germs found in the healthy urethra are 
 generally of a very low degree of virulence. But it is 
 otherwise when infective vaginitis is present and its secre- 
 tion flows round the urethral orifice. Vaginal irrigation 
 with antiseptics is here suitable. 
 
 The severer cases of cystitis which have been neglected 
 lead to dangerous disorders and changes in the bladder, 
 and prophylactic treatment of these sequelae is important. 
 Among the sequelae are chronic vesical spasm and paresis, 
 producing incontinence or retention of urine according to 
 the muscle which is affected. After long existent cystitis 
 the wall may become hypertrophied and the cavity reduced 
 in size. The latter may be prevented by the injection of 
 fluid into the bladder in daily increasing quantity. In 
 retention complete loss of power of the muscle may be 
 prevented by massage, cool comjpresses and douches, by 
 catheterization and by electricity. To carry out the 
 application of electricity the bladder is filled with water, 
 one pole well insulated is passed into the bladder, the 
 other pole is placed upon the symphj'-sis or in the lumbar 
 region or on the perineum, and the induced current employed. 
 To avoid paresis of the sphincter, which produces inconti- 
 nence, the exercise of the will with tonic treatment and 
 
 320 
 
PEOPHYLAXIS IN THE DISEASES OF WOMEN 
 
 hydrotlierapeutic measures plays the chief part. The pres- 
 ence of calculi, foreign bodies and sacculation of the bladder 
 must previously be excluded. 
 
 IV. The Prevention of Injuries and their 
 Sequelae 
 
 {a) Lesions and chcmges produced hy scar tissue. 
 
 Lesions of the generative organs are caused mostly by 
 parturition. The effects vary with the situation. Healing 
 by scar tissue at the vulva seldom causes atresia ; on the 
 contrary gaping is more commonly produced. The same 
 result is seen at the os uteri ; lacerations heal by scar 
 tissue and eversion is produced. However in the vagina, the 
 vaginal vault and the cervix we meet more frequently with 
 stenosis and atresia. 
 
 How lacerations of the perineum may be prevented will 
 be later described under " Obstetrics"; their sequelae have 
 already been treated of under " Prolapse " and under 
 " Inflammations of the Mucous Membranes." 
 
 Two other kinds of lesions of the vulva are known : 
 traumatic lesions and lesions arising during coitus. Severe 
 traumatic lesions, especially those near the clitoris, may 
 cause serious loss of blood which may prove fatal in 
 pregnancy, and the bleeding points should therefore be 
 ligatured. A tough hymen should be incised by a crucial 
 incision, and in vaginismus the entrance of the vagina 
 should be forcibly stretched under an anaesthetic, or dilated 
 by the passage of specula. All other troubles resulting 
 from perineal lacerations, such as urethritis by descent of 
 the unsupported anterior vaginal wall, incontinence of 
 faeces in complete lacerations of the perineum, intertrigo, 
 " garrulitas vulvae," that is the audible exit of air which 
 has made its way into a gaping vagina, pruritus and 
 the formation of rhagades at the base of the scar — all may 
 be prevented from becoming chronic by an excision of the 
 scar and by bringing together the freshened surfaces by 
 sutures. 
 
 Ruptures of the vagina are the result of violence : in 
 
 321 Y 
 
^rHE PREVENTION OE DISEASE 
 
 coitus, or according to tlie author's observations in vagin- 
 ismus with, cramp of the muscles of the fornix, want of skill 
 in performing operations, the introduction of the hand or 
 of pessaries and specula which are too large, and attempts 
 to procure abortion. 
 
 To arrest bleeding the bleeding points should be 
 ligatured or be compressed with iodoform gauze, the 
 parts having first been thoroughly disinfected and all 
 necrosed shreds removed. 
 
 Lacerations of the cervix produce eversion ; their treat- 
 ment has already been given, together with that of their 
 sequelae, under the heaxiing of " Cervical Catarrh." To 
 prevent the formation of fissure ulcers and parametritis 
 vaginal douches with antiseptics are needed. 
 
 Annular and extensive injuries (in parturition or by 
 cauterizing or by ulceration) cause traumatic stenosis 
 and atresia of the vulva, vagina, or uterus. Preventive 
 treatment consists partly in suitable obstetric aid, partly 
 in maintaining absolute cleanliness of the wounds and 
 thereby hastening their healing. If nevertheless contrac- 
 tions set in they should be overcome by stretching with 
 plugs, or if there has been much loss of mucous membrane 
 by a suitable plastic operation after excision of the scar 
 tissue. 
 
 If complete atresia is present very serious results may 
 follow when pregnancy exists or when the retained men- 
 strual fluid produces haematometra and haematosalpinx. 
 In acquired atresia the menstrual fluid, unlike that in con- 
 genital atresia, readily undergoes decomposition. If unfor- 
 tunately the haematosalpinx is burst by reflex contraction 
 while the incision is being made for the relief of the atresia 
 of the vagina or uterus severe peritonitis is the immediate 
 result. The menstrual fluid should therefore be very slowly 
 drained off, and afterwards a large incision should be made 
 and plugged with iodoform gauze. 
 
 (h) The jjrevention of fistulae. 
 
 Fistulae arise most often as the result of injuries during 
 childbirth ; they may appear at once as tears through the 
 tissues or they may appear a few days after delivery, 
 
 322 
 
PROPHYLAXIS IN THE DISEASES OF WOMEN 
 
 having been formed by the sloughing of a portion of tissue 
 which had been subjected to too great pressure by the 
 foetal head or injured by pressure with the forceps. Their 
 preventive treatment will be given under '^ Obstetrics." 
 Such conditions arise in a generally contracted pelvis with 
 impaction of the head with brow and face presentations. 
 It should be remembered that vesico-vaginal and even 
 uretero-cervical iistulae produced in parturition tend to 
 become spontaneousl}'' cured by the drawing together of 
 the parts during involution and by the formation of granu- 
 lations. The introduction of a self retaining catheter will 
 assist this natural process. 
 
 Fistulae may be produced by ^^essaries, especially by 
 Zwanck's winged pessary, and this was referred to in 
 detail under " Prolapse." They may also be caused by 
 operations, by foreign bodies and other injuries, or by 
 ulcerative processes which produce perforation, as seen in 
 malignant growths, diphtheritic puerperal and venereal 
 ulcers, vesical calculi, perimetritic and parametritic abscesses, 
 haematocele, or extra-uterine gestation. 
 
 To prevent the formation of fistulae during operations 
 ligatures should not be too close together, and not too tense 
 when there is a narrow septum between two hollow organs, 
 otherwise necrosis is apt to occur. Spaces should not be 
 allowed to remain in the connective tissue in which fluid 
 can accumulate and pus be formed producing abscesses 
 which afterwards break. Adjacent cavities must not be 
 opened by mistake and diverticula or tubes, such as the 
 ureters, must not by oversight be caught in the ligatures. 
 
 Large bleeding vessels must not be allowed to remain 
 unligatured and so produce haematomata. Foreign bodies 
 are generally put into the vagina for the purpose of 
 procuring criminal abortion or for masturbation. Their 
 removal often presents great difficulty, especially as such 
 bodies as hairpins are found even in the bladder. If 
 a parametritic or perimetritic abscess or an ectopic 
 gestation threatens to open into the vagina or into the 
 rectum or bladder, a free outlet for it must be made into 
 the vagina, otherwise decomposition is apt to occur and 
 
 323 
 
THE PREVENTION OF DISEASE 
 
 the fistiilae produced by the perforation are more difficult 
 to heal. 
 
 "When inoperable tumours reach the wall of the bladder 
 or of the rectum they should no longer be treated by 
 curetting but only by the benzene cautery or by hot 
 steam, or a fifty jDer cent, solution of zinc chloride may be 
 applied to stop decomposition and pain, and to leave a 
 firm fibrous layer. By the so-called prophylactic total 
 extirpation in cases of inoperable cancer these serious 
 complications are avoided. 
 
 (c) The prevention of traumatic haemorrhage. 
 
 Traumatic haemorrhage into the connective tissue around 
 the genitalia produces haematomata ; if into the abdominal 
 cavity it produces intraperitoneal haematocele. Haema- 
 toma vulvae is formed almost exclusively by the bursting 
 of a varicose vein during parturition and occasionally by 
 direct violence. The author saw one such case which 
 reached half way up the vagina and afterwards suppurated. 
 
 Compression by bandages with lead lotion, frequent as- 
 sumption of the recumbent posture and regular evacuation 
 of the bowels will reduce the varicose veins. If a vein 
 bursts a firm pad should be at once put on and secured by 
 a T bandage and an ice bag applied. The treatment for a 
 sup23urating haematoma is important. If the skin is whole 
 or there is only an excoriation or a fissure applications of 
 aluminium acetate may suffice. Even if the skin threaten 
 to necrose but there is no fever an attempt may still be 
 made with this application ; but as soon as fever sets in 
 an incision must be made and the cavity firmly packed 
 with iodoform gauze. If the haematoma of the vulva 
 increases in size in spite of compression and use of the ice 
 bag, the physician must not leave the patient, because 
 pressure may cause the skin to give way and the patient 
 may quickly bleed to death. This risk is prevented by 
 immediate incision and ligature of the vessel, and the 
 danger of suppuration so common in large haematomata 
 is also removed. 
 
 Haematomata behind, by the side of, or in front of the 
 uterus are most often caused by a fall. Slight lesions of 
 
 324 
 
PROPHYLAXIS IN THE DISEASES OE WOMEN 
 
 the uterine ligaments produced by stretching we have 
 noticed in delicate women after heavy lifting or falling 
 backwards, and these are similar to the haemorrhages 
 occurring in lesions of the abdominal muscles. Preventive 
 treatment of the sequelae should be directed first to the 
 prevention of further haemorrhage and next to the removal 
 of the relaxation of the ligamentous apparatus and descent 
 and retroversion of the uterus which have been left by the 
 acute overstrain. In every case the patient should remain 
 in bed, and firm plugging is needed together with a sand 
 bag on the abdomen, and later a pessary may be needed. 
 Colds and heavy work should be avoided at the menstrual 
 periods, otherwise relapse is very likely to occur. 
 
 When the haematoma tends to become inflamed, an ice 
 bag upon the abdomen combined with compression through 
 the vagina is useful. If the haematoma continues to 
 increase in size and there is danger of its bursting into 
 the abdominal cavity, it may become necessary to lay it 
 open. 
 
 Retro-uterine intraperitoneal liaematocele most often 
 arises from the bursting of a tubal gestation or from a 
 tubal abortion. Rarer causes are a haematosalpinx, a 
 parovarian varicocele which has burst, haemorrhage from a 
 Graafian follicle, perimetritis, and rupture of an abdominal 
 viscus or of a haematoma of the broad ligament. 
 
 These haemorrhages, especially that caused by ectopic 
 gestation, may prove rapidly fatal, and it is important 
 therefore to remove any of the above mentioned causes 
 directly they have been diagnosed. 
 
 One of two procedures is possible in the case of tubal 
 gestation : — 1. During the first three months one or two 
 attempts may be made to destroy the foetus by injecting 
 about a third of a grain of morphine hydrochloride into the 
 sac. 2. The ovum may be removed by abdominal section or 
 per vaginam if the sac is small and pedunculated. 
 
 When the sac is not pedunculated it is best to wait till 
 the foetus is dead, otherwise haemorrhage is apt to be 
 abundant — six months is the most favourable time. 
 
 If haemorrhage has already occurred the abdomen should 
 
 325 
 
THE PEEVENTION OF DISEASE 
 
 not be opened unless, from the increasing anaemia or recur- 
 ring collaj)se, it is evident that haemorrhage has not ceased. 
 But every available means should be taken to prevent this: 
 by ice bag and sand bags on the abdomen, rest in bed with 
 the head and body low and the pelvis raised to procure 
 absorption of the intraperitoneal blood, opiates, saline solu- 
 tion hypodermically and per rectum. Stimulants should be 
 given with caution. Later, when the clot begins to sup- 
 purate an incision should be made through the vaginal 
 wall, and plugs of itrol gauze or iodoform gauze applied 
 in order to prevent the formation of chronic abscesses 
 which might eventually break through into the abdominal 
 cavity. 
 
 If the sac is firmly adherent with abundant vascular 
 adhesions, as in abdominal gestation, the sac may be par- 
 tially or entirely left, provided that precautions have been 
 taken to prevent peritonitis by packing with strijDS of 
 gauze, the ends of which should be brought out at the 
 lower angle of the wound for drainage, or by an extra- 
 peritoneal suturing of the sac to the edges of the wound. 
 As a precautionary measure the ovarian vessels and ana- 
 stomoses with the uterine vessels should be temporarily 
 clamped. If it is decided to empty a haematocele because 
 it threatens to break through into the rectum, leading to 
 decomposition of the clot, it is advisable to remove the mass 
 together with its fibrin capsule as one would a tumour. 
 
 "When haematosalpinx exists there is the constant 
 danger of its bursting : it is advisable to remove it by an 
 abdominal section, especially when there is a uterus 
 bicornis with an imperforate cornu ; because when the tube 
 is tensely filled a careful examination or an incision into 
 the haematometra from the vagina may cause the haema- 
 tosalpinx to burst. The danger is less when the atresia is 
 lower down. AVhen a vaginal operation is performed care 
 should be taken to let the blood escape slowly, and after- 
 wards to remove a large piece of the septum to prevent a 
 recurrence of the atresia. In these cases and in all cases of 
 haematocele no intra-uterine manipulations such as the use 
 of the sound or curette are permissible. 
 
 326 
 
PEOPHYLAXIS IN THE DISEASES OF WOMEN 
 
 To prevent the formation of indurations after absorption, 
 use is made of mud baths, saline baths, hot vaginal douches, 
 compression by plugging and by a weight upon the 
 abdomen, and pledgets of iodine, potassium iodide and 
 glycerine. During subsequent menstrual periods the 
 patient should remain in bed, as haemorrhage is apt to 
 recur at these times. 
 
 The preventive treatment of the other causes of intra- 
 peritoneal haemorrhage has already been described. 
 
 (c?) Preventive treatment of foreign bodies in the genito-urinary 
 organs. 
 
 Foreign bodies in these organs may cause injuries by 
 their passage into the organ, or may later cause inflamma- 
 tory changes by their presence. Preventive treatment for 
 the first group of injuries has been given under " Lacera- 
 tions of the Yulva, Vagina, or Cervix." 
 
 Foreign bodies may reach the bladder or vagina in four 
 different ways : 
 
 1. Pieces of surgical instruments may be left behind, 
 such as pieces of vaginal tubes or glass specula, incrusted 
 pessaries, needles, tampons — which by their foetor may be 
 mistaken by an unobservant physician for a carcinoma — 
 gauze pledgets, laminaria, forgotten silk sutures, and 
 an incrusted catheter. 
 
 2. Through masturbation or criminal acts: bodies such as 
 hairpins, tapers, pencils and cotton reels ; tampons, sponges 
 and pessaries used to prevent conception ; knitting needles 
 and other ]3ointed instruments used to procure abortion. 
 
 3. By falls upon a pointed stake. 
 
 4. Derived from the body itself ; as from perforating 
 tumours, dermoid cysts giving rise to teeth and hair ; the 
 bones of a macerated or decomposed foetus from an extra- 
 uterine gestation ; echinococcus vesicles ; bodies coming 
 through fistulae from other hollow organs. To this class 
 belong vesical calculi and retained products of conception, 
 as in missed abortion or missed labour. 
 
 These foreign bodies may lead to inflammation, ulceration 
 or the formation of fistulge. 
 
 For the prophjdaxis of group 1 a few practical hints 
 
 327 
 
THE PRE^^NTION OF DISEASE 
 
 may be given. Some opaque glass specula of a cheap kind, 
 with thin walls of a greyish colour, break very easily and in 
 many there are chips and rough places. The glass bivalve 
 specula are dangerous. As to pessaries, all that is necessary 
 has already been said in the chapter on " Prolapse." The 
 vaginal mucous membrane is particularly prone to become 
 excoriated after the menopause. Tampons should be made 
 with a firmly knotted strong piece of silk, or a band long 
 enough to hang from the vulva ; the silk is tied either 
 round the centre of a cylindrical pledget made of cotton 
 wool which can be passed into the vagina crosswise, or in 
 the pedicled mushroom form used for applying medica- 
 ments ; the silk is made fast inside the ball of the tampon, 
 the outer layer of the ball is twisted round the stalk and 
 the projecting piece of silk is then tied to the stalk. Lam- 
 in aria and tupelo tents should be inserted so that one 
 end of the tent j)rojects beyond the os uteri, otherwise 
 they may become fixed within the os and an incision may 
 then be needed to remove them. It is still better to cover 
 the tent with a piece of gauze and let this hang down 
 from the os. A similar gauze sac passed through a specu- 
 lum and filled with pledgets of cotton wool is very useful 
 as a plug to produce compression ; the gauze bag with its 
 contents can then be pulled out and nothing can be left 
 behind by oversight. Deep silk sutures have an unpleasant 
 way of wandering even after months or years into some 
 hollow organ (see " Cystitis "). Except for the main vessels 
 (uterine vessels), all ligatures used for mucous membranes 
 and for internal organs should be made of well prepared 
 cymol catgut. For the skin, nonabsorbent ligatures should 
 be used: silver wire, silkworm gut, celluloid thread, or 
 caoutchouc silk. Grlass and rubber catheters should be 
 examined directly before and after use to see that they are 
 perfect. 
 
 In extracting foreign bodies certain precautions must be 
 taken to avoid causing injuries elsewhere, which may be 
 very difficult to heal. Grenerally there is some inflammation 
 and some decomposition ; the genitalia are swollen and the 
 foreign bodies of such a shape as to be difficult to extract : 
 
 328 
 
PROPHYLAXIS IN THE DISEASES OF WOMEN 
 
 such as liairpins witli their divergent pointed ends towards 
 the vulva. Before the foreign body is removed, injections, 
 with disinfectants (lysol is the best for this purpose), 
 should be used. Long foreign bodies should be seized by 
 one end and thus extracted. In some cases it is best to 
 make more room by incisions, and so prevent the risk of 
 lacerations and contusions which might afterwards become 
 infected. Deep anaesthesia is needed to produce insensi- 
 bility and relaxation of the muscles, especially of the con- 
 strictor vaginae. 
 
 In removing foreign bodies and large calculi from the 
 bladder a cystoscope should be used, the urethra should be 
 dilated sufficiently to admit the little finger and a pair of 
 dressing forceps, the bladder being filled with boracic acid 
 lotion. If the foreign body cannot be reduced in size it be- 
 comes necessary to make an opening into the bladder from 
 the vagina, or to perform a suprapubic cystotomy. Yesical 
 calculi are seldom found in women, because of the shortness 
 and width of the urethra, which permit concretions as large 
 as a cherry stone to pass. All foreign bodies, including the 
 mucus and pus of vesical catarrh and of vesical diverticula, 
 become encased by deposits of urates, phosphates and oxalates 
 or of cystin, and therefore all causes which lead to catarrh 
 of the bladder and to retention of urine should be speedily 
 removed. 
 
 V. The Prophylaxis of New Growths 
 
 From the aetiology of tumours, which is still largely 
 only speculative, we gather for purposes of preventive 
 treatment that among the causes which predispose to the 
 formation of tumours, both benign and maligmant, are long 
 continued inflammatory processes of all kinds, chronic 
 infective diseases, wounds which have healed by granula- 
 tion tissue and subsequent formation of scars at places 
 where two kinds of epithelium meet, chronic congestion, 
 certain tumours primarily benign, and the retained pro- 
 ducts of conception. "We also believe that further causes 
 are to be found in the vulnerability of the genitalia 
 
 329 
 
THE PREVENTION OF DISEASE 
 
 after excessive canterizatioii, and at the menopaiTse when 
 there is at the same time some general predisposition. 
 
 Finally, mention must be made of congenital sarcoma 
 and of dermoids, the cause of the origin of which is still 
 obscure. 
 
 "Whether malignant epithelioma is an amoeba infection 
 is still a contended point. It should be remembered too that 
 Ribbert and Weigert and recently Lubarsch think that 
 the cause of the increased growth lies not in any increased 
 activity of the epithelium but rather in a diminished 
 resistance of the surrounding connective tissue, that is a 
 failure to resist the growth of the epithelium. 
 
 Tumours may also produce secondary growths in struc- 
 tures which have vasomotor connexions with them or which 
 are supplied by the same vessels. So endometritis fungosa 
 is associated with ovarian cysts and with intramural 
 fibromyomata. Of special interest is the occurrence of 
 cancerous growths in the pedicle of the uterus after supra- 
 vaginal amputation for myoma of the uterus. 
 
 (a) Benign Tumours. 
 
 The formation of mucous polypi should be prevented by 
 early treatment of the primary endometritis by curetting 
 or by atmocausis. Removal of polypi with the whole of 
 the pedicle is indicated to prevent general anaemia. 
 
 Prophylactic treatment is powerless to prevent the forma- 
 tion of myoma, but can be applied to prevent increase in 
 size of the tumour ; for the prolonged use of ergot and the 
 ligature of the uterine vessels will check the growth. The 
 same measures will arrest those cases of menorrhagia which 
 last beyond the climacteric and weaken the body, often 
 to so great a degree that it is not possible to perform a 
 radical operation. Further measures which can be adopted 
 to check these haemorrhages are hydrastis, stypticin, hot 
 vaginal douches (117° F.) hot fomentations, aseptic plug- 
 ging of the vagina, and finally intra-uterine tampons with 
 ferripyrin or injections of solutions of gelatine. 
 
 Vaginal fibromyomata may cause serious difficulties 
 during childbirth, and should therefore be enucleated. 
 Pigmental naevi of the vulva tend to undergo malignant 
 
 330 
 
PEOPHYLAXIS IN THE DISEASES OE WOMEN 
 
 degenerative processes, and should be removed. The same 
 holds good for vesical papilloma, though histologically 
 benign, quite aj^art from the fact that they tend also to 
 produce haematuria, obstruction of the urethra by clots, 
 and vesical catarrh and calculi. A-mong benign tumours of 
 the uterine adnexa, parovarian cysts which are large 
 enough to reach up to the pelvic brim should be punctured, 
 because they are apt to give rise to trouble. After punc- 
 ture they generally remain shrunken. Puncture of ovarian 
 cysts is useless ; but the cyst may be reduced in size, if 
 unilocular, by vaginal pessaries of potassium iodide till 
 symptoms of iodism develop, and by painting with iodine 
 and the application of cold water compresses to the abdo- 
 men. 
 
 (b) Tumours innocent histologicaUy^ Vjhicli under certain 
 conditions may become a source of danger. 
 
 To this group the vesical papilloma above mentioned really 
 belongs. Further, we may include in this class certain 
 large fibromyomata of the vagina, uterus and ovaries 
 which do not remain stationary, especially the intraparietal 
 and intraligamentous fibromyomata and those seated upon a 
 broad base — indeed, all large new formations of this nature 
 which are not polypoid, that is seated upon a narrow base. 
 Multilocular ovarian cysts also belong to this category. 
 
 Preventive measures are most important to obviate the 
 dangerous sequelae of fibromyomata, among which are — 
 
 1. A severe form of anaemia, which is permanent, and 
 is caused by the haemorrhages, or later by the bursting of 
 dilated thin walled vessels, and secondary heart disease. 
 
 2. Haemorrhages into the structures of the tumour itself. 
 The cause is generally a disturbance in the circulation and 
 thrombosis, which may after operation lead to fatal embol- 
 ism. These extravasations readily undergo putrefactive 
 changes, and so give rise to sepsis. 
 
 3. In large subserous polypi the pedicle may become 
 twisted, and produce necrosis and inflammation in the 
 tumour and in submucous polypi, ulceration and gangrene. 
 
 4. Inflammatory adhesions maj^ form between the tumour 
 and intestines. 
 
 331 
 
THE PEEYENTION OE DISEASE 
 
 6, Submucous polypi may, as already mentioned, pro- 
 duce inversion of the uterus, when tlie polypus is attached 
 to the fundus and numerous strong muscular fibres pass into 
 it from the uterus so that it cannot readily break away. 
 Other consequences are necrosis by pressure and gan- 
 grene. 
 
 6. By their size, especially when there is cystic degenera- 
 tion, they may j)roduce symptoms of incarceration and of 
 traction upon the pelvic organs, causing intestinal obstruc- 
 tion, uraemia, cystitis, and secondary pyelonephritis ; or 
 they may give rise to difficulties in labour, and they are 
 then especially dangerous if calcification has occurred. 
 
 7. Myxomatous degeneration may readily go on to the 
 formation of a myxosarcoma. 
 
 8. Primary sarcomatous degeneration and primary 
 cancerous degeneration of the tumour itself or of the 
 fungoid endometrium may occur, 
 
 9. The dangers of operative removal are haemorrhage 
 and sepsis ; and when removal by abdominal section is 
 necessary j)eritonitis may occur. This is also true of intra- 
 ligamentous tumours and large fibromata of the cervix. 
 Infection may arise directly or secondarily by the bursting 
 of an abscess which has formed in the stump. 
 
 Finally, pulmonary embolism is much more common 
 than in the removal by operation of other large tumours of 
 the genitalia. All these dangers are the more serious the 
 more anaemic the 23atient already is. 
 
 Preventive treatment in 1, 2, 6, 9 must be directed to 
 keeping the tumour small, to checking haemorrhage, and 
 to improving the general health. 
 
 The earliest possible removal of the tumour, to avoid 
 complications and severe anaemia, should be undertaken for 
 3, 4, 5, 6, 7, 8. 
 
 For ovarian cysts there is no preventive treatment pos- 
 sible. When a cyst has attained the size of a foetal head 
 and continues to increase in size it should be removed. If 
 ascites is present with an ovarian tumour immediate 
 abdominal section should be done, because ascites suggests 
 malignancy. 
 
 332 
 
PEOPHYLAXIS IN THE DISEASES OF WOMEN 
 
 (c) Malignant Tumours. 
 
 Pigmented naevi of the vulva should be removed, because 
 they tend to undergo malignant degeneration, and the 
 small flat red prominences which may form with pruritus 
 of the vulva should be removed also. At the climacteric 
 any large or weeping wart on the vulva should be removed 
 without previous cauterization. 
 
 Eversion and erosions on the vaginal portion of the cervix 
 should be removed either by cauterizing or by excision. 
 The occurrence at the climacteric period of any watery or 
 sanguineous discharge with shreds or foetid odour should 
 suggest a very careful examination of the vagina, cervix, 
 and uterine cavity, the latter with the curette or finger 
 after dilatation of the os. The upper part of the cervix 
 may already be deeply invaded while the infravaginal 
 cervix and the external os show no sign of disease. With 
 the sound a considerable excavation may sometimes be de- 
 tected. The entire uterus and its adnexa should be at once 
 removed in these cases. Supravaginal amputation of the 
 cervix is admissible only when there is commencing cancer- 
 ous growth of the vaginal portion of the cervix. We should 
 remember that the obstinate endometritis which occurs at 
 the climacteric, and is called fungoid, is generally only the 
 commencement of a carcinoma. In this case also it is better 
 to operate freely rather than leave it until it is too late. 
 
 Even when the cancer is inoperable a palliative extirpa- 
 tion is a prophylactic measure, because according to expe- 
 rience the decomposition is then much less profuse and 
 fistulous openings occur less commonly. The actual cautery 
 may be applied to the infiltrated parts as it checks haemor- 
 rhage. Later on atmocausis is applicable. 
 
 With regard to sarcoma it must be mentioned that its 
 cause is entirely unknown, that fibromyomata may degene- 
 rate into sarcoma, that obstinate multiple flat polypoid 
 growths are malignant or readily become malignant, that 
 sarcomata may appear even in early youth, and that they 
 are more malignant and form secondary growths sooner 
 than do carcinomata. 
 
 In sarcoma or carcinoma of the adnexa all measures are 
 
 333 
 
THE PEEVENTION OF DISEASE 
 
 usually in vain, because symptoms mtake their appearance 
 so late. The most important symptom is ascites. 
 
 VI. Gynaecological Operations and 
 Procedures 
 
 Every operation, even digital examination or the use of 
 the sound, must be undertaken under strict aseptic pre- 
 cautions, even when decomposition has already occurred or 
 the patient is septic or has gonorrhoea. The uterine sound 
 in rough and unskilled hands is a dangerous instrument : to 
 pass it through a stenosed or spasmodically contracted os 
 uteri may be difficult and at times impossible. If the 
 uterine walls are thin, as in chronic metritis and after 
 abortion, perforation may occur though no sense of resist- 
 ance has been felt by the operator ; the length of sound 
 which has entered makes him aware of the perforation. It 
 is best that he should accept the fact, and not attempt to 
 explain it away and proceed with the operation (curetting, 
 or washing out the uterus), for he would then be directly 
 responsible for the results. The perforation itself has 
 generally no further consequence. Perforation may occur 
 during curetting ; this oj^eration should therefore only be 
 j)erformed bimanually, and only blunt curettes with wide 
 ends should be used, and they should not be pushed in 
 and turned round, but carefully passed over the uterine 
 surface. The larger masses left behind after abortion 
 should be removed by the finger : unruptured ova should be 
 expressed. 
 
 Intra-uterine irrigation is done with Fritsch's double 
 canula. The return current must be watched because the 
 tube is liable to become blocked with debris. The injection of 
 fluids, such as liquor ferri perchloridi, into the cavity of the 
 uterus must be done carefully during the slow withdrawal 
 of a Braun's syringe. The best way to do it is to fasten 
 a small gauze pad on to the end of the syringe tube, which 
 is provided with lateral apertures. To scrape the sacculated 
 uterine cavity in cases of submucous myomatous formations 
 is dangerous, as decomposition readily sets in. Dilatation 
 
 334 
 
PROPHYLAXIS m THE DISEASES OF WOMEN 
 
 of the cervical canal may be effected quickly by smooth 
 conical metal dilators of increasing size, or by the introduc- 
 tion of laminaria or tupelo tents. The latter should first be 
 made quite smooth and be sterilized by quickly boiling in a 
 five 23er cent, solution of carbolic acid or by leaving them for 
 several days in a solution of iodoform in ether and alcohol. 
 The vagina and cervical canal must previously be carefully 
 cleansed (see " Foreign Bodies "). Instead of tents firm 
 plugging with iodoform gauze may be used to dilate the 
 cervix. 
 
 Concerning the introduction of pessaries prophylactic 
 measures will be found in the chapters on "Prolapse " and on 
 '• Foreign Bodies." The prophylaxis in joerineoplasty and 
 colporrhaphy will be found in the chapters on " Prolapse " 
 and on the repair of "ruptured perineum," and in the Obste- 
 tric section under suture of "recent perineal lacerations." 
 Extensive wedge-shaped excisions of and removal of the 
 vaginal portion of the cervix in metritis and elongation of 
 the cervix and annular hypertrophy of the cervix of a pro- 
 lapsed uterus give rise to serious difficulties during child- 
 birth owing to the firm scar tissue. In operating we must 
 remember that the hypertrophy is largely only apjDarent, 
 that is, it is produced by hyperaemia and oedema, and 
 will disappear when the uterus is replaced and still more 
 by measures which produce depletion. For these reasons 
 Schroeder's excision of the cervical mucous membrane in 
 cases of metritis is the best method, because thereby the 
 diseased mucous membrane is entirely removed with its 
 tendency to cancerous change and to eversion, yet the 
 cervical canal is not reduced in diameter. 
 
 The prophylactic measures to be observed in the more 
 complex operations are outside the scope of this work. 
 
 335 
 
Prophylaxis in Midwifery 
 
 BY 
 
 DE. 0. SCHAEFFER, 
 
 OF THE UNIVERSITY OF HEIDELBERG. 
 
 337 
 
Prophylaxis in Midwifery 
 
 Preventive treatment in midwifery has botli a wider and 
 a narrower range. For in the first place the development 
 of the embryo is influenced by the life history of the mother 
 and her physical constitution, and also by the state of 
 health of the father. In the second place disease of the 
 embryo may lead to conditions which are a source of danger 
 to the mother during pregnancy and labour, as for instance 
 hydramnios, hydrocephalus and placenta praevia. 
 
 Further prophylactic measures may be adopted even 
 before the occurrence of pregnancy, when an affection of 
 some organ or some constitutional condition exists which 
 we know by experience will be aggravated if complicated 
 by pregnancy, such as tuberculosis and cardiac and renal 
 disease. In other cases again the object of prophylactic 
 treatment is to prevent the establishment of certain condi- 
 tions during pregnancy labour and the puerperium, which 
 will become a source of trouble in later life, such as 
 enteroptosis. 
 
 I. Preventive Treatment during Pregnancy 
 
 1. GENEEAL MEASUEES DUEING PEEGNANCY 
 
 Among these are included not only (1) diet and hygiene 
 during pregnancy, but also (2) the diagnosis of conditions 
 which may make delivery at full term difficult, as con- 
 tracted pelvis, tumours and vaginal stenosis, in order that 
 they may be removed or a timely induction of premature 
 labour rendered possible ; and (3) the cure of existing 
 diseases which might lead to serious consequences during 
 
 339 
 
THE PEEVENTION OF DISEASE 
 
 parturition or tlie pnerperinm, especially uncompensated 
 valvular disease of the heart and nephritis. 
 
 Avoidable causes of injury to the embryo are excessive hard 
 work, especially heavy lifting, long frequent journeys by 
 carriage or by railway (which cause injury not only mechanic- 
 ally but also through the lumbar centre of the spinal cord), 
 violent movements, such as leaping, and mental excitement. 
 
 Among the forms of mental excitement which may be pre- 
 sent is fear of the approaching childbirth, and it may be re- 
 moved by reassuring the patient and by making necessary 
 provisions for her comfort, as by providing a suitable nurse 
 or pleasant surroundings, or getting her admitted into an 
 institution. It is remarkable for example how very much 
 more frequently eclampsia occurs in illegitimate births, 
 even in those cases where the surrounding circumstances 
 are extremely favourable, and the co-operation of some 
 nervous factors cannot therefore well be excluded. Neu- 
 rasthenic and hysterical women should be kept from all 
 irregularities in food and drink, because these tend to pro- 
 duce disorders during pregnancy which may assume very 
 dangerous proportions, as excessive vomiting and ptyalism. 
 These patients should go to bed earh^, their food should be 
 easily digestible, and no alcohol or other stimulants should 
 be given. Regular action of the bowels should be procured 
 by diet, mild laxations and enemata. The care of the skin, 
 breasts and abdominal muscles require daily washing 
 with cold or slightly warm water, but not too many 
 warm baths should be taken as they are often badly borne, 
 a bath once a week or fortnight would not be too fre- 
 quent. The nipples should be drawn out from time to 
 time as a precautionary measure. 
 
 Besides the examination of the heart and kidneys, one 
 should examine for tuberculosis, enlargement of the 
 thyroid, varicose veins and diabetes. "With regard to the 
 treatment of anaemia and chlorosis, we must draw atten- 
 tion to the fact that overfeeding is useful only during the 
 first half of pregnancy and not during the last half, because 
 it then only goes to nourish the foetus and may thereby 
 make delivery more difficult. For the same reason it is 
 
 340 
 
PEOPHYLAXIS IN MIDWIFERY 
 
 unadvisable for the patient to take liquids in large 
 quantities. In cases of cardiac disease with, absence of 
 compensation, a possible abortion or fatal syncope during 
 or immediately after delivery should be prevented by pre- 
 scribing digitalis or strophanthus to restore compensation 
 as soon as possible. For nephritis a diet consisting largely 
 of milk should be given, and the kidneys should be relieved 
 by exciting the activity of the skin by hydropathic 
 measures, such as warm baths, massage, wet packs and 
 diaphoretics. For varicose veins elastic bandages or elastic 
 stockings should be worn : they should be put on directly on 
 getting up in the morning. When there is much swelling 
 of the legs the patient should be recommended to lie down 
 frequently. Serious enlargement of the thyroid gland 
 should be treated by excision even during pregnancy. 
 
 2. ABOETION : ITS PEEVENTIYE TEEATMENT 
 
 Abortion occurring before the fourth month of pregnancy 
 and formation of the placenta, or occurring before the 
 viability of the foetus in the seventh month, when it is 
 sometimes called miscarriage, may be produced by four 
 groups of causes : (1) General disease from which the 
 mother is su£fering. (2) Accidents: a fall or blow — and 
 operations. (3) Disease of the genital organs or an un- 
 developed condition of the genital organs in the mother. 
 (4) Disease of the foetus and the membranes. 
 
 The general treatment in threatened abortion should 
 consist of rest in bed and administration of opiates as 
 suppositories and a light diet. The lower bowel should be 
 emptied by an enema. The prognosis is bad in cases 
 arising from general disease, but is generally good in 
 cases arising from accidents or operative procedures, pro- 
 vided that there is no dilatation of the cervix. The forma- 
 tion of intraplacental haematomata and free haemorrhage 
 should be prevented as far as possible by opiates, by 
 lukewarm or cold irrigations with sterilized salt solution, 
 and by cold water abdominal compresses. Examinations 
 and intravaginal treatment must be conducted with strict 
 asepsis, that no infection may arise if the ovum 
 
 341 
 
THE PEEVEiS'TION OF DISEASE 
 
 later becomes completely separated. To the first group 
 beloDg acute infectious diseases, such as typhoid fever, 
 cholera, pneumonia, variola, and influenza. These cause 
 death of the foetus by direct infection or by the toxines, 
 or by the formation of subchorionic haematomata which 
 obstruct the circulation, or sometimes by long continued 
 pyrexia. For the latter cause antipyretics are useful. The 
 elimination of toxines may be promoted by dia23horesis, by 
 the action of the bowels, and by injection of normal saline 
 solution (-7 to "9 per cent.), by the rectum or hypoder- 
 mically. 
 
 Among the chronic constitutional diseases which cause 
 abortion the most frequent is sj^philis. Others are 
 diabetes, leucaemia, haemophilia, scurvy and lastly 
 eclampsia arising from renal or hepatic inadequacy. 
 Among organic lesions which predispose to abortion the 
 most important is cardiac disease with lack of compensa- 
 tion. Among neuroses the most important is chorea and 
 among chronic poisons the most important are lead and 
 nicotine. Lead is capable of causing abortion even though 
 present only in the father. 
 
 Preventive treatment consists in treating the disease and 
 this without delay. For syphilis, sodium iodide should be 
 given, 2 grains to 15 grains a day ; with calomel ^ grain 
 to i- grain three times a day. The treatment may also be 
 carried out by inunction. Permission to marry should not 
 be given till at least four years, or better still five years, 
 have elapsed since the infection, and three years since the 
 last appearance of symptoms ; and treatment by inunction 
 should be ordered immediately before marriage. 
 
 For the second group rest in bed is the best treatment 
 for the strain upon the uterine ligaments caused by 
 accidents. In gunshot wounds of the uterine wall 
 premature expulsion of the embryo always occurs. If in its 
 course the shot has perforated the uterus expulsion of the 
 embryo generally begins immediately, or the liquor 
 amnii may rapidly flow into the abdominal cavity and 
 cause the omentum to float into the gunshot track in the 
 abdominal wall and so jieritonitis may be set up. Imme- 
 
 3^2 
 
PROPHYLAXIS IN MIDWIFERY 
 
 diate abdominal section is tlie best treatment, and Czerny 
 has recently recommended this treatment for every 
 jDerforating gunshot wound of the abdomen. If the ball 
 lodges in the uterine wall premature delivery will ensue in 
 the course of a few weeks, and it is not necessary to per- 
 form an abdominal section as a prophylactic measure but 
 merely to watch in case symptoms of peritonitis set in. 
 
 Injuries inflicted by blunt instruments seldom cause 
 rupture of the uterus, but produce separation of the placenta 
 with internal haemorrhage. The patient should be put to 
 bed and the pulse watched. 
 
 Lacerated wounds of the abdomen and uterus should be 
 treated by a Mikulicz tampon, unless removal of the uterus 
 is indicated because the tissues have been injured beyond 
 possibility of recovery or because the wound is septic. . 
 
 Operations should be performed during pregnancy when 
 there is urgent necessity for them, as for carcinoma or for 
 tumours which will cause trouble in childbirth. Nephrec- 
 tomy, also operations for appendicitis and for perforations 
 which will lead to peritonitis may be done when neces- 
 sary. Any operation may be performed without risk to 
 the embryo, provided only that the uterus is not inter- 
 fered with ; and as a matter of precaution all interference 
 with the uterus should be strictly avoided. ExjDerience has 
 shown too that operations on the vulva, even incisions, may 
 induce labour pains. Special mention must be made of the 
 great danger arising from injury to the vessels of the 
 vestibule for fatal haemorrhage may arise from this cause. 
 
 The question whether further pregnancies should be 
 avoided by patients who have undergone nephrectomy 
 has been answered in the negative by Fritsch, because 
 pregnancy may run a normal course after this operation. 
 The prognosis however in subsequent pregnancies de23ends 
 entirely upon the condition of the remaining kidney ; a case 
 ending fatally has recently been reported. 
 
 To the third group belong endometritis and metritis, 
 retroversion and retroflexion with descent or prolapse of 
 the uterus, and tumours of the true pelvis. The latter 
 should be pushed ujd into the false pelvis if possible ; they 
 
 343 
 
THE PREVENTION OE DISEASE 
 
 must be removed if they are incarcerated or adherent or 
 have too short a pedicle. This is described in detail under 
 " Tumours." 
 
 If conception has taken place it is obvious that no 
 further local treatment for metritis is admissible. 
 
 It is both fortunate and remarkable how seldom the 
 inflammation in metritis spreads to the foetal membranes : 
 and it is only when it spreads that abortion will ensue. 
 Several pathological conditions may result. Haemorrhages 
 into the decidua may occur with the formation of a 
 carneous mole ; or hydrorrhoea gravidarum caused by 
 catarrhal endometritis ; decidua polyposa, decidua atrophica ; 
 or a hydatidiform mole, hydramnios, or placentitis with the 
 formation of infarcts. 
 
 Preventive treatment in these cases can only succeed in 
 warding off dangers and sequelae which commonly follow 
 abortion. Strict asepsis should be observed, decomposing 
 ova should be removed as soon as possible, and retained 
 products of gestation must be removed digitally or by the 
 blunt curette. This treatment serves at the same time to 
 prevent that form of endometritis which is liable to follow 
 an abortion, and to prevent subinvolution of the uterus and 
 the resulting chronic metritis. For the same reason con- 
 traction of the uterus should be excited by plugging with 
 iodoform gauze for twenty-four hours, and then by the 
 administration of ergot and by hot irrigations. This is 
 the best way of preventing the habitual abortion which 
 results from subinvolution of the uterus or weakened 
 innervation. 
 
 In cases of vesicular mole the uterus should be evacuated 
 as soon as possible, and all fragments left behind should be 
 carefully removed from the uterus by the finger or by a 
 blunt curette, because these degenerated villi often grow 
 into the uterine wall and are apt to become malignant. 
 For the same reason the patient should remain under 
 medical observation for several months, and the process of 
 involution of the uterus or possible formation of .new 
 growths should be watched. 
 
 For hydramnios repeated puncture is sometimes useful. 
 
 344 
 
PROPHYLAXIS IN MIDWIFERY 
 
 Abortion does not necessarily follow the puncturing of the 
 membranes, because of the remarkable fact that, in spite of 
 the very great tension of the uterus, the bag of membranes 
 remains lax. 
 
 Preventive treatment can do much to prevent habitual 
 abortion in cases of descent of the uterus caused by laxity 
 of the ligaments. A pessary should be worn till the fifth 
 or sixth month of pregnancy, and afterwards an abdominal 
 belt. The prognosis is not so good when eversion of the 
 lips of the OS exists, whether as the result of lacerations of 
 the cervix or of laxity of the uterine walls, indeed in the 
 latter case the wearing of a round ring would according to 
 the writer's observation tend to increase the eversion of 
 the mucous membrane. 
 
 A retroflexed uterus should be replaced in the third 
 month, unless spontaneous rectification has already occurred. 
 It is still better to insert a lever pessary from the com- 
 mencement of pregnancy. 
 
 In arrested development of the uterus especially of the 
 body of the uterus, as in the infantile form of uterus, the 
 tendency to habitual abortion is successfully treated by 
 uterine tents inserted for twelve to twenty-four hours 
 several days in succession. The tents should be shorter 
 than the cavity of the uterus, and daily hot vaginal douches 
 should be given. The author has also found that a brief 
 application of atmocausis for a quarter of a minute is useful, 
 after the cervix has been dilated for forty-eight hours by 
 tents. In addition general tonic treatment is needed. 
 
 3. THE INDUCTION OF ABORTION AS A PREVENTIVE 
 MEASURE IN AFFECTIONS OF OTHER ORGANS 
 
 An indication to induce abortion as a preventive treat- 
 ment is present in only a few cases of disease. It must be 
 noted that the exanthemata, such as smallpox and measles, 
 render the foetus immune, either by the action of their 
 toxines, or because traces of the infection reach the foetus. 
 Threatening abortion is a sign of the severity of the illness 
 and generally of bad prognosis for the mother, so that the 
 induction of premature labour is of no use whatever. 
 
 345 
 
THE PREVENTION OF DISEASE 
 
 On the other hand vaccination of the mother during 
 pregnancy does not render the newborn infant immune. 
 In the rare febrile Impetigo herpetiformis gravidarum, 
 good results follow the induction of premature labour, 
 possibly because the disease generally first appears in the 
 middle of pregnancy. 
 
 Induction of premature labour cannot be recommended 
 for cardiac and pulmonary affections except in a few 
 special cases. The indications for and against may be 
 formulated thus — There must be some special indication 
 with regard to the patient which requires that premature 
 labour should be induced, not because it is desirable to 
 bring about a premature delivery, but because it is desirable 
 to end the pregnancy, and because it seems probable 
 that premature termination of the pregnancy will be more 
 favourable for the patient than delivery at full term ; for 
 the chief dangers arise during labour from its length and 
 severity, and after delivery from the circulatory changes 
 which occur during the puerperium. 
 
 The first object of preventive treatment in cardiac lesions 
 must be to obtain compensatory hypertrophy in the heart, 
 by the administration of strophanthus and digitalis, except 
 in aortic incompetence. When compensation cannot be re- 
 stored the successful issue of the induction of abortion will 
 depend upon the rapidity of the expulsion of the ovum and 
 upon the month of pregnancy reached, that is upon the 
 expulsive force required to complete delivery. The latter is 
 indeed less in premature births, but on the other hand a 
 premature labour is apt to be more prolonged. It is best to 
 puncture the membranes, because this affords immediate 
 relief. The good effect of the induction of premature labour 
 is seen in those cases in which unfavourable symptoms 
 arise, not from the shock of the expulsion of the embryo, but 
 rather from the long duration of the strain ujDon the heart 
 and circulation, especially in aortic valvular disease. We 
 must be guided too in our decision by the experience that 
 prolonged strain u]3on the heart is of worse prognosis for 
 those women who work hard, for those in whom the cardiac 
 lesion appeared early in life and for multiparae. Further 
 
 346 
 
PEOPHYLAXIS IN MIDWIFERY 
 
 we must take into consideration the state of the heart 
 muscles, whether myocarditis or degeneration is present as a 
 complication. 
 
 Threatened collapse is best prevented by injections of 
 ether and of camphor, or even by venesection; ether is 
 useful even for anaesthesia. The treatment directly after 
 the expulsion of the foetus is important ; a sand bag should 
 be placed upon the abdomen to prevent sudden collapse by 
 the reduction of blood pressure in the abdominal cavity, 
 and ether should be given, but never ergot. Post partum 
 haemorrhage is of less serious import than usual, because it 
 relieves the heart. 
 
 Seeing that the induction of premature labour is under- 
 taken under such very unfavourable conditions, it is best to 
 explain to the relatives what are the risks and the gravity 
 of the prognosis. In forming a prognosis we must take 
 into consideration too any complications which may exist, 
 whether renal, gastric, intestinal or hepatic, because 
 the retention of toxins resulting from disease of these 
 organs acts as an additional burden upon the heart. 
 
 Even without these latter complications we find, as has 
 been mentioned above, that degeneration of the heart muscle, 
 early appearance of the cardiac lesion, and serious failure in 
 cardiac compensation render the prognosis much more un- 
 favourable, especially in weakly and very anaemic patients 
 and in cases where the conditions of life do not permit 
 of the necessary care being taken. Medical consent 
 to marry should not be given to girls so affected. The 
 number of pregnancies in such cases should not exceed 
 two. 
 
 In pulmonary affections, especially in phthisis, the 
 effects of parturition are not less serious ; those are the loss 
 of blood, the muscular exertion, and a tendency to cardiac 
 inadequacy with consequent oedema of the lungs. For 
 these reasons the induction of premature labour should not 
 be undertaken, though artificial abortion may be advisable 
 in cases where it appears probable that the end of pregnancy 
 will not be reached or will be reached under very serious 
 conditions. In these cases of chronic organic disease the 
 
 347 
 
THE PREVENTION OF DISEASE 
 
 question may arise wlietlier it is justifiable to produce 
 sterility in tlie woman by obliteration of tlie uterine cavity 
 by repeated application of steam, or by removal of the 
 ovaries, or by excising the Fallopian tubes and closing the 
 uterine apertures. 
 
 Similar indications will guide us in deciding upon the 
 induction of abortion prophylactically in diseases of 
 metabolism and nervous affections caused by retention of 
 the toxins of metabolism, that is by auto-intoxication. 
 The most serious and most common of these affections are 
 excessive vomiting at the beginning of pregnancy and 
 eclampsia towards the end of pregnancy. Others are ptyal- 
 ism, uncontrollable diarrhoea, icterus gravidarum, diabetes, 
 haemophilia, scurvy, exophthalmic goitre, many forms of 
 neuritis, and a severe form of chorea, which has a mortality 
 of thirty per cent, and premature delivery in twenty per 
 cent, of the cases. Epilepsy, hysteria, tetany, myelitis 
 and various psychoses may also occur. The general 
 prophylaxis for all these disorders consists in suitable 
 hydropathic treatment and in imi^roving the general 
 health. It is more important still that this plan of treatment 
 should be followed when pregnancy has occurred, especially 
 for the reflex neuroses which are associated with hysteria. 
 
 For excessive vomiting in mild cases, increase of its 
 severity may be prevented by a light or fluid diet, though 
 milk is unfortunately often badly tolerated even with the 
 addition of lime water, or when boiled with starch flour. 
 A strong exercise of the will and determination not to 
 yield to the inclination to vomit is also of great value. A 
 cautious examination of the generative organs should be 
 made to determine whether retroflexion of the incarcerated 
 gravid uterus is present or some anomaly of the ovum, 
 such as vesicular mole, missed abortion or hydramnios. 
 
 In these cases puncture of the membranes and dilata- 
 tion of the cervix are often of use in addition to a pessary, 
 and are not followed by abortion. Vomiting caused by 
 dyspepsia is best treated with orexin 5 grains to 8 grains 
 in capsules two or three times a day. In the severer forms 
 of uncontrollable vomiting, the stomach must be given 
 
 348 
 
PROPHYLAXIS IN MIDWIFERY 
 
 complete rest to prevent serious consequences, or even 
 fatal results, Nourishment must be given entirely per 
 rectum ; at first normal saline solution, tlien oatmeal water, 
 then white of egg in water, and lastly nutrient enemata of 
 milk, egg, butter and sugar. The author has found alkar- 
 nose enemata very satisfactory. Sometimes enemata may 
 at first cause retching and bilious vomiting. In patients 
 who have become much emaciated the action of the heart 
 may be so seriously impaired by deficiency of fluid in the 
 body and by an overloading of the tissues with toxines, 
 that it becomes necessary to have recourse to hypodermic 
 or to intravenous injections of sterilized normal saline 
 solution. 
 
 But these are the cases for which induction of abortion is 
 the right treatment and is successful if not done too late. 
 The condition of the pulse is the best guide, for death has 
 occurred even after spontaneous or artificial abortion when 
 weakness of the heart's action is too far advanced. 
 
 The same holds good for uncontrollable ptyalism and 
 diarrhoea, which reduce the patient's strength by loss of 
 sleep and loss of albuminous fluids. For both these dis- 
 orders treatment consists in stimulating the action of the 
 skin by hydrotherapy and in promoting diaphoresis and 
 diuresis, but if these are unsuccessful nothing can be done 
 except induction of abortion. 
 
 In all these cases the use of narcotics is strictly contra- 
 indicated. 
 
 For chorea with very severe symptoms, especially with 
 insomnia, induction of abortion offers the only chance of 
 saving life. In leukaemia and in pernicious anaemia an 
 improvement in the patient's general condition has followed 
 the induction of abortion. In very bad cases of exophthal- 
 mic goitre abortion occurs spontaneously ; if it does not 
 occur the prognosis is good. 
 
 Artificial abortion is strictly contra-indicated in all 
 diseases of the blood, and treatment consists in injections of 
 20 cubic centimetres of a 2 per cent, gelatine emulsion, 
 or of a 10 to 20 per cent, emulsion per rectum. Calcium 
 hypophosphite may be given to the extent of 2 drams per 
 
 349 
 
THE PREVENTION OF DISEASE 
 
 day by mouth, or 3 drains per rectum. Sodium iodide may 
 also be prescribed. 
 
 Diabetes is considerably aggravated by pregnancy, and 
 tends to premature expulsion of tlie ovum during tbe latter 
 ball of pregnancy. It should first be treated by dieting 
 and by regularity of living. The induction of premature 
 labour is indicated in those cases only where it is impossible 
 to reduce the excessive excretion of sugar, and where there 
 is rapid deterioration in the general condition of the 
 patient ; but such cases are extremely rare. The embryos 
 are often of low vitality. Women who have diabetes should 
 not marry. 
 
 In renal disease, with a tendency to eclampsia towards 
 the end of gestation, or with retinitis albuminurica, much 
 may be done during pregnancy to relieve the kidneys 
 which are affected by Bright's disease. The patient should 
 be treated by hydropathic '"iDacking," and not by the in- 
 duction of premature labour. But when serious symptoms 
 arise which threaten life, such as an extreme degree of 
 dropsy and retinitis, with vision less than one-sixth, it 
 becomes necessary to consider the advisability of inducing 
 premature labour as a preventive measure. But it must be 
 remembered that measures intended to excite labour pains 
 will also reflexly excite attacks of eclampsia, or if eclampsia 
 has already appeared will increase the fits to a dangerous 
 extent. Preventive treatment for eclampsia consists in 
 elimination of the toxines from the blood as speedily as 
 possible, and in relieving the kidneys and cerebral con- 
 gestion by exciting diaphoresis by baths and by wet 
 packs. The eclamptic convulsions may be checked by 
 chloralhydrate or morphia, and by the avoidance of every- 
 thing that tends reflexly to produce them, such as noises in 
 the room, vaginal examinations and futile attemjjts to 
 bring about delivery. For all obstetric procedures the 
 patient should be under the influence of chloroform. 
 
 Thus in the preventive treatment of general diseases, and 
 of disease of organs other than the generative, the indica- 
 tions for the induction of abortion or of premature labour 
 depend entirely on the individual case, and are not 
 
 350 
 
PROPHYLAXIS IN MIDWIFERY 
 
 sharply defined or absolute. In the preventive treatment 
 of anomalies of the pelvis and of the generative organs 
 however the indications for the induction of abortion are 
 definite and exact. 
 
 A. Indications for the induction of abortion up to the 
 fourth month : 
 
 (a) Great pelvic contraction, the shortest diameter being 
 2 inches or less, where a viable child of thirty -four weeks 
 could not be delivered ; and a mature child could not be 
 delivered by craniotomy. 
 
 (&) The presence in the true pelvis of a tumour which 
 cannot be removed or reduced in size or pushed out of the 
 pelvis. This indication is rarely present except in carci- 
 noma of the uterus. 
 
 (c) Displacement of the uterus which cannot be reduced, 
 especially retroflexion caused by adhesions, or with sup- 
 puration. 
 
 (d) Hydatidiform mole. 
 
 B. Indications for the induction of premature labour if 
 possible not till after the thirty-fourth week : 
 
 {a) Pelvic contraction, according to the following rules : 
 In the thirty-fifth week when the true conjugate is slightly 
 over 3 inches, or in generally contracted pelves even when 
 the conjugate is 3| inches, or in infundibular pelves when 
 the transverse diameter at the outlet is 3 inches. 
 
 In the thirty-third to the thirty-fourth week, for a true 
 conjugate of 3 inches, with 2| to 3 inches between the 
 tuberosities in an infundibular pelvis. 
 
 In thirty-first to thirty-third week for a true conjugate 
 of 2f to 3 inches. 
 
 Before the thirtieth week for a true conjugate of 21 to 
 2f inches. 
 
 "With a true conjugate of 2^- inches the induction of 
 abortion is generally required. 
 
 With regard to further preventive treatment, it must 
 be mentioned that by a suitable diet consistently and 
 regularly followed, children decidedly thinner than usual 
 are in many cases brought into the world. The food should 
 be such as does not form much fat or much liquid. If any 
 
 351 
 
THE PREVENTION OF DISEASE 
 
 good is to be attained from tliis method, it must be 
 employed sufficiently early. 
 
 (})) Placenta praevia with, serious haemorrhages. 
 
 (c) Habitnal death of the foetus at a certain time. 
 
 (d) Hydramnios with great danger to the mother when 
 it obstructs the diaphragm and causes great disturbance of 
 the circulation. 
 
 4. PREVENTIVE TREATMENT FOR ANOMALIES OF FORM 
 AND OF POSITION OF THE UTERUS DURING PREGNANCY 
 
 Want of space and circulatory disturbances may in these 
 cases lead to spontaneous abortion, or more frequently to 
 premature delivery, and in very rare cases may make it 
 necessary to induce labour. 
 
 (a) The dangers arising out of anomalies of development 
 are on the one hand laceration of the distended uterine 
 cornu in uterus unicornis and bicornis, and in uterus 
 didelphys ; and on the other hand obstruction of the pelvis 
 by the other cornu. The question of the preventive treat- 
 ment depends upon our diagnosis of the case, and unfortu- 
 nately there is very little experience to guide us. 
 
 The preventive treatment for pregnancy in a rudimen- 
 tary uterine cornu with atresia is the same as that for 
 extra-uterine gestation ; the results of both conditions are 
 the same. 
 
 (&) In retroflexion of the gravid uterus the uterus must 
 first be replaced and then kept anteflexed by a lever 
 pessary from the first to the fifth month, which should 
 be taken out occasionally and then reinserted. By this 
 treatment we prevent incarceration of the uterus with its 
 serious consequences. Among these are abortion, severe 
 reflex phenomena, such as uncontrollable vomiting and 
 ptyalism, difficulty in micturition, with subsequent gan- 
 grene of the bladder, and lastly rupture of the bladder. 
 
 The bladder and the bowel must be emptied before any 
 attempt is made to replace the uterus. The attempt often 
 fails, and it then becomes necessary to draw down the 
 cervix by vulsellum forceps, and to push up the body 
 of the uterus by pressure, either through the posterior 
 
 352 
 
PROPHYLAXIS IN MIDWIFERY 
 
 vagiual vault or through the rectum, or finally by the 
 hand on the abdomen. This can be done most easily 
 when the patient stands upright, or is placed so that 
 the pelvis is raised — that is, the knee-elbow position. 
 There is often difficulty and danger in passing the 
 catheter, and sometimes it becomes impossible till the 
 vaginal part of the uterus has been lifted and pushed away 
 from the symphysis. In other cases all attempts are in 
 vain, and to use force is always dangerous. For these 
 cases we use the slow steady pressure exerted by Meyer's 
 elastic ring pessary or by a dilatable vaginal bag. Sims' 
 lateral position, or the knee-elbow position, is best for this 
 purpose, "While filling the dilatable vaginal bag with 
 sterilized fluid, care must be taken not to make the bag too 
 tense, as lacerations of the vagina have been produced in 
 this way. 
 
 "When all efforts to introduce a catheter have failed, as 
 force must not be used lest the bladder should burst, it 
 must be punctured through the vagina, so that the urine 
 may not infiltrate the connective tissue around the bladder, 
 or the bag of membranes may be punctured through the 
 posterior vaginal vault. If the cervix and the cervical 
 canal are within reach, and the canal is patent, it is best in 
 these cases to induce abortion by passing a bougie, and by 
 plugging with gauze soaked in glycerine. The uterus 
 may be rapidly emptied of the contained ovum by an 
 incision into it made through the posterior vaginal vault. 
 On the other hand abortion may be prevented by replacing 
 the uterus from above, that is by an incision through the 
 abdominal wall. 
 
 (c) Descent and prolapse of the uterus readily lead to 
 abortion. It may be prevented by the use of a pessary till 
 the fifth month. Plastic operations, such as colporrhaphy, 
 perineorrhaphy, are also practicable, and are especially 
 useful when excoriations of the os uteri are combined 
 with prolapse, because in case of spontaneous abortion such 
 excoriations readily become infected, and may lead to 
 serious consequences. 
 
 The best preventive treatment in all case of anomalies 
 
 353 A A 
 
THE PREVENTION OF DISEASE 
 
 of position is their rectification before conception takes 
 place. 
 
 {d) There are several varieties of anteflexion whicli give 
 rise to symptoms in pregnancy, some of which, are very 
 troublesome and serious. One form is infantile anteflexion, 
 which predisposes to abortion, and is often associated in 
 primiparae with excessive vomiting, according to the 
 author's observations. Other anteflexions occur in conse- 
 quence of lax ligaments and of a lax abdominal wall, and 
 in flattened pelvis, which causes a pendulous abdomen. 
 Lastly anteflexion may be caused by vaginal or vesical 
 fixation, or more rarely by ventrifixation ; these fixations, 
 as well as those produced in other ways, may lead to the 
 formation of pouches in the uterus. Abortion is frequent 
 in cases of antefixation. The induction of abortion is 
 indicated when the embryo in its development causes over- 
 stretching and great tension of the posterior uterine wall, 
 and when at the same time the vaginal portion of the 
 cervix is pulled backwards. 
 
 The best preventive treatment is to avoid hysteropexies 
 during the years when childbearing is possible, for they 
 are capable of producing these uncontrollable adhesions. 
 
 A pendulous abdomen should be supported by means of a 
 strong wide belt which fits the convex form of the abdomen. 
 This will prevent overstretching of the abdominal fasciae 
 and separation of the recti, and thus from the very first will 
 prevent a faulty position and faulty presentation of the 
 embryo. Hydramnios and twin pregnancies also predis- 
 pose to this condition. 
 
 Laxity of the ligaments combined with rickety pelvis, 
 and also infantile anteflexion of the uterus are found in 
 hysterical, neurasthenic and chlorotic young women. Pre- 
 ventive treatment should be early begun to remove these 
 conditions of weakness. 
 
 (e) For the rare cases in which the pregnant uterus is 
 found in a hernia, ventral, inguinal or femoral, preventive 
 treatment consists in reduction, or in artificial abortion, or 
 in herniotomy and removal of the uterus or uterine horn. 
 The best treatment of all is for the patient to wear a strong 
 
 354 
 
PROPHYLAXIS IN MIDWIFERY 
 
 truss before pregnancy occurs or to have a radical cure 
 performed. 
 
 5. PREVENTIVE TREATMENT FOR TUMOURS OF THE 
 GENERATIVE ORGANS IN PREGNANCY 
 
 Tumours may interfere with pregnancy by obstructing 
 the true pelvis. The tumours may be derived from pelvic 
 organs or may have come down through the pelvic brim, 
 as for instance a floating kidney or a hydronephrosis. 
 
 (a) For fibromyomata great experience is required in 
 deciding what is the right treatment for any given case. 
 The following questions must first be answered : " Have 
 serious symptoms already appeared during the pregnancy ? " 
 "Do we think that such symptoms will appear before the 
 time when the child is viable? " " Will labour at full term 
 cause dangerous conditions which it will be very difficult 
 or even impossible to overcome, and thus endanger the lives 
 both of mother and child? " " Is the immediate removal of 
 the tumour less dangerous than if longer delayed? and 
 must the ovum be removed at the same time? or will it 
 suffice to induce premature labour ? " 
 
 The answers depend upon the situation and size of the 
 tumour. 
 
 The dangers in so far as the embryo is concerned are 
 many. First, conception is difficult or impossible because 
 of the presence of large or polypoid fibromata, or because of 
 the resulting changes in the endometrium. Next, abortion 
 may occur with possible retention of parts of the ovum and 
 decomposition. Other possible results are malformations of 
 the foetus through want of sufficient space, placenta praevia 
 or even tubal gestation. 
 
 The dangers during pregnancy which arise from the 
 tumour are incarceration of the tumour under the pro- 
 montory of the sacrum ; or torsion of its pedicle, followed by 
 strangulation, which may also be produced by disturbances 
 of the circulation and haemorrhages when there is a ten- 
 dency to thrombosis of the veins of the uterine appendages. 
 A further danger is a marked increase in size of the tumour 
 owing to oedema and to fibrous growth. Even when the 
 
 355 
 
THE PREVENTION OF DISEASE 
 
 shape and situation of the tumour are such that it will not 
 cause difficulty during labour, central hsemorrhages and 
 softening readily occur, and may give rise to sepsis. 
 
 Experience has shown that we should be guided by the 
 following rules for treating tumours : 
 
 Small fibroids of the body of the uterus should be left un- 
 touched. Cervical polypi should be removed at once in the 
 simplest and most careful way possible. If the fibroids are 
 upon a broad base in the cervical wall, they should be left 
 till the time of childbirth ; and the same holds good for 
 submucous fibroids. 
 
 With large cervical fibromyomata which obstruct the 
 passage we have to consider whether it is possible either 
 now or later to push the tumour out of the waj^ or to remove 
 it ; and here our knowledge both of the increase in size and 
 of the change in form of myomata from the effect of labour 
 pains is of value. Labour pains have often easily accom- 
 plished what energetic efforts to push the tumour out of 
 the way have failed to do under an anaesthetic. No attempt 
 should be made to alter the position of the tumour before 
 the eighth month for fear of producing abortion, except 
 when there are symptoms of incarceration. If the tumour 
 cannot be pushed out of the way it must be removed by 
 abdominal section. 
 
 The same considerations, as to the possibility of altering 
 the position of the tumour, apply to subserous fibroids 
 which become fixed in the pehds beneath the j^regnant 
 uterus. In some cases the induction of premature labour 
 is indicated, according to the rules already given for the 
 induction of labour in contracted pelves. 
 
 After such induction of labour and after spontaneous 
 abortion all retained products of conception should at once 
 be removed to prevent sepsis. If septic infection is already 
 present, the uterus and tumour should be removed without 
 delay to prevent a general septic infection. 
 
 Removal of the fibroid by abdominal section is best 
 undertaken at the end of pregnancy, and may then be 
 looked upon as a curative and not as a preventive procedure. 
 It is a preventive measure only when performed for some 
 
 356 
 
PROPHYLAXIS IN MIDWIFERY 
 
 threatening danger, such as torsion of the pedicle or irre- 
 ducible incarceration, decomposition, or when the fibroid is 
 complicated with disease of some other organ, especially 
 cardiac, pulmonary or renal affections, so commonly seen m 
 patients with myomata. In many cases, as when the 
 tumour is already infected, total extirpation is advisable. 
 
 (&) Ovarian tumours should generally be removed during 
 pregnancy without further consideration, and this is best 
 done during the early months : even double ovariotomies 
 very seldom cause abortion. The induction of abortion 
 instead of removal of the tumour is not indicated, except 
 when the tumour is generally adherent in Douglas' pouch, 
 or is situated within the folds of the broad ligament. 
 
 Ovariotomy should be performed when certain dangers 
 in pregnancy have arisen or are anticipated. These dangers 
 do not arise from an increase in size, as is the case with 
 myomata, but from circulatory disturbances, such as hsema- 
 tomata and thromboses, ]3roduced by the uterus as it rises 
 in the abdomen and drags upon the pedicle. A further 
 danger is torsion of the pedicle, resulting in necrosis of the 
 tumours, which affords a locus minoris resistentiae for infec- 
 tion, or which may give way if there is softening of the 
 wall. The danger with small tumours is that they may 
 become fixed beneath the promontory of the sacrum, and 
 fibromata which cannot be punctured may completely 
 obstruct the pelvis. Incarceration of the retroflexed uterus, 
 followed by abortion or by prolapse of the uterus, is pro- 
 duced by large tumours which obstruct the pelvic brim. 
 
 (c) The preventive treatment in carcinoma of the uterus 
 consists in : (1) For operable cases, the whole uterus should 
 at once be removed. During the latter half of pregnancy, 
 before the viability of the foetus, this should be done after 
 previously removing the ovum by an anterior vagino- 
 cervical incision. From the thirty-second week onwards, 
 by induction of premature birth by deep incisions in the 
 cervical wall and vaginal extirpation of the uterus ; but if 
 the cervical canal cannot be sufficiently dilated, the foetus 
 must be delivered bj^ Caesarian section, and then the body 
 of the uterus be amputated by the supravaginal operation, 
 
 357 
 
THE PEEVENTION OF DISEASE 
 
 while the cancerous cervix is removed per vaginam. (2) In 
 inoperable cases the utmost must be done to preserve the 
 life of the mother, and so save the child. Palliative 
 measures should be used to check growth and decompo- 
 sition, as by the use of the thermocautery, atmocausis, or 
 cauterizing with chloride of zinc, 
 
 "When it is desired to induce premature labour, and the 
 cervical canal is impassable through the presence of an 
 inoperable malignant mass, Caesarian section must be per- 
 formed, and then as a preventive measure supravaginal 
 hysterectomy should be performed to prevent infection. 
 
 6. PREVENTIVE TREATMENT OF EXTRA-UTERINE 
 GESTATION 
 
 To prevent extra-uterine gestation the causes which 
 most frequently lead to it should be removed. Amongst 
 these are all forms of inflammation of the generati^^e organs ; 
 gonorrhoea! inflammations, which may cause or have already 
 produced salpingitis, tuberculous salpingitis and jDeri- 
 oophoritis, as well as all pelvic congestions. 
 
 When a diagnosis of ectopic (generally tubal; gestation 
 has been made, definite prophylactic measures should be 
 taken to prevent serious consequences. 
 
 The most favourable course relatively is the bursting of 
 the embryo sac during the first two months, followed by 
 absorption of the retro-uterine hsematocele so formed and 
 of the ovum. In the later months fatal haemorrhages and 
 decomposition of the embr^^o readily set in. There is not 
 complete unanimit}^ as to the treatment which should be 
 adopted. 
 
 1. During the first three months injections of one-third 
 grain of morphia may be made into the embryo sac on two 
 occasions, without aspiration of the liquor amnii, and with 
 strict aseptic precautions, to kill the embryo. 
 
 2. If the ovum continues to grow in spite of this treat- 
 ment, or if, especially in obscure cases, the symptoms are 
 serious and urgent, the embrj^'O sac should be removed bj- 
 abdominal section, or if it is distinctly pedunculated, mov- 
 able and small it may be removed jjer vaginam. 
 
 358 
 
PROPHYLAXIS IN MIDWIFERY 
 
 3. Ill rare cases when the foetus is still alive and has 
 reached the thirty-second week, abdominal section should 
 generally be performed in order to remove as far as possible 
 the dangers with which the mother is threatened. In 
 exceptional cases when the mother urgently desires it for 
 the child's sake, one may wait till the thirty-fifth week, 
 and then deliver the patient by abdominal section. In 
 these cases all possible precautionary measures should be 
 taken to prevent bursting of the embryo sac ; the patient 
 should be kept in bed, opiates given, and if serious symptoms 
 appear we must at once proceed to open the abdomen. It 
 is best that the patient should be in a hospital. 
 
 4. If the rupture of the sac has occurred the abdomen 
 must be opened and the bleeding vessels ligatured to 
 prevent a fatal result from the continuance of intraperitoneal 
 haemorrhage, but this is only practicable when a few hours 
 have elapsed and collapse is not too severe. 
 
 5. When an intraperitoneal haematocele has formed and 
 there are no symptoms of further internal haemorrhage, 
 measures should be taken, preliminary to eventual operative 
 treatment, to assist in preventing further ill effects. Thus 
 the patient should be kept in bed with the pelvis raised, 
 a sand bag placed upon the abdomen, and the coagulability 
 of the blood increased by giving calcium hypophosphite, or 
 injections of -8 or -9 per cent, sodium chloride solution, or 
 of 2 per cent, gelatine emulsion. 
 
 If fever appears, pointing to sepsis or suppuration, further 
 danger must be avoided by a timely incision through the 
 vaginal vault or abdominal wall. 
 
 7. PREVENTIVE TREATMENT IN PLACENTA PRAEVIA 
 Placenta praevia, with the serious consequences arising 
 from the low attachment of the ovum, may be prevented 
 by removing the primary causes which produce it, and we 
 are able to do this in some cases, for example in chronic 
 endometritis and metritis, submucous fibroids, subinvolution 
 of the uterus and lacerations of the cervix. 
 
 Among the consequences of placenta praevia haemorrhage 
 fjom the detached lower part of the placenta is the^mosl^ 
 
 359 
 
THE PREVENTION OF DISEASE 
 
 serious. This may begin during pregnancy through the 
 stretching of the lower uterine segment, or may not begin 
 till labour sets in. For these reasons preventive treatment 
 consists, not only in checking the haemorrhage, but also in 
 raising the power of resistance of the patient from the 
 moment that a probable placenta praevia is diagnosed by 
 the occurrence of frequent metrorrhagia. 
 
 The induction of premature labour is indicated when the 
 haemorrhage is profuse. This is accomplished by dilating 
 the cervix with a hydrostatic dilator and rupturing the 
 membranes to prevent further detachment of the lower 
 part of the placenta, and in cases where the head does 
 not descend by performing version and bringing down a 
 leg. 
 
 Great care should be taken to ensure perfect asepsis and 
 to prevent much air entering, which might easily reach the 
 utero-placental veins and cause air emboli. When ruptur- 
 ing the membranes we should look out for vessels on the 
 chorion, as insertio velamentosa is not a rare occurrence in 
 cases of placenta praevia. The third stage of labour should 
 be closely watched, abnormal separation of the placenta with 
 post partu.m haemorrhage being almost the rule. . 
 
 11. Preventive Treatment during Delivery 
 
 1. GENEEAL PREVENTIVE TREATMENT FOR 
 ABNORMALITIES OF THE PELVIS 
 
 To prevent abnormal development of the pelvis the 
 causes which produce it must be treated, in most cases 
 during early childhood or at puberty. The chief causes are 
 defective general development of the body — which produces 
 the " generally contracted pelvis," funnel shaped pelvis and 
 dwarf pelvis — and rickets. These causes may in most cases 
 be removed by suitable regulation of the conditions of life 
 and diet and by the administration of phosphorus. With the 
 strengthening and the better development of the bones of 
 the body, the tendency to abnormal development of the 
 pelvis disappears. During the period while the bones 
 remain soft the patient should walk as little as possible, 
 
 360 
 
PROPHYLAXIS IN MIDWIFERY 
 
 so that the pelvis may not have any great weight to bear, 
 and at puberty these patients should not lift or carry heavy 
 weights. The development of the bony genital canal is 
 much influenced by tuberculosis although indirectly — 
 partly through lateral curvature of the spinal column 
 leading to tilting of the pelvis, and partly by the formation 
 of oblique pelvis through disease of the hip and synostosis. 
 Apart from these contractions and displacements of pelvic 
 diameters which are of importance in obstetric practice, 
 exostoses arising most commonly from rickets, less often 
 from fractures or overgrowth, may give rise to serious 
 conditions by the injury they inflict on the soft parts. 
 
 Even when the unfavourable conditions produced by 
 such abnormalities are to a considerable extent compensated 
 for by the yielding of joints and by the compressibility of 
 the foetal skull, yet, excluding the mere obstruction to 
 delivery of the child, injuries may result either to the soft 
 parts, such as the uterus and vagina, to the joints, or to the 
 foetal skull bones. The more abnormal the position and 
 presentation of the child, the earlier the membranes rupture 
 before dilatation of the os, and the more violent the labour 
 pains are, the more readily will lacerations of the maternal 
 soft parts be produced. 
 
 Preventive treatment is of great value in these cases. The 
 results of experience show that when all complications 
 which add to the difficulty have been removed, nature is 
 able to bring about spontaneous delivery in 70 per cent, of 
 the cases of contracted pelvis. The limit to the degree of 
 contraction in which delivery may run a smooth course 
 is, according to Litzmann, in a true conjugate of 3| 
 inches ; and when this limit is exceeded anomalies in 
 position and in presentation are found in a markedly greater 
 number of cases. 
 
 To prevent the results which may follow from a con- 
 tracted pelvis treatment should be commenced during 
 pregnancy, as soon as the diagnosis of contracted pelvis 
 has been made. When the degree of contraction is very 
 great the induction of premature labour or even the 
 induction of abortion may be indicated, in accordance with 
 
 361 
 
THE PREVENTION OF DISEASE 
 
 the rules laid down under "Artificial Abortion." For 
 slighter degrees of contraction it is possible by frequent 
 warm baths and by work and active exercise in the open 
 air to prevent the regular duration of pregnancy from 
 being exceeded ; indeed labour pains may thereby be 
 made to set in a fortnight earlier (Ahlfeld) and the child 
 be full timed though with very little fat upon it. The 
 same principle may be carried out by Prochownik's dieting 
 which has been referred to above. During the last month 
 it is useful to place the child so that it lies as in a vertex 
 presentation and to press the skull into the pelvic brim ; it 
 should be done for several minutes at a time, several times 
 a week. If labour has set in the bag of membranes 
 should be kept intact as long as possible, and when they 
 have broken we must prevent the further escape of liquor 
 amnii. For the latter purpose a hydrostatic dilator should 
 be inserted ; it is a fiddle shaped elastic bag which is then 
 filled with sterilized water or a weak antiseptic solution 
 (Barnes and Fehling). The pressure of the head upon the 
 still undilated os uteri produces oedema of the lips and 
 leads to fissures and sepsis ; it also prematurely excites very 
 strong and painful labour pains and abdominal efforts, 
 which are often rendered ineffectual by partial tetanic 
 spasm. This too is prevented by the use of hydrostatic 
 dilators, which causes dilatation of the cervical canal. If 
 the external os is still quite closed the vaginal dilator is 
 used only when there is a complete cessation of pains. 
 
 This is for vertex presentations. But if the vertex does 
 not enter the pelvis and the pains become violent and 
 almost uninterrupted, and if any contraction ring is plainly 
 made out, which is rising towards the umbilicus while the 
 region of the bladder is flat and very tender, then it 
 becomes necessary to diminish the intensity of the pains 
 by applying mustard leaves, or very hot cloths, or employing 
 opium suppositories, or the inhalation of ether or chloroform 
 even to the stage of deep anaesthesia. An examination should 
 be made to see whether the position of the head is favourable 
 or unfavourable, and with this we must take into considera- 
 tion- -too the particular kind of abnormality of ;pelvis which, 
 
 362 
 
PROPHYLAXIS IN MIDWIFERY 
 
 is present. Rules for these are given in the following 
 paragraphs. 
 
 The condition above described readily leads on to tonic 
 spasm of the uterus and then to rupture of the uterus. 
 The same result will occur if a transverse presentation has 
 been assumed by the child when the liquor amnii has 
 escaped. While the bag of membranes is intact a rupture 
 is improbable. Preventive treatment in transverse presen- 
 tations consists in podalic version. Only very rarely is 
 cephalic version advisable, and that is when the relations 
 between pelvis and head are very favourable. Faulty 
 presentations are often produced by faulty postures in 
 pregnancy, arising from lax abdominal and uterine walls, 
 as with a pendulous abdomen with anteflexion of the uterus, 
 and these can be easily corrected when labour begins. 
 Further, anomalies in position may be caused by premature 
 rupture of the membranes in flat pelves and the carrying 
 down of limbs or of the umbilical cord by the escaping 
 liquor amnii, when the promontory projects and the head 
 cannot descend to fill the cervical canal. These anomalies 
 must also be speedily removed to prevent secondary faulty 
 presentations such as brow or face presentations, and to 
 prevent direct danger to the child's life when the cord has 
 prolapsed. 
 
 Even when the head has entered the pelvis it may 
 nevertheless, especially in generally contracted pelves, 
 become incarcerated or remain fixed, and extraction by 
 forceps or perforation becomes necessary. This must not 
 be delayed too long, and the forceps should be very carefully 
 used to avoid any risk of splitting open the pelvic joints, or 
 lacerations and bruising of the soft parts, which would lead 
 later to the formation of fistulae. In infundibuliform 
 pelves the head sinks deep into the pelvis and rests upon 
 the ischia. There is no danger of laceration through 
 dilatation, but injuries are caused by the severe pressure or 
 by the forceps, and when the labour pains are strong the 
 head should not be allowed to remain fixed for long. 
 
 Preventive treatment has three objects in these cases : 
 (1) The removal of obstruction caused by faulty presenta- 
 
 363 
 
THE PREVENTION OP DISEASE 
 
 tion aiid posture of the child, by too early and too copious 
 loss of liquor amnii and by abnormalities in the labour 
 pains. (2) Aseptic precautions and the avoidance of too 
 early interference. (3) Timely interference to prevent 
 injuries to mother and child. 
 
 A careful consideration of the advance and of the rota- 
 tion of the head, and of the strength of the pains, gives 
 the conditions for the posture which should be assumed. 
 The difficulty caused by too short a conjugate may be 
 lessened by putting the patient in "Walcher's " hanging- 
 posture," because when the legs are allowed to hang down 
 the distance between the symphysis pubis and the pro- 
 montory is increased. If we notice that the advancing 
 part of the child always tends to one side the patient 
 should be placed on that side. By this lateral posture the 
 trunk of the child with the fundus uteri falls towards that 
 side and the advancing part of the child is brought exactly 
 over the pelvic inlet. It is useful too to press the head 
 into the inlet with every labour pain. 
 
 "When the head does not enter the pelvic brim podalic 
 version is required in those cases where the true conjugate 
 is not less than 2f inches. By '' version as a preventive 
 measure " we understand those versions which are under- 
 taken when there is only moderate contraction of the pelvis, 
 either because the advancing head tends again and again 
 to pass to one side, or because we gather from the previous 
 history given by the patient that vertex presentations 
 have previously always ended unfavourably, whereas a 
 pelvic presentation has ended favourably. 
 
 In generally contracted pelves a true conjugate of 
 2^ inches is the lowest limit. In the infundibular pelvis 
 a distance of 3 inches between the tuberosities of the ischia, 
 the other diameters at the outlet being normal, is the limit 
 for application of forceps. 
 
 But if the distance between the tuberosity of the 
 ischium and the apex of the sacrum is only 2f inches, the 
 normal distance being 3f inches, then the distance between 
 the tuberosities of the ischia must not be less than 3^ inches ; 
 and this applies also to cases where the conjugate at the 
 
 364 
 
PROPHYLAXIS IN MIDWIFERY 
 
 Flattened Pelvis. 
 True Conjugate. 
 
 Child. 
 
 Head movable 
 
 above the 
 Pelvic Brim. 
 
 Head tixed 
 
 in the 
 True Pelvis. 
 
 2| inches to 4 inches . Living. 
 Dead . 
 
 Version . . . 
 Perforation or 
 version. 
 
 Forceps. 
 
 Perforation ; crani- 
 otomy forceps. 
 
 2ii inches to 3 inches . 
 
 Living. 
 Dead . 
 
 Symphysiotonl^ 
 Version . . . 
 
 ' in multiparae. 
 Perforation ; crani- 
 otomy forceps. 
 
 2 inches to 2| inches . 
 
 Living. 
 Dead . 
 
 Wait ; but if danger to the mother, 
 perforation, or possibly Caesarian 
 section. 
 
 Perforation and craniotomy forceps 
 or embryotomy. 
 
 Under 2 inches . . . 
 
 Living or 
 dead. 
 
 Absolute indication' for Caesarian 
 section. 
 
 narrowest part of the pelvic cavity is reduced to 3| inches, 
 the normal being 4| inches. Below these limits perforation 
 or symphysiotomy is indicated, unless the distance between 
 the tuberosities is less than 2 inches, and then Caesarian 
 section becomes necessary. 
 
 2. SPECIAL PREVENTIVE MEASURES DURING PREGNANCY 
 AND CHILDBIRTH FOR THE VARIOUS FORMS OF AB- 
 NORMAL PELVIS 
 
 In the generally-contracted pelvis we must prevent the 
 presentation from becoming a fronto-anterior or a brow 
 presentation, and must secure an occipito-anterior presenta- 
 tion, because experience has shown that when the occiput 
 sinks very low it is possible for the head to pass. It may 
 be aided by putting the patient in the lateral posture, on 
 the side on which the occiput lies, and by manually assisting 
 the rotation of the head. The same holds good for the 
 after-coming head in pelvic presentations : it should be 
 pressed into the pelvic brim and the chin be kept in close 
 
 365 
 
THE PEEVENTION OF DISEASE 
 
 contact with the breast. Eclampsia occurs frequently with 
 this kind of pelvis, and we should be on the lookout for its 
 premonitory signs. 
 
 With regard to all preventive treatment, including the 
 induction of premature labour, we must bear in mind that 
 we have to consider not only the degree of contraction of 
 the true conjugate, but also the fact that this is complicated 
 by contraction of all the other diameters. 
 
 When the head is fixed and the pains are strong but 
 no progress is made, it is best not to wait too long, 
 especially when the child is dead or its life endangered. 
 There is great danger of injury to the tissues by pressure, 
 and forceps should not be used at all, or only with great 
 caution, if the child is still alive. 
 
 The best preventive treatment, when the diagnosis is 
 made sufficiently early, is the induction of premature labour. 
 
 In the simple flattened pelvis the preventive treatment 
 is that of rickets and the induction of premature labour 
 given above. 
 
 The pregnant and retroflexed uterus which has become 
 incarcerated should be replaced in its normal position during 
 the second month. For a pendulous abdomen an abdominal 
 belt should be worn ; it should also be worn during parturi- 
 tion when the uterus falls too much forwards or too much 
 to one side, as this tends to produce lateral flexion of the 
 child's cervical spine and extreme obliquities of the head ; 
 the uterus may also be supported by cushions. It should 
 be remembered that moderate obliquity with descent of the 
 narrower frontal region into the pelvic brim is favourable 
 and should be encouraged. 
 
 In a flattened pelvis which will not allow the head to 
 pass through, the imminent danger of rupture of the uterus 
 must be prevented by the methods already described. The 
 premature rupture of the membranes must also be pre- 
 vented, for it predisposes to rupture of the uterus and 
 favours prolapse of the umbilical cord or of a hand or foot. 
 The strength of the labour pains must be restrained if 
 necessary. 
 
 In the generally-contracted and flattened pelvis all these 
 
 366 
 
PROPHYLAXIS IN MIDWIFERY 
 
 difficulties during pregnancy and at cbildbirtli are increased. 
 This pelvis, so far as the pelvic cavity is concerned, has all 
 the peculiarities of a simple generally-contracted pelvis, 
 and descent of the forehead must be prevented and an 
 occipital presentation be brought about. Presentation of 
 the forehead may, in this form of pelvis, much more readily 
 necessitate perforation and destruction of the child. A 
 combination of posterior parietal and occipital presentation 
 is very favourable. 
 
 In osteomalachic and similar pelves the prognosis of 
 childbirth depends less upon the degree of deformity than 
 upon the question whether the pelvis is soft or has become 
 ossified and rigid. Phosphorus should be given at the very 
 first appearance of well marked symptoms : these are pains 
 in the bones, first in the horizontal pubic rami ; cramps in 
 the muscles ; softening of the bones, occurring first at the 
 pelvic outlet ; and a waddling gait. 
 
 In malacosteon pelves spontaneous delivery or delivery 
 by forceps is possible. One need therefore only try to obtain 
 a favourable position and presentation of the child. 
 
 "With a rigid rostrated pelvis the danger of laceration 
 must be prevented ; it varies with the degree of contraction, 
 and Caesarian section may possibly be required. 
 
 In funnel shaped pelves the rotation forwards of the 
 occiput must be assisted. Timely and cautious interference 
 is required. Possibly symphysiotomy may be advisable to 
 prevent injurious pressure and straining of the sacro-iliac 
 articulations. 
 
 In oblique pelves with a considerable degree of con- 
 traction of one half, there remains only the other half 
 of the pelvic inlet, and the conditions are similar to those 
 of the generally contracted pelvis, and an occipital presenta- 
 tion is the most favourable. An endeavour must be made 
 to bring the sagittal suture into the shorter oblique 
 diameter, so that the descending occiput may be turned 
 towards the flattened or narrowed half of the pelvis. 
 Naegele's oblique pelvis, produced by an asymmetry of the 
 alae of the sacrum and synostosis, is of worse prognosis than 
 the oblique pelvis produced by scoliosis or anchylosis ; for in 
 
 367 
 
THE PREVENTION OF DISEASE 
 
 the Naegele pelvis forceps and version are almost invariably 
 harmful. 
 
 3. PEEVENTIVE TREATMENT OF LACERATIONS OF THE 
 
 UTERUS 
 
 Among the rare lacerations of the uterus during preg- 
 nancy very few afford an opportunity for preventive 
 treatment, since most of them are the result of criminal 
 attempts to procure abortion or are ruptures of rudimentary 
 uterine cornua. Old scars, after Caesarian section, which 
 have given way form the remainder. The suturing should 
 therefore be very carefully done in this operation. The use 
 of catgut and inclusion of the endometrium in the stitches 
 are now condemned. Various operators have however had 
 very good results with both. Miiller always sutures the 
 endometrium independently by itself. 
 
 The chief point of importance seems to be an exact 
 adjustment of the edges of the wound in the uterus and 
 the avoidance of sutures which are too tense. If the 
 condition of the patient admits of it, the serous coat should 
 also in addition be separately sutured. The preventive 
 treatment of ruptures of the uterus which occur during 
 parturition has already been described under " General 
 Remarks in Anomalies of the Pelvis." All that applies to 
 obstruction in delivery there is applicable also here. 
 When the obstruction which blocks the pelvic entry cannot 
 be removed, as in contracted pelvis, tumours, stenoses, 
 hydrocephalus, and oblique positions of the child, and the 
 pains are strong and increasing and the liquor amnii has 
 escaped prematurely, there is always the danger of lacera- 
 tion of the lower uterine segment. The treatment embraces : 
 
 1. The removal of the obstruction. This may be effected 
 by Walcher's " hanging posture," or by symphysiotomy ; 
 or if an ovarian cyst is the cause of the obstruction it may 
 be punctured ; a fibroid may be pushed upwards into the 
 abdomen or removed. The presentation of the foetus may 
 be improved, version may be performed, a hydrocephalic 
 head may be punctured, or the cervix may be dilated by 
 a hydrostatic dilator. 
 
 368 
 
PEOPHYLAXIS IN MIDWIFERY 
 
 2. Prevention of laceration by recognizing the approach.- 
 ing danger by the appearance of Bancll's contraction ring. 
 Whein this appears version must on no account be 
 attempted, and the patient must be cautioned against 
 straining. She should be anaesthetised and labour should 
 then be terminated at once by perforation, decapitation, 
 or Caesarian section. 
 
 3. Prevention of the serious consequences of laceration. 
 Most dangerous of all are the complete ruptures which at 
 the same time open into the vaginal vault and the trans- 
 verse ruptures of the body of the uterus, because in both 
 these cases germs which have got into the vagina by 
 explorations and by operations may pass direct into the 
 abdominal cavity. If far from a hospital it is best even 
 today in complete rupture of the uterus to deliver the 
 child through the natural passages, even when it has 
 passed through into the -abdominal cavity, and afterwards 
 to plug with iodoform gauze. Lacerations which bleed 
 much should be stitched up. When there is extensive 
 laceration and undermining of the broad ligaments the 
 uterus must be removed to prevent infection, for which the 
 necrosed tissues and the blood clots afford a favourable 
 soil in cavities of the connective tissue. 
 
 In these cases, as indeed in obstetric practice generally, 
 frequent examinations and futile operative procedures 
 should be avoided : if a laceration occurs after such inter- 
 ference the prognosis is certainly very much worse. 
 
 The prognosis is much better when the laceration, even 
 if complete, is caused by abrasion of the tissues, because 
 a circumscribed adhesive peritonitis will at once close it. 
 Genito-urinary fistulae are very fatal. Those occurrences 
 may be prevented in generally contracted pelves and in 
 the so-called " spinous pelvis," if the head is not permitted 
 to remain fixed and stationary for too long a time when 
 the pains are strong : the head should be carefully levered 
 with the forceps, which should not be put on while the 
 OS uteri is insufficiently dilated. 
 
 369 BB 
 
THE PEE\^NTION OF DISEASE 
 
 4. PEEVENTIVE TEEATMENT FOE LACEEATIONS OF THE 
 
 GENITAL CANAL— CEEVIX, VAGINA, PEEINEUM 
 
 The usual laceration of the os uteri heljDS delivery and 
 may almost be regarded as a physiological event, and 
 may even be imitated with advantage by making small 
 incisions. Deep lacerations of the cervix are mechanically 
 produced in most cases by the too early use of forceps. If 
 it is necessary to apply forceps early, the necessary space 
 should first be made by crucial incisions through the lips of 
 the OS uteri, avoiding the commissures of the lips. In this 
 way laceration is prevented, or if laceration should take 
 place its direction has been determined by the incision 
 and the uterine vessels wbich lie laterally will be avoided. 
 The lacerations must be carefully stitched up to prevent 
 loss of blood and infection. For stenosis, atresia and 
 cancer as causes of lacerations of the cervix, reference should 
 be made to those sections. 
 
 Lacerations of the vaginal vault are extremely serious, 
 because the connective tissue of the broad ligaments may 
 be extensively undermined even as far as the peritoneum 
 which may be torn. Some of these lacerations are the 
 result of mechanical violence ; others are caused, like the 
 ruptures of the lower uterine segment, by too great a 
 tension of the vaginal vault when the uterine contractions 
 are tonic in character or expend their force in an unfavour- 
 able direction, for example when the abdomen is pendulous or 
 when the patient is standing up and bending too far forward. 
 Others again are caused by primary rigidity and inelasticity 
 of the tissues. By careful watching uiany of the lacera- 
 tions may be prevented ; in some it is however impossible 
 to foresee and to prevent the laceration, and this applies 
 especially to exhausted women who have borne many 
 children. The symptoms of the laceration may not be at 
 all conspicuous at first, but when the laceration has 
 occurred delivery should be completed as soon as possible, 
 otherwise internal haemorrhage may follow. If the injury 
 is not very extensive the laceration should be stitched, 
 
 370 
 
PROPHYLAXIS IN MIDWIFERY 
 
 but if very severe the uterus will have to be removed, or 
 at least plugged with iodoform gauze. 
 
 Lacerations in the middle of the vagina are longitudinal, 
 generally the result of violence and brought about by the 
 too hasty introduction of forceps or too early raising of 
 the handles of the forceps. They should be at once sutured : 
 they often cause vesico-vaginal fistulae, but rarely recto- 
 vaginal fistulae. 
 
 Lacerations at the vulval orifice and of the perineum 
 may be produced by very rapid passage of the head, by 
 a large and hard head when the perineum is rigid and 
 inelastic, by passage of the occiput over the perineum in 
 brow and in face presentations, by wrong posture of the 
 patient at the moment of birth, such as sitting up. When 
 the child's shoulders are very broad laceration may be 
 caused by the passage of the posterior shoulder if the child's 
 head is allowed to fall backwards, or if traction ir. made. 
 It is also produced by raising the handles of the forceps 
 too quickly. Many lacerations are therefore avoidable. 
 Appropriate preventive treatment consists in protection 
 of the perineum, and occasionally lateral incisions in the 
 perineum may be required. The latter are only needed 
 when there is danger of laceration of the whole perineum 
 (complete laceration of the third degree), or when it is 
 desirable to hasten the birth of the child ; such incisions 
 heal less well than lacerations of moderate severity. In 
 suturing these deep incisions which are midway between 
 the anus and tuber ischii, it is very important to fit 
 accurately together the surfaces of the divided levator 
 ani muscles. 
 
 Protection of the perineum consists in relieving the 
 perineum from excessive tension ; the right thumb and 
 index finger placed outside the labia draw together the 
 tense skin, while the thenar eminence lies against the 
 perineum and presses the head forward towards the 
 symphysis and keeps it fixed there. During a pain 
 the head is held back by the left hand till the anterior 
 fontanelle is born. After this straining efforts should be 
 forbidden during a pain ; the patient should be urged to 
 
 371 
 
THE PREVENTION OE DISEASE 
 
 strain in the intervals between the pains, and the perineum 
 should be turned back at the same time so that the face 
 may be born. In delayed birth of the head it is useful to 
 express the head and protect the perineum by the Ritgen- 
 Pehling method, that is by manipulation from the sacrum 
 and perineum (posterior perineal method), or by the Smellie- 
 Ritgen method, that is by manipulation from the rectum. 
 The best posture for the patient at this moment is the 
 dorsal with the knees raised or the lateral position with the 
 knees drawn up. 
 
 The birth of the shoulders also requires care. The head 
 should first be lowered to allow the anterior shoulder to 
 appear, and be fixed behind the symphysis. Then, while 
 the perineum is protected, the posterior shoulder should be 
 guided over the perineum and pressed towards the sym- 
 physis, the head at the same time being raised. This pro- 
 cedure may be aided by grasping the axilla. "When the 
 shoulders are too large absolutely, division of a clavicle is 
 indicated to make it possible for the shoulders to fall to- 
 gether. 
 
 "When the head has been born by forceps as far as the large 
 fontanelle, it is best, especially in primiparae or when the 
 perineum is rigid, to remove the blades of the forceps while 
 the four fingers support the perineum and the thumb holds 
 back the head. Afterwards the head should be expressed. 
 
 When laceration of the perineum has occurred it should 
 at once be sutured to prevent both immediate and remote 
 sequelae. The latter have been described in the section on 
 Gynaecology , under " Prolapse " and " Plastic Perineal 
 Operations." The patient should be kept in bed rather 
 longer, because of the granulating tissues and the ease 
 with which the wound is apt to ulcerate and thus extend 
 further. The most dangerous lacerations are the complete 
 lacerations, because faeces may reach the vagina. The 
 parts should be sutured after the expulsion of the placenta, 
 otherwise primary union may fail, but not later than six 
 hours after delivery ; secondary suturing generally fails. 
 
 To suture a complete laceration the following method is 
 adopted. The entire surface of the wound up to the re- 
 
 372 
 
PROPHYLAXIS IN MIDWIFERY 
 
 motest angle in the vagina should be exposed. The wound 
 has the shape of a butterfly, the thinner middle part corre- 
 sponds to the deepest part of the laceration in the vagina, and 
 the two wings correspond with the lateral walls formed by the 
 rent in the larger mass of the perineal body. Commencing 
 at the deep angle of the rent in the vagina, catgut sutures 
 should be inserted to unite the rectal mucous membrane, in 
 such a way that the sutures may include sufficient connec- 
 tive tissue and the ends of the sutures come to lie in the 
 lumen of the rectum. The bowel should previously have been 
 thoroughly emptied by an enema and the rectum should 
 have been washed out. Then similarly the vaginal rent 
 should be sutured, the sutures passing deeply into the recto- 
 vaginal septum and being tied inside the vagina ; catgut 
 or silk or celluloid thread may be used. These sutures 
 should only reach to the place occupied by the former 
 frenulum perinaei, because the sutures of the perineum 
 itself must be entered in another direction, commencing 
 from the anus, in order that the correct form of the peri- 
 neum may be restored. These sutures may be of silver 
 wire, silkworm, or celluloid thread. The ligatures must lie 
 at right angles to the perineum and be entered therefore 
 perpendicularly to the surface of the perineum. Fine 
 superficial sutures may be added to remove any irregularity 
 or gaping of the edges of the wound and at the sphincter 
 ani and frenulum perinei. The weakest spot is at the deep 
 angle in the vagina where the recto-vaginal septum is 
 very thin. Here the sutures must be so placed that the 
 vaginal sutures do not touch the rectal sutures ; and they 
 must not be too tight, so as to avoid injury to and death of 
 the tissues. 
 
 The after treatment is most important, because the 
 chances of perfect union are reduced by the fact that the 
 patients in whom lacerations occur are generally those 
 who have little power of resistance. The strictest cleanli- 
 ness, a trustworthy trained nurse and obedience on the 
 part of the patient are further conditions required. As to 
 the nurse I would particularly emphasize this point, be- 
 cause it happened to me once, when the relatives preferred 
 
 373 
 
THE PREVENTION OF DISEASE 
 
 to choose their own nurse, that instead of giving the castor 
 oil prescribed, the nurse gave an oil enema either from 
 misunderstanding or because she thought it was better, 
 and in a few hours the patient, who before was doing very 
 well, suffered from endometritis which, in spite of all that 
 could be done, led to parametritis on both sides which 
 lasted for months : the nozzle of the sj^ringe had perforated 
 the sutured recto- vaginal septum. 
 
 It is best for this reason to make an easy passage for 
 flatus by inserting a drainage tube covered with iodoform 
 gauze or a Simon's urethral speculum. Evacuation of the 
 bowels should be prevented for five days by tincture of 
 opium ; and liquid diet should be given for a week. The 
 line of suture itself should not be touched, but lotion may 
 be frequently run over the surface, and it may be dusted 
 with airol or dermatol, or smeared with airol paste, which 
 melts at the temperature of the body. The vaginal sutures 
 should not be touched. 
 
 All this holds good, mutatis mutandis, for lacerations of 
 the perineum of the first and second degrees, which extend 
 at furthest only to the sphincter ani. It must be empha- 
 sized that often when the perineum seems intact externally 
 there may yet be a deep perineal laceration when a vaginal 
 laceration in the fossa navicularis has extended into the 
 perineal body. The results of these are similar to those 
 of laceration of the first and second degree, and the lacera- 
 tions should therefore be carefully sutured. 
 
 5. PEEYENTIVE TEEATMENT FOR DIFFICULTIES ARISING 
 FROM ANOMALIES OF POSITION AND OF FORM OF 
 THE GENITAL ORGANS 
 
 Difficulties arising from faulty development of the genital 
 organs may be the result of weakness of the muscular tissue, 
 such as lacerations, protracted labour, and post partum 
 haemorrhages, or they may be the result of the expulsive 
 contractions of the uterus acting in a wrong direction, 
 obliquely to the pelvic brim as in face presentations, obliquity 
 
 374 
 
PROPHYLAXIS IN MIDWIFERY 
 
 of the uterus, pelvic presentations and transverse pre- 
 sentations. Sometimes in uterus bicornis the second 
 and empty uterine cornu becomes incarcerated like a 
 tumour under the promontory : it should be early pushed 
 away from under the promontory or possibly be removed. 
 These difficulties may when they first appear be removed 
 by correct postural treatment or by some obstetric proce- 
 dure, after dilating with a hydrostatic dilator, and the 
 threatened dangers may thus be prevented. 
 
 The troubles arising from anteflexion and lateral flexion 
 of the uterus are generally those of laxity of the abdom- 
 inal walls and lead to faulty presentation when the advan- 
 cing part enters the pelvic brim, as in obliquity of the 
 head, face and brow presentations and transverse pre- 
 sentations. They produce also lateral flexion of the trunk 
 of the child. 
 
 Preventive treatment consists in keeping the uterus in 
 position by a binder, in placing the patient on the corres- 
 ponding side so that the presenting part may be brought over 
 the inlet of the pelvis, in supporting the uterus by cushions, 
 in pressing the occiput into the pelvic brim, in internal 
 manual correction of an unfavourable presentation and 
 version. By these measures the head may be made to 
 enter the brim and become fixed or a foot presentation 
 may be obtained. 
 
 With retroflexion when birth is at term we need to 
 consider only the partial bulging or pouches produced, the 
 remainder of the body of the uterus is generally anteflexed. 
 Many causes may lead to this : for example adhesions after 
 parametritis, adhesions after hysteropexies making it im- 
 possible for the anterior uterine wall to expand in preg- 
 nancy. Other causes are subserous fibroids and ovarian 
 cysts, or the foetal head may remain below the promontory 
 in incarceration of the gravid retroflexed uterus after the 
 trunk of the child has risen out of the pelvis, and lastly 
 with pendulous abdomen it may be caused by the faulty 
 direction in which the uterine forces act. 
 
 The head is thereby pushed aside from its normal median 
 position over the pelvic brim, and is pressed into the dis- 
 
 376 
 
THE PEEVENTION OF DISEASE 
 
 tended lower uterine segment. Laceration may occur or 
 delivery may become impossible. 
 
 The object of preventive treatment first of all should be 
 to remove the primary cause, and when this is impossible 
 we must endeavour to correct the abnormal position of the 
 head. For the latter it generally becomes necessary to 
 bring the whole cervical canal into the axis of the pelvis : 
 this can be accomplished by a hydrostatic dilator, which at 
 the same time serves to dilate the cervix. If this fails an 
 incision must be made through the anterior wall of the 
 cervix. The same treatment must be followed if rupture 
 of the uterus threatens. If a tumour is present and at- 
 tempts to push it out of the pelvis have failed, we should 
 wait to see what effect the labour pains will have. A cyst 
 should be punctured or incised from the vagina. 
 
 Many obstructions situated in the genital canal may be 
 removed during pregnancy or shortly before delivery or 
 during labour itself. Among these are stenoses and septa 
 of the vagina which may be congenital or acquired. 
 Cicatrices of the cervix occurring after extensive opera- 
 tions and obliteration of the external os in primiparae may 
 also be dealt with. Cystocele due to prolapse of the vagina, 
 perhaps complicated by the j)resence of a vesical calculus 
 in the cystocele, and lastly subcutaneous haomatomata and 
 other vaginal tumours may also need treatment. 
 
 Simple septa and stenoses of the vagina should be divided 
 and bleeding points ligatured, or they may be forcibly 
 stretched or incised. If a considerable degree of atresia 
 exists a new vaginal passage may be made, by several 
 operations, but it will later again become constricted. It 
 would however be difficult to deliver a living child through 
 the passage, and in some cases Caesarian section is unavoid- 
 able. To prevent haemorrhage when there is a haematoma, 
 especially in twin pregnancies, the child must be quickly 
 extracted, the haematoma incised, the bleeding points 
 ligatured and the cavity plugged. 
 
 376 
 
PROPHYLAXIS IN MIDWIFERY 
 
 6. PREVENTIVE TREATMENT FOR DIFFICULTIES ARISING 
 FROM TUMOURS OF THE GENITAL ORGANS 
 
 The measures to be taken against complications during 
 pregnancy and at the onset of premature labour have 
 already been described above ; there are other measures 
 which have reference to delivery at term. 
 
 The consequences resulting from large intramural and 
 from cervical myomata are similar to those which follow 
 contracted pelves. The j^reventive treatment at the onset 
 of labour at term is the same as that for contracted 
 pelvis, the various degrees of contraction have the same 
 relative effect, and prolapse of the umbilical cord or of the 
 extremities is apt to occur. 
 
 Submucous myomata of the cervix often become enucle- 
 ated and expelled. Preventive treatment should aim at 
 assisting this natural process, and at preventing infection 
 of the site of the tumour. 
 
 Subserous fibroids situated higher up are often raised out 
 of the pelvis by the labour pains, though all attempts to 
 push them up had failed. But if this does not occur and 
 the tumour cannot be removed then Caesarian section be- 
 comes necessary and should be followed by removal or total 
 extirpation to prevent the sepsis which is so apt to occur. 
 
 Even after spontaneous delivery it is often advisable to 
 carry out this radical operative procedure, because the 
 bruised tumour so readily leads to severe post partum 
 haemorrhage, to retention of the placenta, or to suppura- 
 tion. 
 
 Through the lack of room in the pelvis faulty attach- 
 ment of the ovum often exists as a complication, producing 
 placenta praevia or extra-uterine gestation, and these must 
 also be considered in treating the case. 
 
 Among ovarian tumours the most dangerous are the 
 fibrous tumours when they become wedged in under the 
 promontory ; but in all ovarian tumours there are the 
 dangers of septic infection after bruising of the tumour, or 
 avulsion of the tumour, or twisting of the pedicle when 
 the tumour is pulled up into the abdominal cavity. Accord- 
 
 377 
 
THE PREVENTION OF DISEASE 
 
 ing to the degree of narrowing of the pelvis lacerations of 
 tlie uterus or vagina may also occur. 
 
 These dangers can be prevented either by pushing the 
 tumour out of the pelvis, or by reducing it in size, or by 
 removing it, or finally by Caesarian section and subsequent 
 removal of the tumour. 
 
 When the cervix is infiltrated by carcinomatous growth 
 laceration is apt to occur, because the vaginal part cannot 
 be dilated. If it is impossible to make a passage by 
 deep incisions or by an incision through the anterior wall 
 of the cervix, the only alternative which remains is 
 Caesarian section and subsequent removal of the body of 
 the uterus from above and of the cervix from the vagina in 
 order to avoid peritonitis, 
 
 7. PREVENTIVE TREATMENT FOR DIFFICULTIES IN 
 LABOUR CAUSED BY ABNORMAL PRESENTATIONS 
 AND POSTURES OF THE CHILD. 
 
 In each case we must determine exactly whether the 
 faulty position of the child is a primary condition or, as is 
 more common, a secondary condition. "We shall then be 
 able to select the method to remove the obstruction, and 
 the method for secondary forms is often very di£ferent from 
 that required to remove the primary anomalies of position. 
 
 (a) Preventive treatment of complications in normal pre- 
 sentations. 
 
 In occipito-anterior presentations there will, under 
 favourable circumstances, be only two conditions which 
 may arise and require treatment. The head may be low 
 and yet advance slowly : the cause of this may be that the 
 cord is twisted several times round the neck and thus may 
 endanger the child's life. This condition would be probably 
 present if the heart sounds are persistently below 100 or over 
 160, if there is umbilical souffle, the uterus painful, and the 
 head does not press upon the examining finger or upon the 
 perineum though the labour j)ains are strong; the head 
 is also prevented from rotating forwards, and sometimes 
 the cord may be felt round the neck by a finger in the 
 rectum covered with an indiarubber finger stall. For such 
 a case immediate extraction by forceps is indicated. 
 
 378 
 
PROPHYLAXIS IN MIDWIFERY 
 
 Further, the perineum may require to be protected during 
 the passage through the vulval orifice. It should be borne 
 in mind too that in the second vertex presentation the head 
 may very readily become transverse, or may become an 
 occipito-posterior presentation by rotation of the occiput 
 backwards. This backward rotation may be prevented by 
 placing the patient on her right side or by bringing the occi- 
 put to the front by means of the right blade of the forceps. 
 
 Occipito-posterior presentations are favourable when the 
 chin is close to the chest, but the perineum is endangered 
 by the passage over it of the occiput. 
 
 This is the case also, and even to a greater degree, in 
 face presentations with the chin to the front. If there is 
 great pelvic contraction, or the child is very large and the 
 skull hard, the risk of bruising of the maternal soft parts 
 and the formation of urogenital fistulae is great. There 
 is danger too for the child through the excessive stretching 
 of the cervical spinal column and spinal cord, and also from 
 cerebral apoplexy as the result of pressure on the jugular 
 veins. 
 
 The best treatment is to convert it into an occipito- 
 anterior presentation while the head is still movable, or 
 later by timely extraction with forceps when, in spite of 
 strong labour pains, no progress is noted. When examining 
 care must be taken not to injure an eye. 
 
 Among the causes which lead to face presentations are 
 pendulous abdomen and contracted pelvis, and to prevent a 
 presentation from becoming a face presentation the uterus 
 should be held back by a binder, the patient should be 
 placed on her side (the side corresponding with the child's 
 occiput), and the uterus should be supported and the occiput 
 pressed into the pelvic brim. If the tendency of the head 
 to take up an abnormal position persists version should be 
 performed as a preventive measure. 
 
 Pelvic presentations are often dangerous for the child, 
 because after the birth of the breech attempts at respiration 
 are made by the unborn head directly the cord becomes 
 pressed upon, and prolapse of the cord is apt to occur. This 
 sign and enfeeblement of the heart sounds after a pain are 
 
 379 
 
THE PREVElvTION OF DISEASE 
 
 indications for extraction of the child, and the further pre- 
 cautionary measures already described under " Extraction " 
 must be adopted. 
 
 "When we remember the causes which produce pelvic 
 presentations it becomes evident that interference to alter 
 the presentation is not required. "When the child is small 
 and premature a pelvic presentation adds no danger to 
 delivery ; so too when the foetus is malformed or macerated. 
 In twin pregnancies one child has very often a pelvic 
 presentation : here too interference is not required ; on the 
 contrary it may be necessary to perform podalic version 
 with the second child. And when a uterus, through laxity 
 of its walls or through over-distension, tends to cause a 
 pelvic presentation, here too this presentation is best, 
 because when the head is the advancing part it is apt to be 
 forced into a recess in the lax lower uterine segment, so 
 that the cervix does not become dilated, and podalic version 
 would eventually become necessary. And even when the 
 breech j)i'esents it may become necessary to bring down a 
 foot for the same reason, or because the breech does not 
 enter a contracted pelvis. It may also be required when 
 there is prolapse of the cord or placenta praevia and the 
 breech is still movable, in order to save the child and not 
 expose the mother to further dangers. 
 
 (h) Preventive treatment for cases icJiere patTiological forms 
 of pelvis or other typical causes have produced loresentations 
 which are favourable in those forms of pelvis or not unfavour- 
 aUe. 
 
 When describing the prophylactic measures required for 
 contracted pelves it was stated that obliquity in vertex 
 presentations was favourable in a flattened pelvis, and that 
 excessive descent of the occiput was desirable in generally 
 contracted and certain oblique pelves. Such presentations 
 I include in this group. 
 
 When the sagittal suture enters in the oblique diameter, 
 or even in the conjugate of the brim, nothing should be 
 done to change the position, especially when the cause of it 
 is a generally contracted or a lumbo-sacral kyphotic pelvis. 
 Under ordinary circumstances the head will turn into the 
 
 380 
 
PROPHYLAXIS IN MIDWIFERY 
 
 transverse diameter at the brim if the pains are strong and 
 the patient lies on the side towards which the occiput ought 
 to turn. 
 
 Presentation of the anterior parietal bone or Naegele's 
 obliquity is the most favourable presentation in flattened 
 pelves, and it should not be interfered with unless the 
 deviation is extreme and the sagittal suture remains 
 stationary, and there is a tendency towards an ear presenta- 
 tion, or unless some other serious symptom appears, such as 
 distension of the lower uterine segment. If the coexisting 
 lateral flexion of the child's body is too great because of a 
 penduloiis abdomen, the uterus should be supported and 
 held up by the various methods already described. Naegele's 
 obliquity, which often occurs at the onset of labour under 
 normal conditions, is of no significance. 
 
 Presentation of the posterior parietal bone, or Litzmann's 
 obliquity, is mu.ch less favourable than the former, and 
 when there is much pelvic contraction leads to very great 
 difficulties. The case should be very carefully watched, 
 and interference will be required according to the table 
 drawn up for general preventive treatment in abnor- 
 malities of the pelvis. Two additional points have to be 
 considered : which kind of pelvis is present ? and does the 
 occiput or the forehead descend most under the influence of 
 the pains ? The latter is the less favourable presentation, 
 and becomes the worse according to the degree of general 
 contraction of the pelvis which is combined with the flat- 
 tened pelvis. On the other hand a combination of presenta- 
 tion of the occipital bone and of the posterior parietal bone 
 affords relatively the best prognosis for generally-contracted 
 pelves, and should therefore be encouraged as a preventive 
 measure by suitable posture of the patient and by pressing 
 the occiput into the pelvic brim. 
 
 Descent of the large fontanelle in occipital presentations 
 and in obliquities of the head is favourable in flattened 
 pelves and unfavourable in generally-contracted pelves. In 
 the latter the presentation should be corrected by internal 
 and external manipulation and by placing the patient on 
 the side corresponding to the occiput. 
 
 381 
 
THE PREVENTION OF DISEASE 
 
 Presentation of the occiput, or Roederer's obliquity, is 
 favourable for a generally-contracted pelvis and for a flat- 
 tened generally-contracted pelvis when combined with 
 Litzmann's obliquity. If the contraction is great impaction 
 readily occurs. For this see " Generally-contracted Pelves," 
 
 A transverse position of the head low down in the pelvis 
 is not seldom the consequence of obliquities, as it occurs in 
 fronto-anterior presentations, where rotation forwards of 
 the occiput commences in the interspinous line but is not 
 completed, and in prolapse of the anterior arm, in inefEcient 
 labour pains with fronto-anterior presentations, in funnel 
 shaped pelves and when the pelvis is too wide or the head 
 too small. 
 
 If then the presenting part of the vertex is already near 
 the interspinous line and there is no rotation forwards of 
 the occiput we must prevent the head from remaining in 
 this transverse position, because spontaneous delivery 
 would be very difficult. According to the cause we must 
 either place the patient on the side corresponding with the 
 occiput (more rarely on the side corresponding with the 
 forehead, when the presentation was originally fronto- 
 anterior), or else rotate forwards the small fontanelle (or in 
 certain cases the large fontanelle) by hand or by the 
 posterior blade of the forceps. In " spontaneous evolution " 
 and in delivering '' conduplicato corpore " of small embryos 
 in transverse presentations, we merely assist this process of 
 delivery, because immature and macerated embryos can be 
 delivered spontaneously in this way. Traction on the 
 advancing limb will help. 
 
 (c) Preventive treatment for positions and presentations 
 which in themselves produce difficulties. 
 
 Fronto-anterior presentations with descent of the fore- 
 head and extension of the head occurs when the resistance 
 is abnormal. To prevent descent of the forehead the 
 patient should be placed on her side, the side corresponding 
 with the foetal occiput, and an attempt may be made to hold 
 back the forehead by internal manipulation. If this fail 
 and the brow becomes fixed on the horizontal ramus of the 
 pubis, the head should be extracted with forceps, in order 
 
 382 
 
PROPHYLAXIS IN MIDWIFERY 
 
 to prevent further danger to mother and child. This is in 
 reality a preventive measure, seeing that the brow must 
 first be pushed up from its fixed position on the pelvic ramus 
 and rotated into the transverse diameter and afterwards 
 extracted. If the child is dead it is better for the mother's 
 sake to perforate and extract with craniotomy forceps. 
 
 Brow and face presentations are aetiologically closely 
 related ; in the former the prognosis is generally bad ; in 
 the latter, when the chin remains posterior, the prognosis 
 is invariably bad. It is therefore urgent that these 
 presentations should be prevented or should be converted 
 into more favourable ones. These unfavourable presenta- 
 tions may be produced by abnormal resistance and by 
 functional abnormalities. On the part of the mother they 
 may arise from the pelvis, from the soft parts, or from the 
 nature of the labour pains, and from incorrect posture or 
 restlessness. On the side of the embryo, they may arise 
 from too great or too little rigidity, from faulty position 
 through prolapse of an arm, from twins, from hydramnios, 
 or from placenta praevia. A short umbilical cord twisted 
 round the neck, or incorrect operative interference, such 
 as traction with forceps in the wrong direction, may also 
 give rise to them. 
 
 All the above named causes must be met and treated 
 according to the rules already given. "When the brow 
 or face begins to come down, or when these presentations 
 already exist and the head is still movable, they should 
 be converted into occipital presentations bimanually by 
 the combined action of external and internal manipulations. 
 Should this method fail, or if we anticipate danger either 
 immediately or later from a vertex presentation, podalic 
 version should be performed as a prophylactic measure. 
 But even when the head is already low in the pelvic, brow 
 presentations and mento-posterior face presentations can 
 still be manually converted into mento - anterior face 
 presentations. These are however more difficult to correct 
 than when the head is movable, and if the attempt is not 
 successful we have then only to consider the safety of the 
 mother. No attempt should generally be made with forceps, 
 
 383 
 
THE PEEVENTION OE DISEASE 
 
 because tlie mother is thereby exposed to serious injuries, 
 and the child too — and a successful issue is more than 
 doubtful from the very beginning. 
 
 Presentations of the anterior or posterior ear are unfavour- 
 able extreme results of presentations of the anterior or 
 posterior parietal bones, and what was said under the 
 latter applies still more here. 
 
 In pelvic presentations, the unfavourable are presentation 
 of the foot, lateral lodgment of the breech, a catching of 
 the after-coming head on the symphysis by the brow or 
 chin, and fixation of the anterior arm [in the nape of the 
 neck behind the occiput. 
 
 "When the breech has become lodged in the iliac fossa, 
 and when there is incomplete presentation of the posterior 
 foot, the anterior leg should be brought down. It should 
 be borne in mind that the os uteri is incompletely dilated 
 in foot presentations, and incision of the os may be 
 needed. Above all, it is best to wait as long as possible 
 before extracting, unless examination of the heart-sounds 
 shows it to be necessary. 
 
 When abnormal rotation of the after-coming head has 
 been diagnosed — that is when the occiput is posterior — and 
 the breech is still movable, it is possible at once to act so 
 as to prevent difficulties which would later arise. Thus, 
 if in spite of good labour pains and dilatation of the os 
 uteri rotation has not taken place, the anterior foot should 
 be brought down. If the breech is fixed and high, a loop 
 should be passed round the groin of the anterior thigh, and 
 traction be made in a direction from the side towards the 
 front. Should the breech be fixed but already low in the 
 pelvis, rotation of the trunk is effected by the index finger 
 in the groin with the help of the thumb and middle finger, 
 while with the other hand upon the abdomen the head is 
 brought into the transverse diameter and then is pressed 
 through the brim of the pelvis by pressing on the forehead. 
 If the head is already in the pelvis, it can be brought into 
 the transverse diameter by the finger in the mouth and the 
 occiput be rotated forwards. When this fails, with dead 
 children, a blunt hook can be inserted in the canine fossa to 
 
 384 
 
PROPHYLAXIS IN MIDWIFERY 
 
 make traction. Then the finger being placed in the mouth 
 and the shoulders grasped from behind, the occiput is guided 
 over the perineum while the face is fixed against the pubic 
 symphysis. 
 
 Extension of the arms, which makes it possible for 
 the anterior arm to become fixed behind the head, can 
 be avoided by extracting the child slowly and only 
 during a pain ; or the labour pains may be replaced by the 
 strong pressure of two hands upon the fundus uteri. 
 
 The preventive treatment for oblique and transverse 
 presentations (shoulder presentations) depends largely upon 
 the causes which have produced them, and which may in 
 brief be summed up as abnormally increased or diminished 
 resistances during childbirth. 
 
 There may have been faulty posture or sudden violent 
 movements on the part of the mother. The pelvic inlet 
 may have been contracted. The uterus may have been 
 too broad or its walls too lax, especially in multiparae, or 
 the uterus may have been abnormal in shape or in position, 
 as in anteflexion. The labour pains may have been 
 anomalous. The ovum may have been in fault, as in 
 placenta praevia, hydramnios, or premature rupture of the 
 membranes. The child may have been too large or too 
 small or hydrocephalic, or twins may have been present. 
 
 Many of these primary causes may be removed or 
 rendered harmless during pregnancy and during labour 
 by the methods already described. 
 
 If at the onset of labour an oblique position has been 
 diagnosed, it is generally possible to restore the vertical 
 position when the pains become stronger, if other circum- 
 stances are favourable. The patient should be placed in 
 the lateral position, on the side towards which the child's 
 head tends, and in this way we can help to convert it into 
 a vertex presentation. 
 
 The oblique presentation may be corrected by external 
 manipulation when the presenting part (shoulder) is not 
 already fixed in the pelvis and the membranes are still 
 intact ; it may be done even when the os uteri is almost 
 completely dilated. 
 
 386 c 
 
THE PREVENTION OF DISEASE 
 
 When combined internal version is required, though only- 
 two or three fingers are employed in Braxton Hicks' method, 
 it is preferable as a prophylactic measure to perform podalic 
 rather than cephalic version, even in those cases where 
 podalic version is not indicated so far as the primary cause 
 of the oblique position is concerned. 
 
 When " spontaneous version " has taken place in the pelvis, 
 or " spontaneous evolution " or " spontaneous expulsion," in 
 the former two, the prognosis is good for the child in only 
 one-seventh of all cases, and is doubtful as regards the mother ; 
 but in spontaneous expulsion the prognosis is bad for the 
 child, and very serious as regards the mother. These cases 
 may become " neglected transverse presentations," and 
 the many serious consequences resulting from the protracted 
 labour and the treatment of these has already been described 
 under " Rupture of the Uterus " and " The General Treat- 
 ment of Anomalies of the Pelvis." The primary condition 
 for success is to keep the membranes intact as long as 
 possible, and to retain the liquor amnii. Premature 
 separation of the placenta is one of the dangers. 
 
 8. PEEVENTIVE TEEATMENT FOE DIFFICULTIES IN 
 LABOUE CAUSED BY THE FOETUS 
 
 (a) Twin pregnancies and multiple pregnancies. 
 
 Pelvic presentations, oblique presentations, and the more 
 unfavourable presentations are far more frequent in twin 
 and in multiple pregnancies than in single pregnancies. 
 Sometimes the second placenta is separated before the birth 
 of the second child, and very rapid extraction can alone 
 save the second child from asphyxia. 
 
 As a result of over-distension and atony of the uterus, 
 post-partum haemorrhage is to be feared ; ergot should be 
 given as a preventive measure shortly before the expulsion 
 of the second child, and the uterus must be carefully 
 watched. The placental end of the umbilical cord of the 
 firstborn child should always be ligatured to prevent loss 
 of blood by the second child through placental anastomoses. 
 
 386 
 
PROPHYLAXIS IN MIDWIFERY 
 
 (b) Malformations. 
 
 Difficulties seldom arise because a foetus is premature or 
 poorly developed. Difficulties, even rupture of the uterus, 
 may arise most frequently from hydroceplialus and from 
 distension of the abdomen of the foetus by hydronephrosis 
 or ascites. These are often combined with hydramnios. 
 Pelvic presentations are very common. In a fourth of all 
 cases spontaneous delivery occurs by the hydrocephalic head 
 being squeezed through with a vertex presentation. This 
 should be promoted, and puncture of the vertex is most 
 rational. For the same reason, diminution in size of the 
 abdomen of a foetus which in any case cannot live, can be 
 effected by means of Sie hold's scissors. 
 
 The results of the delivery of excessively large foetuses, 
 or those with much ossified skulls or abnormally broad 
 shoulders are very serious. One should not wait too long. 
 To deliver the shoulders, division of one clavicle is recom- 
 mended. 
 
 9. PREVENTIVE TREATMENT FOR DIFFICULTIES ARISING- 
 FROM THE UMBILICAL CORD OR MEMBRANES 
 
 Prolapse of the cord greatly endangers the life of the 
 child, and attempts should be made to replace it even when 
 the OS uteri is insufficiently dilated. It is safest to perform 
 podalic version either immediately, according to Braxton 
 Hicks' method, or after complete dilatation of the os uteri 
 by a hydrostatic dilator which serves to dilate the os and 
 at the same time to hold back the umbilical cord. Under 
 " Preventive Treatment in Occipital Presentations " I have 
 already referred to twisting of the cord round the neck. 
 
 Intra-uterine placental haemorrhage may be caused by 
 many conditions. Placenta praevia or insertio velamentosa 
 may give rise to it, or it may result from premature separa- 
 tion of the placenta or its partial adhesion, by its retention, 
 or by atony of the site from which it has come. 
 
 In insertio velamentosa we must guard against injuring 
 any vessel on the membrane when the membranes are 
 artificially ruptured, and we must in most cases attempt to 
 
 387 
 
THE PREVENTION OF DISEASE 
 
 keep the bag of membranes entire till the os uteri is com- 
 pletely dilated, and then immediately proceed with the 
 extraction of the foetus. 
 
 Premature separation of the placenta may arise from 
 nephritis, eclampsia, infective diseases, from all causes which 
 produce abortion, from trauma, too long delayed rupture of 
 tough membranes, and from excessive labour pains. These are 
 for the most part causes which can be successfully removed 
 if diagnosed in time. If the placenta has become pre- 
 maturely detached, the mother runs great danger from 
 haemorrhage and the child's life is certainly lost. For 
 these reasons delivery should be immediately brought 
 about. 
 
 Post-partum haemorrhage through atony of the uterus 
 may be the consequence of inflammatory processes, of 
 which the fibrous adhesion of the placenta is a sign, or it 
 may be the result of disturbances in innervation, especially 
 after an exhausting labour, or over-distension in pregnancy, 
 or after precipitate labour. In multiple myomata of the 
 uterus it is impossible for the uterine wall to contract 
 evenly. 
 
 In the last two groups the atony is known to exist, and 
 ergot should be given as a preventive measure shortly 
 before the expulsion of the child's head. The placenta 
 should then not be expressed too early, unless there is some 
 special indication for it, but we should rather wait for a 
 few hours. When expressing the placenta by Crede's 
 method the fundus uteri must be firmly contracted, other- 
 wise inversion of the uterus is apt to occur, as it would if 
 the cord were pulled upon. If after expulsion of the 
 placenta the uterus disappears from beneath the fingers 
 and kneading of the soft walls of the uterus does not 
 restore it, the uterus must be massaged bimanually ; or 
 lastly, the vaginal portion of the cervix must be drawn 
 down to the vulva by vulsellum forceps. 
 
 When part of the placenta is retained or the placenta is 
 adherent by one edge, it must be removed by hand to 
 prevent haemorrhage, decomposition and sepsis. The 
 strictest asepsis and the greatest care must be observed lest 
 
 388 
 
PROPHYLAXIS IN MIDWIFERY 
 
 a fatal injury or infection should be caused. The uterus 
 must be firm, so that the remains of the placenta can be 
 distinguished from the uterine wall. After the operation 
 ergot should be administered and the uterus should be 
 irrigated with a hot antiseptic solution such as a 1 or 2 per 
 cent, solution of lysol, but corrosive sublimate must not be 
 used. In every case of post-partum haemorrhage the 
 possibility of lacerations of the cervix or vagina should be 
 borne in mind, should be looked for through a speculum, 
 and be sutured. 
 
 10. PREVENTIVE TREATMENT FOR ANOMALIES IN 
 THE LABOUR PAINS 
 
 "We have already repeatedly emphasized the importance 
 of regulating the labour pains as a preventive measure. 
 Excessive labour pains lead to precipitate birth when the 
 resistance offered by the maternal parts is slight, as in 
 multiparae. Heredity or too short an umbilical cord may 
 also play a part in bringing about precipitate labour. 
 Prophylactic treatment will prevent harm occurring. The 
 patient should early assume the recumbent posture, lying 
 on her side, and should not make any bearing down efforts. 
 The perineum must be supported early. 
 
 Labour pains which are progressively stronger and 
 stronger and yet cannot overcome the obstruction lead to 
 tumultuous pains, and finally to tetanic contraction of the 
 uterus. These pains cause no advance of the foetus, but 
 seriously predispose the uterus to rupture. Further, they 
 give rise to premature separation of the placenta and to 
 danger of death of the mother from haemorrhage ; and 
 lastly, this, combined with the interruption of the placental 
 circulation by the long continued uterine contractions, may 
 cause death of the child. Unsuitable and therefore unsuc- 
 cessful attempts at delivery and the administration of large 
 doses of ergot during the first stage must be altogether 
 avoided. 
 
 An anaesthetic should be given to moderate the labour 
 pains, and delivery should be completed under anaesthesia, 
 generally by reducing the size of the foetus. It should be 
 
 389 
 
THE PREVENTION OE DISEASE 
 
 remembered that prolonged narcosis is injurious, as it 
 increases the danger of infection in women who are already 
 exhausted, and often does not remove the spasm of the 
 uterus. Version is always contra-indicated in such cases of 
 neglected transverse presentations. 
 
 Spasmodic strictures of the uterus are rare in labour. 
 Cases which are often regarded as such represent local 
 uterine contractions which do not effectively dilate the 
 cervix. Spasmodic strictures may however be observed in 
 the third stage of labour, and lead to retention of the 
 placenta and haemorrhage ; one edge of the placenta is 
 found to be presenting at the os uteri. Preventive treat- 
 ment consists in great caution in the use of ergot ; some- 
 times indeed it regulates the labour pains and brings about 
 a separation of the rest of the placenta, but it may also 
 increase the spasm by which the placenta has become 
 constricted. Great caution must be observed also with 
 narcotics, because of post partum haemorrhage. Premature 
 attempts at expression of the placenta after the expulsion 
 of the child readily call forth such conditions ; no advantage 
 is ever gained by such haste. If there is no haemorrhage 
 we may wait for hours, or even half a day, applying hot 
 compresses, promoting diaphoresis, and endeavouring to 
 procure sleep for the patient, who should of course be 
 watched. The placenta may then be expressed by Crede's 
 method, or if this fails must be extracted by hand. 
 
 Partial spasmodic labour pains occur frequently in nervous 
 chlorotic patients. They are ineffectual because they do 
 not perfectly direct the long axis of the child towards the 
 internal os uteri, because they drive the head into a recess 
 of the lower uterine segment when the latter is lax, and 
 because later their painfulness prevents the proper use 
 of bearing down efforts. The primary causes may be 
 chronic inflammations or disturbances in innervation ; or 
 when there is hyperaesthesia of the vaginal vault or of the 
 cervix, they may be caused by digital examination. In 
 such j)atients an internal examination should therefore 
 be made only when there is urgent necessity for it. 
 
 The labour pains should be regulated and their effects 
 
 390 
 
PROPHYLAXIS IN MIDWIFERY 
 
 controlled by narcotics, or by baths, hot compresses, or a 
 mustard leaf. 
 
 The author regards the promoting of diaphoresis as 
 an excellent method of regulating the pains. If it does 
 not succeed podalic version may be required when, after 
 dilatation by a hydrostatic dilator, the head does not 
 present. 
 
 True weakness of the labour pains, which is not 
 produced by tetanic uterine spasm, is seldom met with. It 
 may be produced by many different causes, which should 
 be known in order that they may be successfully over- 
 come by preventive treatment. The danger begins with 
 the early rupture of the membranes, which allows the 
 uterine cavity to become invaded by cocci, and causes death 
 of the child through the prolonged labour. This however 
 is true only for certain forms of weakness of the labour 
 pains, which may be grouped together as secondary causes. 
 The primary causes are the previous over-distension of the 
 uterus by hydramnios and twins, the exhaustion of the 
 uterus by a protracted labour or haemorrhage, chronic 
 inflammations, adhesions of the uterus to other structures, 
 and faulty inclination of the uterus. Indirect weakness 
 of labour pains is produced by inefHcient action of the 
 abdominal muscles, by an overfilled bladder or rectum, and 
 by pelvic inflammations. 
 
 The knowledge of the causes enables us to remove or to 
 reduce them to some extent; or if they are already acting^ 
 it leads us to shorten the labour as far as possible, and to 
 take all due care, especially in the third stage of labour 
 which should not be too actively treated. Ergot may 
 sometimes be given as a preventive. Primary weakness of 
 the labour pains may be due to general bodily weakness, or 
 to weakness of the uterine walls when the uterus is ill 
 developed or contains tumours. It occurs also from a want 
 of contractility in older patients, which results from sub- 
 involution. This weakness of the labour pains may be 
 prevented by rest, by keeping the membranes unruptured 
 as long as possible, and by rupturing them after the os uteri 
 is completely dilated. The labour pains should be stimu- 
 
 391 
 
THE PREVENTION OF DISEASE 
 
 lated by warm baths or by bot vaginal doucbes, at a 
 
 temperature of 108° to 117° F. every one or two hours, 
 
 using each time one or two gallons of sterilized "8 per 
 
 cent, saline solution, or a quarter per cent, solution of lysol. 
 
 The fluid must be injected under a very low pressure. Hot 
 
 compresses over the fundus of the uterus may also be 
 
 employed, diaphoresis should be promoted, and stimulants, 
 
 especially broth and tea, are useful. Narcotics must not be 
 
 used till towards the end of the second stage of labour. 
 
 Do not forget to empty the urinary bladder and rectum. 
 
 If the uterus is over-distended rupture the membranes. 
 
 In other cases hydrostatic dilators of the cervix and vagina 
 
 may be employed. The various methods of expression and 
 
 of extraction may have to be considered, and should be 
 
 selected strictly in accordance with the indications. They 
 
 should be slowly carried out in conjunction with the labour 
 
 pains, and the simplest methods should be first tried. The 
 
 third stage of labour must be treated in the way already 
 
 described. A very rare consequence of relaxation of the 
 
 cervix is acute inversion of the uterus, already referred to 
 
 in the G-ynaecological section. Therefore, pulling on the 
 
 umbilical cord and expression of the placenta when the 
 
 uterus is not firmly contracted, are strictly contra-indicated. 
 
 11. PEEVENTIVE TEEATMENT FOE DIFFICULTIES AEISINQ 
 FEOM DISEASE OF OTHEE OEQANS 
 
 The most important of these are disease of the heart, 
 disease of the lungs, such as pneumonia, influenza, and 
 especially tuberculosis, chronic nephritis (with eclampsia) and 
 erysipelas, which readily leads on to puerperal fever. When 
 cardiac lesions are present, the heart action is injuriously 
 affected by labour and by the circulatory changes accom- 
 panying it, especially in the abdominal region. This can 
 be prevented by securing cardiac compensation during 
 pregnancy. The membranes should be ruptured early, 
 injections and inhalations of ether should be given during 
 and after parturition, sand bags should be placed on the 
 abdomen after delivery, and delivery may even be 
 accelerated by a hydrostatic dilator and extraction, which 
 
 392 
 
PROPHYLAXIS IN MIDWIFERY 
 
 should be very slowly performed. Some liaemorrliage 
 post partum is not altogether unfavourable. Ergot is 
 injurious. Oedema of the lungs readily sets in, both in 
 pulmonary and in cardiac disease. "With tuberculosis there 
 is a rapid loss of strength by progress of the disease, and 
 this is aggravated by severe haemorrhage. The latter 
 should be prevented, and symptoms treated. 
 
 The preventive treatment of eclampsia has already been 
 given. When the pulse is bad, narcotics, and especially 
 chloroform, should be avoided as much as possible. 
 
 12. PREVENTIVE TREA.TMENT IN OBSTETRIC PRO- 
 CEDURES 
 
 General prophylactic measures against puerperal infec- 
 tion are assumed to be known in every detail to the 
 obstetric practitioner. There must be no contact with any 
 septic person or thing. There must be the most minute 
 mechanical and chemical purity, and for this purpose 
 Mikulicz recommends the spiritus saponatus of the German 
 Pharmacopoeia. No vaginal examinations, or as few as 
 possible, should be made. No operative interferences should 
 be undertaken except according to the indications. These 
 are the principles. Antiseptics, at the head of which are 
 cresol and lysol, must be very sparingly used in the genital 
 canal. In private practice we need not as a routine 
 principle carry out a vaginal antisepsis, nor yet under all 
 circumstances refrain from using it. If required, as before 
 and after operative interference, or versions, or when one 
 is doubtful of the aseptic conditions of previous examina- 
 tions, the physician himself should, at least once, give the 
 antiseptic douche, and then entrust it to a trained and 
 conscientious nurse. It is sometimes advisable first to 
 inspect the irrigator tubes and nozzle and see how the 
 nurse uses them. Under the preventive treatment of 
 operative interference are included the most careful 
 examination, and diagnosis of the presentation, and for 
 this purpose the bladder and rectum should previously 
 have been emptied. 
 
 Operations intended to improve the presentation, turn- 
 
 393 
 
THE PREVENTION OF DISEASE 
 
 ing and the reposition of prolapsed parts, should not be 
 undertaken when the lower uterine segment is tensely dis- 
 tended and the contraction ring is approaching the umbili- 
 cus. Further, they shou.ld not be undertaken when the 
 head has passed the pelvic brim and is fixed in the pelvis. 
 To prevent a threatened prolapse of a hand or foot or of the 
 cord, the bag of membranes should be kept intact as long 
 as possible, the patient be at once placed in the recumbent 
 posture, on the side towards which the presenting part of 
 the child has shifted, or lastly should assume the knee- 
 elbow position. Early bearing down efforts should be 
 forbidden. When the prolapsed part has been successfully 
 replaced, the presenting head should be firmly pressed 
 down into the pelvic brim so that the replaced part cannot 
 descend. 
 
 These operative procedures may only be used to reinstate 
 the vertex presentation when there is no immediate danger, 
 and when presumably no further obstacle is present, other- 
 wise by podalic version we make it possible to deliver at 
 any moment when the os uteri is sufficiently dilated. The 
 anterior foot should be used to turn, because the back of 
 the child is thereby brought to the front, or remains in 
 front. In oblique presentations the advancing foot should 
 be brought down, and when the back of the child is directed 
 posteriorly, the version should be completed by bringing 
 down the upper foot, that is, after the lower foot has been 
 brought down and left in the vagina to fix the child. The 
 liquor amnii may be allowed to escape early, so that the 
 head may become fixed after the version. 
 
 "When it is desired to puncture the membranes, but to 
 retain the liquor amnii if possible, the membranes should 
 be perforated as high up as possible above the internal os 
 uteri. The patient should afterwards lie still in the dorsal 
 position. The membranes may similarly be punctured in 
 the second stage of labour, when the membranes are very 
 tough and the placental site is being pulled upon. Here 
 too care must be taken not to injure any placental vessels 
 on the membranes (insertio velamentosa), which might 
 cause death of the child by loss of blood. Puncture of the 
 
 394 
 
PROPHYLAXIS IN MIDWIFERY 
 
 membranes is a preventive measure against the possibility 
 of premature separation of tbe placenta and concealed 
 haemorrhage. 
 
 In perforation the head must be fixed from above ; for 
 perforation of the after-coming head one selects the 
 posterior temporal fontanelle. When applying the cranio- 
 clast, no maternal soft parts or foetal membranes should be 
 included. If the sharp hook is used in the extraction, it 
 must be well protected and firmly fixed so that it may 
 not slip off and cause serious injury. In performing 
 embryotomy never divide or grasp anything which cannot 
 be well included within the two examining fingers and 
 its nature diagnosed. 
 
 Delivery by expression is the operation which is least 
 injurious and dangerous, because the internal genitalia are 
 not interfered with. But Crede's expression of the placenta 
 must not be adopted too soon, not before expiration of half 
 an hour after the birth of the child, and not during an 
 interval between two pains, or it may cause inversion of 
 the uterus. 
 
 In pelvic presentations the following points must be 
 observed in the extraction of the child. The back of the 
 child should be brought to the front, the traction must be 
 slowly made, and not in the intervals between the pains ; 
 the mistake should not be made of trying to bring down 
 the legs too soon. The head, the face being directed back- 
 ward, should not be drawn into the cervical canal till the 
 latter is sufficiently dilated. The umbilical cord should be 
 put back when the child " rides " upon it. The arms must 
 not be permitted to become extended by too rapid traction 
 during the intervals between the pains, but pressure should 
 also be made upon the fundus of the uterus externally. 
 The arms should be brought down in a curve over the face 
 and chest. The anterior arm should only be brought 
 straight down when the elbow presents. Great care 
 must be taken when extracting the head and protecting 
 the perineum, because too strong a traction or levering 
 may cause serious tension on the cervical muscles, and 
 even lacerations of the vertebral column. The method 
 
 395 
 
THE PREVENTION OF DISEASE 
 
 may be modified by placing tlie index and ring fijigers over 
 tbe shoulders of the child, the middle finger stretched 
 towards the occiput, the other index fijiger and possibly 
 also the middle finger is placed in the mouth, and the 
 thumb outside against the lower jaw. 
 
 Forceps may only be applied, as was stated under 
 " version," when the head is firmly fixed, the os uteri fully 
 dilated, the membranes ruptured, and the child alive. The 
 contraction of the pelvis must not be greater than indicated 
 in the table given above, p. 365. Pressure upon the foetal 
 skull and pendulum movements from above downwards are 
 not permissible. When applying forceps, and with the first 
 trial traction, we must be sure that no maternal soft 
 parts or foetal membranes or parts of the child have been 
 included, and that the head is following as traction is made, 
 and is rotating correctly. Traction should be slow and 
 steady, and should be made only during the pains. The 
 forceps must be applied so that the concavity of their 
 pelvic curve is directed forwards and turned towards 
 the part presenting. If the head does not rotate 
 sufficiently, the blades of the forceps should be re- 
 moved and re-a]3plied in the transverse or obhque diameter. 
 The forceps should be removed before the head passes over 
 the perineum, and the four fingers should protect the 
 perineum while the thumb holds back the head. A lateral 
 incision should be made if the vulval orifice is too small. 
 Forceps are indicated for the after-coming head when 
 manual traction to overcome the resistance would be danger- 
 ous for the child. They should never be used when the 
 head is still high. In funnel shaped pelvis a transverse 
 diameter of about three inches is the limit within which it 
 is possible to extract by forceps. 
 
 Preventive treatment as regards surgical measures to 
 bring about delivery consists essentially in their limitation 
 both in frequency and in extent. They are in reality 
 wounds and are exposed to contact with lochial discharge, 
 especially in protracted and so-called " dry " labours, so that 
 the conditions for healing are far more unfavourable than 
 in gynaecological operations. During the first few months 
 
 396 
 
PEOPHYLAXIS IN MIDWIFERY 
 
 after delivery and when the patient suckles her child, it is 
 very difficult, and may be impossible, to persuade her to 
 undergo an operation which will confine her to bed, 
 and unless primary union has taken place, the defects 
 remain until the appearance of other symptoms demands 
 treatment. Lateral incisions into the perineum should be 
 especially considered in this respect, the very limited 
 indications for which I have already given under " Vertex 
 Presentations " ; they heal far less readily than perineal 
 lacerations of the second degree. In suturing, the deeper 
 parts of the opposed raw surfaces of the levator ani muscle 
 must be closely approximated. In deep vagino-perineal 
 incisions, haemorrhage is severe and must be stopped by 
 clip forceps till delivery is completed. Healing of the 
 wound is best aided by letting lotion run over it frequently, 
 by sprinkling with airol, and by keeping it at rest. 
 The choice of ligature is immaterial, but non-absorbent 
 ligatures are preferable. The superficial crucial incisions 
 of the OS uteri should not be stitched, but if fever sets in 
 they should be examined through the speculum, and if 
 necessary be cauterized and irrigated with creosol or lysol 
 solution under slight pressure. Deep incisions into the 
 vaginal tissues must be sutured. 
 
 Preventive treatment in Caesarian section consists first 
 in performing it at the right moment. Veit defines the 
 right time as that when the genital canal is still aseptic, 
 the bag of membranes entire, and when labour pains have 
 already set in. Infection and post partum haemorrhage 
 are thereby obviated. For the prevention of haemorrhage, 
 a large dose of ergotin is given hypodermically after 
 removal of the placenta, and ergot is again subsequently 
 administered. The cavity of the uterus should be firmly 
 plugged with iodoform gauze. To reduce as far as 
 possible the loss of blood incisions through the fundus 
 of the uterus (and they should be transverse according to 
 Fritsch) are recommended, and in the anterior uterine 
 wall, so that in case suppuration occurs in the wall of 
 the uterus, it may be localized by the overlying 
 omentum, or by adhesions with the adjacent peritoneum 
 
 397 
 
THE PREVEXTIOX OF DISEASE 
 
 and abdominal wall. Haemorrliage may further be 
 ciiecked by applying an elastic ligature around tlie 
 lower uterine segment, or better still by tbe temporarj^ 
 compression of tbe uterine and ovarian vessels by an 
 assistant. It has been suggested that a preliminary 
 puncture and palpation should be made so that the 
 subsequent incision may not involve the placental site. 
 On the other hand, the quick performance of the operation 
 seems more rational. 
 
 It is most important, as a preventive, that eight to ten 
 silk or catgut sutures should be passed very exactly 
 through the entire uterine wall but not including the 
 endometrium. It is also useful afterwards to suture the 
 uterine peritoneum by itself in a way similar to that 
 in Lembert's suture of the intestine. Diaphoresis should 
 be promoted after the operation : it serves not only to 
 eliminate toxines but also to control the after pains. For 
 this purpose, and at the same time to prevent vomiting, 
 several enemata of saline solution should be administered. 
 An ice bag should be placed upon the abdomen and later 
 a wet compress. 
 
 The above holds good, mutatis mutandis^ for Porro's 
 supravaginal amputation of the uterus. The pedicle should 
 be treated extraperitoneally at the lower angle of the 
 abdominal incision ; or should be covered with iodoform 
 gauze, and so cut off as it were from the abdominal 
 cavity : this method is preferred by the author. This gauze 
 is brought down into the vagina. Gauze may be applied 
 in this way too in complete rupture of the uterus. In 
 osteomalachia this operation serves at the same time to 
 prevent subsequent pregnancies. 
 
 Preventive treatment in symphysiotomy consists above 
 all in avoiding the operation in private practice except 
 in very rare cases, and it should never be performed in 
 primiparae, in patients who are already infected, or in 
 cases where the foetal membranes have ruptured pre- 
 maturely. The foetal bag of membranes should be kept 
 intact or be replaced by the action of a hydrostatic dilator. 
 To prevent further separation or straining of joints, the 
 
 398 
 
PROPHYLAXIS IN MIDWIFERY 
 
 sides of the pelvis should be firmly held together by 
 pressure on the trochanters, and the child should be 
 extracted with the patient in Walcher's " hanging 
 position." The pelvis should afterwards be held together 
 by silver wire sutures and a firm pelvic belt. 
 
 Intra-uterine plugging with iodoform gauze should not 
 be lightly nor often undertaken, as it is very liable to lead 
 to infection. For uncontrollable post-partum haemorrhage 
 due to inertia, bimanual massage of the uterus while held 
 anteflexed should first be used, and the vaginal portion of the 
 cervix may then be drawn down. If nevertheless the uterus 
 fails to contract, plugging may then be resorted to — gauze 
 soaked in cresol or lysol solution, or a ten to twenty per 
 cent, solution of aluminium acetate is best ; the latter has 
 the property of stimulating contraction and acts as a 
 haemostatic. We must also be cautious in the use of 
 intra-uterine irrigation, for sudden abrupt elevations 
 of temperature, collapse, and rigors with or without 
 perimetritis or parametritis may often be observed after 
 intra-uterine douching. Two or three irrigations are 
 the maximum — corrosive sublimate should not be used — 
 the fluid should be injected under very slight pressure, 
 with a double tube so that the return current may flow 
 easily. The canula should be inserted very carefully 
 through a speculum so that no fresh lacerations may be 
 produced. Air-bubbles must not be carried in with the 
 fluid injected. 
 
 The application of steam to the interior of the uterus may 
 be used in septic abortions, but not after labour, and the fol- 
 lowing precautions are recommended : one application only 
 should be made lasting fifteen to thirty seconds, the tempera- 
 ture in the steam-vessel being 105° to 110° C, so that the 
 entire endometrium may not be affected. The tube which 
 is passed into the uterus must be prevented from coming into 
 contact with the cervical wall by some bad conductor of 
 heat, such as gauze, to prevent burning and atresia and 
 subsequent haematometra. Before introducing the instru- 
 ment, the length of the uterine cavity should have been 
 accurately measured to prevent perforation of the uterine 
 
 399 
 
THE PREVENTION OF DISEASE 
 
 wall. The catheter should be moved about and -withdrawn 
 a little so that the strong contraction which is excited may 
 not bring the uterus too close to the instrument or allow 
 of excessive action at one spot. The retained products of 
 gestation should previously have been removed. 
 
 III. Preventive Treatment in the Puerperium 
 
 1. PEEVENTIVE TEEATMENT OF PUEBPEEAL FETEE 
 
 Preventive treatment consists essentially in avoiding 
 unnecessary examinations and interference, but when these 
 become necessary the strictest antisepsis should be observed 
 in one's self and instruments, in the patient during labour 
 and during the puerperium, and in her home and surround- 
 ings. Rubber gloves are recommended for very busy 
 practitioners. Above all there should be no contact with 
 septic things or septic people. Beds are not seldom the 
 means for the conveyance of infection. Ulceration after 
 lacerations and incisions is avoided by the methods de- 
 scribed above. If a purulent discharge or gonorrhoea 
 was present before labour, weak antiseptic douches under 
 low pressure should be commenced at once ; a one per cent, 
 solution of lysol or metakresol may be used, but no corrosive 
 sublimate. 
 
 In puerperal endometritis we must distinguish between 
 microbic infection which is virulent and that which is 
 relatively harmless. This is determined by the condition 
 of the pulse, not by the temperature : the greater its 
 tension, the smaller and the more frequent the pulse is, 
 the more serious is the infection and the more cautiously 
 must intra-uterine interference be employed, so that new 
 channels of entry into the body may not be provided along 
 the lymph and blood paths. Intra-uterine interference is 
 indicated only when necrosed pieces of the placenta or 
 membranes have to be removed, and the simplest method 
 is the best. Curetting should not be attempted during the 
 puerperium after full term delivery, even when decomposed 
 products are present. The latter should be washed out, 
 or removed by the finger when this can be done without 
 
 400 
 
PROPHYLAXIS IN MIDWIFERY 
 
 producing lacerations while dilating the cervix, or lastly 
 may be cauterized with concentrated carbolic acid or 
 formalin to prevent extension of the infection. It is 
 important at the very commencement of the endometritis 
 to take measures to limit the growth of microbes. This is 
 best done by good drainage, thus carrying off the lochial dis- 
 charge and necrosed portions of tissues, and for this purpose 
 the vagina should be irrigated several times a day with a 
 weak antiseptic, and the uterus should be stimulated to con- 
 tract more strongly by placing an ice bag on the abdomen, 
 or by wet compresses, and by the regular administration 
 of ergot. The uterine contractions will expel the uterine 
 contents, and will at the same time restore the normal 
 position and anteflexion of the uterus. Pieces of membrane 
 and retained products which have come down into the 
 cervix may be removed by the . finger or by polypus 
 forceps ; the vagina should be douched both before and after. 
 The normal position and slight anteflexion of the uterus 
 allow the lochial discharge to escape freely, while a lax 
 walled uterus with sacculi, or a uterus which is abnormally 
 anteflexed, leads to retention of lochial discharge, and to 
 absorption of septic products giving rise to pyrexia. These 
 conditions may be prevented — the latter by warm applica- 
 tions, or if there are violent colicky after-pains by hot 
 fomentations, and even hot vaginal douches and enemata, 
 the former by an ice bag and by narcotics per rectum. 
 Ergot prevents the occurrence of both these conditions. 
 
 Preventive treatment for the other serious forms of 
 puerperal fever consists in the early treatment of the 
 morbid conditions already named, the ulcerations and 
 endometritis and puerperal vaginitis. These serious forms 
 of puerperal sepsis are metritis, parametritis and perimetritis, 
 salpingitis and acute oophoritis, lymphangitis and phlebitis 
 of the uterus, and lastly general peritonitis, septicaemia 
 and sapraemia. 
 
 The further extension of the infection is checked by the 
 frequent use of ice, and when there is peritonitis by opium 
 in small doses. The virulence of the microbes is lessened 
 by the administration of mercury ; the power of resistance 
 
 401 DD 
 
THE PREVENTION OE DISEASE 
 
 of the body is raised not only by stimulants but also by 
 removing the poison from the body and eliminating the 
 toxines by diaphoresis, frequent evacuation of the bowels, 
 and above all by copious injections of normal saline 
 solution, that is '6 per cent,, in the form of enemata or 
 subcutaneously. 
 
 There is a wider field of treatment for the prevention of 
 septic thrombosis of the uterine sinuses and pyaemia, and 
 preventive treatment here is the more important seeing 
 that we are almost powerless to cope with the disease when 
 once it has appeared. 
 
 We should prevent the formation of large thrombi 
 beginning at the placental site, and it is equally im- 
 portant to prevent post-partum and puerperal uterine 
 haemorrhage. The causes of this haemorrhage should there- 
 fore be constantly borne in mind, namely — 1. Defective 
 uterine contraction after delivery, either from irregularity 
 in contraction of the various parts of the uterus, as 
 in marginal attachment of the placenta ; in this case 
 the haemorrhage is not very serious ; or from paralysis 
 of the placental site only, and this is accompanied by 
 exceedingly dangerous haemorrhage. 2. The retention of 
 products of conception produces haemorrhage generally 
 during the first week only, but their decomposition causes the 
 thrombi in the vessels to breakdown and so leads to secondary 
 haemorrhage. 3. SUght recurring haemorrhages appear- 
 ing after the first week are caused by subinvolution of the 
 uterus, especially of the placental site. 4. This atony is often 
 produced by endometritis, which also causes haemorrhage 
 by giving rise to decomposition of thrombi and to inflam- 
 matory hyperaemia. 5. Haemorrhages are caused not only 
 by congestion following relaxation of the blood vessels, but 
 also by venous stasis, which gives rise also to thrombi. 
 The venous stasis may be the result of anomalies in inner- 
 vation, of the patient getting up too soon when there is a 
 predisposition to subinvolution, of an overfilled bladder 
 or rectum, of excessive straining at stool, of coughing or 
 of work, and of disturbances of the circulation produced by 
 flexion and displacement of a sacciform uterus. 
 
 402 
 
PEOPHYLAXIS IN MIDWIFERY 
 
 Emotioual disturbances and sadden attacks of fever aid 
 these predisposing factors by giving rise to acute hyper- 
 aemia. 
 
 Decomposition of thrombi should, as already stated, be 
 prevented by the immediate treatment of commencing 
 puerperal endometritis. 
 
 If decomposition has set in, the breaking down of the 
 thrombi and the formation of emboli is prevented by 
 securing contraction of the uterus, by removing lochial 
 discharges by means of antiseptic irrigation, and by abso- 
 lute rest in bed. The patient must not be allowed to wash 
 or dress herself, or to sit up for any purpose. Constipation 
 and coughing must be prevented, and errors in diet must be 
 avoided ; a liquid nourishing diet is best. If nevertheless 
 emboli form, symptomatic treatment is required. All that 
 can be done in such cases to prevent the action of these 
 injurious factors is comprised under the rules given for 
 para- and perimetritis. 
 
 2. PREVENTIVE TREATMENT FOR RELAXED CONDITIONS 
 OF THE PELVIC AND ABDOMINAL ORGANS 
 
 The puerperal period afifords a good opportunity for 
 restoring the lost tone of the striated and non-striated 
 muscular fibres and of all the elastic and contractile ele- 
 ments of the abdominal walls, the intestines and generative 
 organs and the ligaments of the pelvis. That the puerperal 
 period alone is the cause of this loss of tone is not correct. 
 The beginnings of that relaxed state are often evident even 
 soon after puberty in neurasthenic girls who are predisposed 
 to it and who are generally also chlorotic. Every subsequent 
 severe strain or abdominal inflammation serves to aggravate 
 the condition ; pregnancy is one such strain, and the liga- 
 ments should be relieved by the use of a pessary up to the 
 fourth month, and the abdominal wall should be S2:)ecially 
 treated after the fifth month. Even more important is the 
 general treatment to raise the tone and strength of the 
 body ; this has been already given in detail in the section 
 on Gynaecology. This must be pursued energetically and 
 persistently in the puerperium. Unfortunately the greater 
 
 403 
 
THE PREVENTION OF DISEASE 
 
 number of nurses have no knowledge of or wish, to 
 understand this treatment ; at the most they merely heap 
 a mass of linen upon the abdomen of the patient, which 
 in some ways is useful but in others injurious. Many 
 patients too regard all efforts in this direction as an unne- 
 cessary trouble, so that even when the physician is called 
 in for advice in the puerperal period he preaches to deaf 
 ears. He must suggest practical measures and he should 
 see that these are carried out ; and he will need to be very 
 alert because the nurse will often disregard his instruc- 
 tions. It is best to gain the ear of the patients through 
 their vanity, by jDointing to the terrible size of the abdomen 
 of friends whom they know. Soon after delivery a belt 
 should be applied to the abdomen : it should be convex, 
 reach to above the umbilicus and have five or six buckles 
 and straps reaching down to the groin. Instead of this, 
 long wide closely-woven cloths or towels may be used, and 
 these may further be weighted. After the fifth day the 
 abdomen should be massaged several times a day if there 
 are no signs of inflammation. A regular action of the 
 bowels should be secured. Flatulence should be treated by 
 oil of peppermint or by enema. The bladder should also be 
 regularly emptied. And, if there is no contra-indication, 
 the patient should twice a day practise using the abdominal 
 muscles by carefully raising herself in bed. For success it 
 is most important too to establish an efficient lactation, and 
 abdominal massage acts reflexly and favourably in this 
 respect. 
 
 For subinvolution of the uterus ergot should be regularly 
 administered. For descent of the uterus and prolapse of 
 the vagina a pessary should be inserted, and later tampons 
 of glycerine of tannin employed. 
 
 3. PEEVENTIVE TEEATMENT FOR DISORDEES IN THE 
 PUERPERIUM ARISING FROM TUMOURS OF THE GEN- 
 ERATIVE ORGANS 
 
 Fibroids diminish in size in the puerj)erium, but very 
 readily undergo nutritive and necrotic changes. Ovarian 
 cysts increase in size and often undergo necrotic changes 
 
 404 
 
PROPHYLAXIS IN MIDWIFERY 
 
 through torsion of the pedicle or contusion. Such tumours 
 and sometimes the entire uterus must be removed to prevent 
 a fatal issue. Polypi should be at once removed for the 
 same reason. The preventive treatment for disturbances in 
 the puerperium, arising from general disease and disease of 
 other organs than the genitals, has already been described. 
 The chief diseases are erysipelas, pneumonia, influenza, 
 phthisis, uncompensated cardiac lesions which readily lead to 
 oedema of the lungs, neuritis, mental disorders, renal disease 
 and diseases of metabolism. With regard to multiple neuritis 
 it must be mentioned that this is generally the result of 
 septic infection, sometimes through the use of too strong 
 disinfectants, sometimes through bruising of the tissues 
 during labour. 
 
 4. PRE^^ENTIVE TREATMENT OF MASTITIS 
 
 The hygienic recommendations given under the heading 
 of " General Preventive Measures," should be carried out. 
 I consider it harmful to harden the nipples by rubbing with 
 brandy ; it is better to wash them daily with cold water, and 
 to brace and improve the general constitution. On the other 
 hand, extension of the inflammatory process must be pre- 
 vented by looking for the fissure of the nipple and treating 
 it with lead lotion compresses, or compresses soaked in a 
 solution of aluminium acetate, which should be renewed 
 every two to ten minutes, or lastly by an ice bag with a 
 thin piece of flannel underneath it. To prevent fissures, 
 glass shields with elastic nipples may be employed. 
 
 405 
 
The Prevention of the Diseases 
 of Children 
 
 BY 
 
 DR. RUDOLF FISCHL 
 
 LECTURER ON THE DISEASES OP CHILDREN IN THE 
 GERMAN UNIVERSITY OF PRAGUE 
 
 407 
 
The Prevention of the Diseases 
 of Children 
 
 The proper care and regulation of life, the avoidance of all 
 injurious factors, tlie isolation of patients suffering from 
 infectious disease, the strengthening of the body by suitable 
 diet, by living in the fresh air of the country, of the moun- 
 tains, or at the seaside, hardening the system by attention 
 to clothing, and by care of the skin — these means to prevent 
 the development or the spread of disease, have been em- 
 ployed nowhere so long and so thoroughly as in childhood. 
 These were the guiding principles of the physicians of old, 
 though their methods had not been confirmed by the results 
 of bacteriological research. The relatively high stage 
 reached in the treatment of the diseases of children, the 
 branch of practical medicine now to be considered, makes it 
 necessary that it shall be dealt with in this work in some- 
 what greater detail than the other subjects. I would, there- 
 fore, in these introductory remarks, ask the indulgence of 
 the reader for the greater length of this part, which is 
 necessitated by the circumstances of the case. 
 
 It will not be possible to treat the whole subject exhaus- 
 tively : firstly, because the constant advance of scientific 
 knowledge compels us to take an expectant attitude 
 towards certain questions connected with preventive treat- 
 ment ; secondly, because this work is addressed mainly to the 
 medical practitioner, and he does ask not for a compila- 
 tion of the results of literary study, but for information 
 derived from and based upon the author's own clinical 
 experience, which may serve as a guide in his own practice. 
 It is obvious that local circumstances and other external 
 
 409 
 
THE PREVENTION OF DISEASE 
 
 conditions must impose certain limitations upon the indi- 
 vidual experience of any one physician, but it seemed to me 
 best to follow this personal method and sacrifice in some 
 degree the completeness, and I proceed, therefore, to describe 
 almost exclusively that which a clinical practice extending 
 over 15 years has shown to be most valuable and beneficial. 
 Before describing the preventive treatment of the different 
 groups of diseases, I will make a few general remarks. The 
 several periods of child-life require each a different hygiene 
 which comprises mostly those prophylactic measures which 
 are best adapted to prevent the development of disease. In 
 the new-born infant — using this term to denote the child 
 during the period between birth and the complete healing 
 of the umbilical wound which is the last sign of the pre- 
 vious physical connection with the mother — the chief aim 
 must be perfect asepsis to prevent the introduction of germs 
 into its body, for which there are so many opportunities, 
 and to prevent germs which may have reached the skin or 
 mucous membranes from becoming active and causing 
 infection. In the second period — that period during which 
 the child is or should be breast-fed — the chief dangers 
 which threaten its life and health are digestive troubles, 
 and these are best warded off by correct feeding. Other 
 dangers, such as those arising from colds and from infec- 
 tion, are only of secondary importance. Early childhood — 
 the period up to the commencement of the second denti- 
 tion — is essentially the chief time for the various acute 
 infectious diseases. The rapid growth of certain organs 
 enables disease germs to effect an easy lodgment, the in- 
 creasing independence of the child exposes it in a greater 
 degree to the ill effects of bad weather, and games and other 
 occupations afford many opportunities for acquiring disease. 
 Here, the aim of preventive treatment must be to fortify 
 the system against disease, to ensure the supervision of 
 patients suffering from infectious disease, and to promote 
 cleanhness in children's games and at meals. Late child- 
 hood — the period up to puberty — is still exposed, in part, 
 to the dangers which threaten early childhood and to the 
 additional risk of ill-effects which may result from school 
 
 410 
 
THE PREVENTION OE THE DISEASES OF CHILDREN 
 
 education and mental work, and thus preventive treatment 
 merges into the hygiene of education. 
 
 The whole subject may, therefore, be roughly divided 
 into several groups, according to the age of the children, 
 each group characterized by its own peculiar dangers to 
 health. The possibilities of preventive treatment are not, 
 however, confined to this. Often, especially in the chronic 
 infections of syphilis and tuberculosis, the physician is 
 obliged to enquire into the social life of the members of the 
 family and give advice before conception has occurred. This 
 branch of prophylactic treatment is, unfortunately, too 
 little practised, in spite of its immense importance for 
 entire generations, and it is partly also beyond the influ- 
 ence of the physician. 
 
 A further scope for preventive treatment lies in preventing 
 complications from arising in disease in children. The task 
 is not only to limit the actual number of infectious cases 
 by isolation and disinfection, but also to check the infective 
 process in the patient himself, and to protect him from 
 germs which give rise to complications often far more dan- 
 gerous than the primary disease. In this way preventive 
 treatment may act most effectually and beneficially against 
 the acute and chronic infective processes of child-life. 
 
 In these introductory remarks, I must not omit to men- 
 tion one other matter, which I will term the prophylaxis of 
 treatment ; by this I mean caution in the use of certain 
 methods of treatment to which children are very suscep- 
 tible because of idiosyncrasies peculiar to childhood. Many 
 mistakes have been and are still made in this — mistakes 
 which are doubly serious because they also injure the 
 physician and lower the good reputation of our profession. 
 The subject will be treated according to the plan sketched 
 out above, beginning with 
 
 PREVENTIVE TREATMENT IN THE NEW-BORN INFANT 
 
 Apart from those cases where the infective process reaches 
 the foetus by way of the placenta and causes premature 
 expulsion of the foetus, death of the foetus, or infection of 
 the child in utero, and which do not come within the scope 
 
 411 
 
THE PREVENTION OF DISEASE 
 
 of OTir subject, there are otliers -wliere tlie germs of disease 
 enter the body of the nnborn child through microbic con- 
 tamination of the liquor amnii when the foetal membranes 
 have become prematurely ruptured. Such cases are very 
 rare, and we are almost powerless to do anything against 
 the disease — generally a septic pneumonia — caused by the 
 contaminated liquor amnii. Infection may also take place 
 during the passage of the child through the genital canal, 
 when some infectious secretion from the mother's vagina 
 penetrates into some cavity or recess in the child — the con- 
 junctiva, the mouth, the vagina, or the rectum — or it may 
 enter and become lodged in some wound of the child's skin, 
 produced during parturition. The chief of these infections 
 is purulent conjunctivitis of new-born children, which is 
 partly gonorrhoeal and partly purulent. The great fre- 
 quency formerly of this eye affection, and its severity as 
 evidenced by the fact that nearly one-third of all cases of 
 blindness can be referred to this cause, long ago attracted 
 the attention of physicians and especially of obstetricians. 
 Preventive measures were recommended, and the good effect 
 of these is beyond doubt. Crede's method is the best ; it 
 consists in washing out the vagina of the mother with a 
 solution of corrosive sublimate, several times, before the com- 
 mencement of the second stage of labour, and in dropping 
 into each eye of the child a drop of some astringent liquid 
 directly after birth, before the umbilical cord is severed. 
 A 2 per cent, solution of silver nitrate may be used for 
 this purpose ; recently a 10 to 20 per cent, solution of 
 protargol has been employed, or lemon-juice may be used, 
 or iodoform may be dusted in. It is important, as already 
 stated, that this treatment should be carried out directly 
 after the birth of the child, because the experience furnished 
 by lying-in institutions proves that this very early treat- 
 ment influences the frequency of conjunctivitis much more 
 than the same treatment later. To use some substance 
 (protargol or iodoform) which is less irritating to the 
 palpebral conjunctiva than the silver salt first recom- 
 mended, is desirable too as a preventive measure because it 
 prevents the possibility of an artificially produced con^ 
 
 412 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 junctivitis aud subsequent secondary infection of tlie in- 
 flamed conjunctiva. When gonorrlioeal conjunctivitis is 
 present, preventive measures must be taken, and foremost 
 among these must be the prevention of extension of the 
 inflammatory process to the cornea, and its subsequent 
 deleterious effects upon vision. This can only be accom- 
 plished by the immediate removal from the palpebral con- 
 junctiva of the secretions. For this purpose, the eyes should 
 be washed out with sterilized water or with a weak anti- 
 septic. Potassium permanganate is especially to be recom- 
 mended for its slightly astringent properties. I -pveter to 
 postpone the use of silver nitrate or protargol to a later 
 stage, when the swelling and secretion of the conjunctiva are 
 subsiding under the influence of the mechanical removal of 
 the purulent discharge and the application of cold compresses. 
 Experience has taught me that the healing process is accele- 
 rated thereby. I do not employ ice but only moderate cold, 
 and thus avoid the risk of inducing superficial necrosis of 
 the conjunctiva. 
 
 A further important factor is the protection of the healthy 
 eye when one eye only is affected ; it should not be covered 
 up, because commencing inflammation which could be 
 immediately treated may in this way be overlooked. Grreat 
 care is required in washing out the inflamed eye ; the 
 stream should be directed from the inner canthus towards 
 the outer to prevent any secretion from flowing towards 
 the healthy eye ; the sound eyeball should not be touched 
 when treating the inflamed one. The hands should be 
 most carefully cleansed with warm water, soap and brush, 
 alcohol and ether ; pieces of wool and gauze which have been 
 used should be destroyed at once and this is best done by 
 burning. 
 
 Care is required to prevent the purulent discharge from 
 flowing into the mouth, or from getting into any abrasion 
 of the skin, or from reaching the genitals, especially in girls. 
 One nurse should be appointed to look after the eye, and her 
 whole time must be given up to this. ♦ All linen used for 
 the child should be washed separately ; the child must be 
 isolated and kept away from its brothers and sisters until 
 
 413 
 
THE PREVENTION OF DISEASE 
 
 the normal appearance of tlie conjunctiva and microscopical 
 examination of tlie secretion show that there is no longer 
 any infection. The sick room should afterwards be 
 thoroughly disinfected (see below) as well as all utensils, 
 especially the bath. The irrigator used for washing out 
 the eye, or at least the nozzle of it, should be destroyed. 
 In institutions, where several such cases may occur at a 
 time, the affected children should be isolated in light, well- 
 ventilated rooms which have been previously disinfected, 
 and their attendants should have been trained in the treat- 
 ment of the eyes, and should not be employed for any other 
 work at the same time. 
 
 During the passage of the child through the genital canal, 
 infectious germs may reach the cavity of the mouth in the 
 same way as they reach the eye, and may set up inflamma- 
 tion. There are no special prophylactic measures against 
 this, but we can do something by avoiding any injury to 
 the buccal mucous membrane. This subject will be dealt 
 with later, when speaking of infections of the buccal cavity. 
 It is possible also for the germs found in the maternal 
 vagina to become lodged in wounds of the skin, which have 
 been caused during parturition, for instance, by forceps. 
 After treating the eyes by Crede's method and severing the 
 umbilical cord, the child should be thoroughly washed and 
 any lesion of the skin should be dressed with an antiseptic. 
 By these means dangers from this source are averted. It 
 is obvious that in institutions such children should be kept 
 away from rooms in which there are patients with any 
 purulent discharge. 
 
 And lastly, mention must be made of infection of the 
 genitals and of other infections occurring during birth. 
 The former occur principally in girls and cause vulvo- 
 vaginitis, and in cases which are suspicious Epstein recom- 
 mends that the vagina should be washed out with a weak 
 antiseptic lotion, such as one of j)otassium permanganate 
 and a 2 per cent, solution of silver nitrate injected as a 
 precautionary measure. Infections at the anal orifice 
 during parturition can only be influenced by very careful 
 cleansing of this region in the first bath. 
 
 414 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 The cliild, after its expulsion from the uterus, is in a 
 medium richly supplied with microbes, some of them patho- 
 genic, and the fact that parts of its body, such as the mouth 
 and the alimentary canal, "which contained no microbes at 
 birth, are found a few hours later to possess a rich flora of 
 microbes, shows clearly that manj^ oj)portunities are 
 afforded for bacteria to attack the delicate organism of the 
 child, and that precautionary measures are required to limit 
 these dangers so far as is possible. "We shall briefly con- 
 sider these various regions separately, commencing with 
 that which is of the greatest importance in the new-born 
 infant — the umbiKcus. 
 
 During the division and ligature of the cord it is possible 
 for pathogenic germs to reach the child's body by soiled 
 hands, by scissors and ligatures which have not been 
 thoroughly cleansed. The strictest cleanliness is therefore 
 required ; the interval which elapses between the birth of 
 the child and cessation of pulsation in the umbilical cord 
 should be utilized for a thorough disinfection of the hands. 
 A double ligature, which has been previously sterilized by 
 boiling, should be passed round the cord and tied, and the 
 cord be divided with sterilized scissors. Elastic ligatures 
 should not be used, for it is very difficult to sterilize them, 
 and they possess other disadvantages. Different views are 
 held about the measures to be adopted for the desiccation of 
 the cord, and until the question has been finally deter- 
 mined it is best to carry out an accepted method and to 
 guard against its dangers ; no harm can result from taking 
 precautions. The child should be put into a bath, of porce- 
 lain or metal by preference and having no corners, filled 
 with water which has been boiled and allowed to cool down 
 sufficiently. G-auze or linen which has been previously 
 boiled should be used to wash the child, and not the ordinary 
 unreliable sponge. The same kind of material should be 
 used for drying the child, and the navel should then be 
 bandaged. To prevent infection, it is necessary to ensure 
 the mummification of the cord, which will then not afford a 
 suitable soil for microbes, and further to hasten the falling 
 off of the cord and to let cicatrization go on unhindered so 
 
 415 
 
THE PREVENTION OF DISEASE 
 
 that germs may not enter the umbilical region. These 
 requirements are best fulfilled by a dry bandage, which does 
 not drag upon the cord and which permits access of air. 
 For this I employ a piece of cotton wool cut in the form of 
 a rectangle with a hole through the middle for the umbilical 
 cord, and fastened by a short binder passing round the body. 
 Cotton wool intercepts germs which are in the air much 
 more efficiently than gauze, and fulfils all other require- 
 ments. The question of the protective bandage appeared to 
 have been definitely answered, yet it has recently again 
 come to the front, together with the question whether, with 
 the object of preventing possible infection, it is better after 
 the first bath of the child to postpone the second bath till 
 after the cord has fallen off. I do not approve of this 
 method and do not think there are well-founded reasons for 
 it; it has not been shown that cicatrization of the 
 umbilicus has been delayed by the daily bath ; the danger 
 of the entrance of germs through this proceeding is reduced 
 to a minimum if the bath is carefully cleansed and boiled 
 water is used, and the daily bath has a number of other 
 hygienic and 23ro23hylactic advantages which far outweigh 
 the disadvantages. The best way to prevent the cord from 
 being dragged upon is to have it as short as convenient, 
 and to handle it as little as possible each time the bandage 
 is changed. The use of dusting powder is unnecessary and 
 has its inconveniences ; the substances generally used are 
 not free from germs, and antiseptic powders are sometimes 
 not well borne, for example, iodoform often causes eczema, 
 and sometimes they delay mummification ; they are, there- 
 fore, best omitted. After the cord has fallen away, a piece 
 of cotton wool should be kej)t over the navel to protect it 
 from dust, until complete healing prevents the possibility of 
 germs entering by this channel. The bandage must be 
 renewed whenever it becomes soiled by faeces or urine, and in 
 every case it should be changed at least once a day directly 
 after the bath ; the strictest cleanliness here, too, is needed, 
 and hands which have touched the soiled bandage should be 
 thoroughly cleansed before they are used to put on the fresh 
 bandage. These details cannot be too often emphasized, 
 
 416 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 especially as tlie directions are not carried out by the doctor 
 but by nurses, and need to be strongly impressed upon them 
 by demonstration and by supervision to see that they are 
 understood and carried out. In private cases, such infection 
 by contact plays a far less important part, though even here 
 it may happen that a nurse who is entrusted with the care 
 of several mothers and children may dress a child suffering 
 from erysipelas of the umbilicus, and then after merely 
 washing her hands dress a healthy navel. If it is unavoid- 
 able that she should attend to both cases, and even to other 
 cases, then, at whatever personal inconvenience to herself, 
 the infectious case should always be the last in turn, and 
 the hands should afterwards be thoroughly cleaned and 
 nothing more undertaken on that day. Midwives who 
 attend to patients who are ill with puerperal fever should 
 not undertake any other cases, and this is even more 
 important still for the doctor who, with his knowledge and 
 conscientiousness, should set an example to those under 
 him. 
 
 Before passing on to other possible ways of infection of 
 new-born infants and the measures for their prevention, 
 I will briefly allude to a few general rules. The child 
 should always be attended to first and the mother after- 
 wards. In this way only is it possible to make sure that 
 no maternal secretions are carried to the child, for even 
 the normal lochial discharge may contain germs that are 
 infective for the child. I have already mentioned the bath ; 
 with regard to the bath water, boiled water should be used 
 till the umbilicus is perfectly healed, and so long as there 
 are any skin lesions or inflammatory processes with loss 
 of substance. I have spoken also of the washing materials ; 
 no sponges, but pieces of gauze or boiled linen should be 
 used. I would only add that water in a separate basin 
 and fresh pieces of linen should be used for washing the 
 face, otherwise germs cannot fail to be carried to the face 
 which have got into the water from the skin or bowel. 
 The bath should be thoroughly cleansed each time after 
 use and then carefully covered over till next required. 
 The same bath must never be used for several children 
 
 417 E E 
 
THE PREVENTION OF DISEASE 
 
 after merely changing the water and rinsing out the bath ; 
 when it is necessary to use it for several children it must 
 be thoroughly cleaned out for each child and the bath 
 must be of metal or earthenware to make sure that it 
 can be thoroughly cleaned. Great importance should be 
 attached to this matter in institutions, as very serious 
 consequences have occurred through infection conveyed 
 by the bath water, the baths or the sponges. 
 
 The mouth should be cleared directly after birth, 
 and sometimes this is directly indicated as in asphyxia. 
 It should be done by the doctor and every care taken 
 to avoid injuring the mucous membrane and so opening 
 a door for the numerous microbes which are present in 
 the mouth. "When it becomes necessary to pass a catheter 
 into the air passage great care must be taken not to injure 
 the mucous membrane because very severe infection has 
 been observed after intubation. The subsequent cleansing 
 of the mouth cavity with a piece of linen on a finger, 
 which the nurse generally does daily after she has bathed 
 the child, I look upon not only as superfluous but also 
 as directly injurious. Superficial lesions of the epithelium 
 can scarcely be avoided by this procedure ; the so-called 
 Bednar^s aphthae^ which may be the starting point of the 
 severest general infection, has been proved by Von Epstein 
 and myself to have been caused in this way. Thrush is 
 also apt to follow these manipulations of the mouth which 
 have artificially produced the stomatitis necessary for this 
 condition, and the germs may be carried in by the finger 
 nails. In short, a number of troubles may be caused by the 
 procedure without any advantages which might com- 
 pensate for them. As to thrush, catarrh of the buccal 
 cavity and dyspepsia are the conditions necessary for its 
 development ; if the buccal catarrh is only a part of the 
 general digestive trouble then washing out the mouth 
 will not prevent thrush. If the thrush is of a directly 
 contagious nature interference with the mouth may convey 
 infection — in short, in breast-fed children there is no good 
 reason whatever for undertaking it, and my experience 
 has been that under ordinary normal conditions, nothing 
 
 418 
 
THE PREA^ENTION OF THE DISEASES OF CHILDEEN 
 
 but good has resulted from its omission. The case is 
 different when the child has to be artificially fed, and 
 there is frequent regurgitation of milk, and large flakes 
 of curdled milk lodge in the buccal pouches and afford 
 a suitable nidus when the temperature is favourable for 
 the growth of the microbes which are already in the 
 mouth or are brought there by the milk and which may 
 set up irritation. When the child is artificially fed I 
 have the mouth cleansed each time the child is fed. This 
 is very carefully done with pledgets of cotton wool and 
 never with a camel hair brush which cannot be properly 
 cleaned. In breast-fed children any affection of the mouth, 
 if it does not already exist, may be prevented by washing 
 the nipples of the mother or wet nurse with a 2 to 
 3 per cent, solution of boric acid both before and directly 
 after the child is put to the breast. If some affection 
 is already present — and there are cases in which gonor- 
 rhoeal stomatitis exists when the child is born — the chief 
 care must be to prevent the inflammation from extending 
 to the pharynx and larynx, or to the salivary glands, 
 or especially to the middle ear. This is done by early 
 and careful treatment, the principles of which cannot be 
 entered into here. The importance of the mouth as a 
 place of entry for infectious germs has been sufficiently 
 dwelt upon, and the mucous membrane of the nose must 
 next be considered, though the infective process begins 
 here much less frequently. Nevertheless attempts are 
 often made in the nursery to remove inspissated nasal 
 secretion with a twisted corner of the handkerchief or 
 with hairpins and such things have been observed some- 
 times to produce abrasions and sometimes to convey germs 
 and implant them. The germs most commonly so conveyed 
 are the pyogenic streptococci so frequently found on the 
 scalp and in the nasal cavities of adults. Many cases 
 of erysipelas, starting from the nasal cavity, and many 
 cases of rhinitis are produced in this way. To prevent 
 this danger all such methods of clearing the nostril should 
 be forbidden ; the inspissated secretion may be removed 
 by washing out the nostril with lukewarm sterilized water 
 
 419 
 
THE PREVENTION OF DISEASE 
 
 or a weak antiseptic, or by pieces of cotton wool lubricated 
 with boracic vaseline or some other pure fat. 
 
 Infection may also begin in the skin of the new-born 
 infant which demands therefore special care. When re- 
 moving the vernix caseosa, at the first bath, care must 
 be taken not to cause any injury to the skin. If there 
 is a cutaneous wound, it should be protected by a dressing 
 and should be watched so that steps may at once be taken 
 to prevent its extension if inflammation sets in. A daily 
 bath is a great protection against erythematous, pustular 
 and ulcerative eruptions on the skin which may be the 
 starting point for a general infection especially when the 
 eruption appears in the perineum. Further preventive 
 measures consist in changing frequently the diapers so 
 that faeces and urine may not remain in contact with the 
 delicate skin, and that the microbes contained in the faeces 
 may be removed from the skin. The kind of linen used 
 and the way in which the diaper is put on are also im- 
 portant, because the skin is mechanically irritated when 
 the linen is coarse and fastened tightly. Linen soaked 
 with urine should not be used again after merely drying 
 it ; the chemical products and the bacteria of the urine 
 would both irritate the skin. "When washing the anal 
 and genital regions rough handling is apt to cause wounds 
 and infection ; it is best to wash these parts with pieces 
 of cotton wool dipped into lukewarm boiled water and then 
 to mop the parts with dry cotton wool. The cotton wool 
 should be kept wrapped up in a clean cloth or in a box, 
 and a fresh piece should be used each time. Even greater 
 care is required when there is any eczematous eruption ; 
 it should be treated at once, and some protective material 
 should be used to prevent the infection from becoming 
 more extensive and deep. In bathing the child cleanse 
 the skin and remove all secretions which have accumulated 
 between the fold of the skin, especially at the neck, 
 axillae, and groins in fat children. If allowed to remain 
 the secretion softens the skin and produces intertigo which 
 may develop into a wide spreading inflammation of the 
 skin or even into general infection. The secretion should 
 
 420 
 
THE PEEVENTION OF THE DISEASES OF CHILDREN 
 
 be carefully but thoroughly removed and a piece of cotton 
 wool placed in the folds to prevent friction between the 
 two adjacent surfaces. A careful look out must be kept 
 for the many different nodular, pustular, and ulcerative 
 eruptions which may appear on the skin of the infant. 
 "When pus is present, especially in the diseases accompanied 
 by the formation of pustules or by superficial and deep 
 abscesses, preventive treatment consists in antiseptic com- 
 presses and dressings and early evacuation of the pus. It 
 is obvious that the physician's hands should be thoroughly 
 cleansed both before and after dressing the patient ; that 
 soiled dressings should be at once destroyed ; and that the 
 sick child should be isolated from the other children of 
 the family. In institutions perfect isolation of these cases 
 is most essential and should be strictly carried out. "What 
 has been said applies also to erysipelas and to cellulitis. 
 The possibility of the conveyance of infection by soiled 
 linen or by the utensils and bath, etc., used for the child 
 must be remembered, and especial care be taken for its 
 prevention. 
 
 Infection may also arise at the anus, either by extension 
 from inflammations of the adjacent skin, or directly 
 as from fissures or ulceration of the mucous membrane 
 at the lower end of the rectum, but these cases are 
 comparatively rare. Prevention consists in careful treat- 
 ment of any inflammation in the vicinity of the anus, 
 in care when washing the perineum and in regulating 
 the evacuations of the bowels, because, as will be later 
 pointed out, the nature and number of the evacuations 
 may also be a cause of these inflammations. 
 
 Lastly, mention must be made of the genital organs, 
 especially in the female, which apart from the infective 
 processes already described may be the seat of catarrhal, 
 suppurative, and even gangrenous processes mostly caused 
 by some local infection. Here, too, absolute cleanliness 
 and the avoidance of an}^ mechanical irritation, or soften- 
 ing of the skin by urine and faeces are of great importance. 
 The extension of inflammation from adjacent parts of the 
 skin, and the importation of germs from other parts of 
 
 421 
 
THE PEEVENTION OF DISEASE 
 
 the body or from the outside, are also of the utmost 
 moment. Dried secretions or masses of epithelium cast off 
 by the vigorous desquamation of the first few days of life 
 should be removed by washing and the parts should 
 afterwards be dabbed with dry cotton wool. When in- 
 flammation of the genitals already exists the chief aim 
 of prophylactic treatment is to prevent the extension of 
 the mischief and to heal quickly the local inflammation. 
 The principal ways in which infection may enter the body 
 of the new-born infant have now been considered, and 
 their prevention explained, and I will add a few words 
 about the nursery considered in its relation to the pre- 
 vention of disease. The room selected should be light, 
 well ventilated, and one that can be warmed ; the floor 
 should be such that it can be easily washed ; for instance, 
 it may be varnished or covered with linoleum. Furniture 
 which creates or collects dust, such as curtains or up- 
 holstered armchairs, should so far as possible be avoided. 
 The cradle should be made of material which can easily 
 be cleaned and there should be at least two sets of bedding 
 so that it may be possible to change it completely in case 
 of need. "Washing soiled diapers and drying them in the 
 nursery is altogether to be condemned, and in institutions 
 I regard the correct disposal of the excreta and washing 
 of soiled linen as most important factors in preventive 
 measures. It seems to me to be best to put the soiled 
 diapers and soiled linen, or linen which has been changed 
 for some other reason, at once into a covered vessel kept 
 in the room and containing a solution of corrosive subli- 
 mate (1 part in 2,000) ; this will not injure the linen and the 
 clothes can remain in it till they are afterwards washed. 
 This is the safest way of preventing germs from getting 
 into the air, whether from dried excreta or from liquid 
 faeces ; and at the same time this treatment of the linen 
 serves to disinfect the faeces and they are made innocuous 
 by the antiseptic and may be poured down the water- 
 closet directly the linen has been removed from the 
 vessel. 
 
 Thermometers are a further source of infection ; they 
 
 422 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 should be put into a strong solution of potassium per- 
 manganate after use and be rubbed dry and smeared 
 with a pure fatty substance such as vaseline (which is 
 kept in a closed jar) before being used again. In new- 
 born infants the temperature is almost invariably taken 
 in the rectum and germs can thus be readily conveyed ; 
 new thermometers should therefore be used. In institu- 
 tions a special thermometer should be kept for each child, 
 which can be destroyed after it has been used for any 
 infectious case, because reliable disinfection of the in- 
 strument cannot be attained even by the method above 
 described. These apparently trivial details are in reality 
 most important, and it must not be thought absurd that 
 I refer to them emphatically and at some length. 
 
 Opinions differ as to the possibility of infection through 
 the air ; my own experience has taught me to regard 
 this as possible, so that in addition to infection by contact 
 I ascribe an important role to infection by the air. In 
 institutions, especially when there is not sufficient room 
 and the place is over-filled and difficult to ventilate and 
 to clean, this is a much more important factor than in 
 private houses where, indeed, it is only in the lowest 
 classes that the squalor and the large number of children 
 exercise a baneful influence. The experience of hospitals 
 conducted upon modern hygienic principles and of found- 
 ling-hospitals has shown that much can be done in this 
 matter by adequate hygienic precautions. A sufficient 
 number of light, airy large rooms with but few patients 
 in each room must be provided, the floors, ceilings and 
 walls must be easily cleaned ; smaller rooms must exist 
 for isolating infants suffering from infectious disorders. 
 It should be possible to use the rooms in turn and to 
 disinfect them thoroughly in the interim. There should 
 be special attendants for the different classes of disease. 
 It is self-evident that in private houses, too, adequate 
 ventilation and thorough cleaning of the nursery are re- 
 quired, and all unnecessary raising of dust should be 
 avoided as by using damp cloths for dusting and the child 
 should be in another room while the cleaning is done. 
 
 423 
 
THE PEEVENTION OF DISEASE 
 
 Some of the preventive measures recommended in the 
 foregoing apply also to older children, for there is no sharp 
 line of demarcation in this respect, and certain ordinary- 
 hygienic and prophylactic principles are true for all 
 pathological conditions. Nevertheless, during the first 
 few days of life there is a greater suscejDtibility to the 
 injurious action of bacteria from without, to the transition 
 from a latent to an active state of the micro-organisms 
 which get lodged in the various cavities of the body, and 
 to general infective processes which are then very com- 
 mon. Preventive measures are therefore more urgently 
 needed than at other times and for this reason I have 
 entered fully into them here. Premature children are 
 very susceptible to infection of every kind and need very 
 special attention ; the apparatus used to produce artificial 
 warmth for them such as incubators must be thoroughly 
 disinfected after each time it is used ; but the skin must 
 not be made too hot by these or by the use of hot-water 
 bottles, otherwise irritation of the skin is readily set up 
 and it may then be invaded by bacteria. 
 
 PREVENTIVE TREATMENT DURING INEANCY 
 
 In the introductory paragraphs I pointed out that a 
 certain number of morbid processes are especially rife 
 during this period of life ; and foremost among these are 
 the very fatal diseases of the gastro-intestinal tract. We 
 shall therefore begin with the measures which can be 
 taken to prevent an attack of these disorders ; next we 
 shall consider the prevention of complications, and lastly, 
 the measures required to check the spread of the disease. 
 And here the hygiene of the feeding of infants coincides 
 to a great extent with the preventive measures required 
 and it becomes necessary to sketch its main outlines. 
 
 We cannot too often or too forcibly emphasize the 
 principle that, with very rare exceptions, the infant 
 thrives best when it is breast-fed by its own mother and 
 in accordance with rational rules. The endeavour to 
 spread this principle must be made not only by the family 
 
 424 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 doctor whose advice is often not songht or is souglit too 
 late, but by all who have an opportunity of giving advice 
 in this matter. I am aware — indeed no unprejudiced 
 observer can close his eyes to the fact — that in certain 
 sections of the population the modern ways of living and 
 claims of life have during the past few years acted 
 against the nursing of infants by their mothers ; on the 
 other hand, if we can enlist the active help of those to 
 whom reference has been made above, I do not think that 
 it is too late to bring about a great change in this matter 
 and to secure for coming generations of children their 
 natural source of nourishment. The subject must not 
 only be treated as an ethical question but also as one of 
 preventive treatment in connection with the feeding 
 and rearing of infants with far-reaching results. The 
 colostrum found in the breast during the first few days 
 after delivery fulfils the double object of preparing the 
 stomach of the new-born infant both quantitatively and 
 qualitatively for the breast milk and of promoting the 
 expulsion of meconium contained in the intestines, and it 
 may be assumed a priori that a mammary gland which 
 has grown to maturity consecutively with the growth of 
 the foetus and which has derived its materials from the 
 same source as that for the foetus, namely, the maternal 
 blood, will satisfy the individual requirements of the child 
 more exactly than will the milk of a wet nurse however 
 carefully she may have been selected after consideration 
 of all necessary factors. There are certain vital tendencies 
 which make for the preservation of the infant, such as 
 the immunity against certain infectious diseases, which 
 is imparted to the infant in utero by way of the placental 
 blood stream, and experiments and statistics during the 
 last few years have conclusively shown that such tendencies 
 are also transmitted through the milk to the offspring. 
 That there are individual characteristics in the milk of 
 different women is shown by the fact that many a child 
 which is perfectly normal and physically well developed 
 does not thrive upon the milk of one wet nurse, though 
 examination can detect nothing wrong in her, and that 
 
 425 
 
THE PEEVENTION OE DISEASE 
 
 tlie same cliilcl will thrive perfectly upon tlie railk of 
 anotlier wet nurse, ttLOugh tlie other circumstances have 
 remained unchanged. It is quite conceivable that the 
 characteristics of the mother's milk are those which best 
 fulfil the conditions required by her offspring. In short, 
 there are many reasons why the mother should nurse her 
 own child and very few why she should not, and we need be 
 much less strict about the conditions which fit a mother 
 to nurse her child than about those which fit a wet nurse. 
 The only cases in which, according to my opinion, we 
 may deviate from this rule are cases of profound anaemia, 
 tuberculosis, cardiac disease, and ^predisposition to neuros- 
 thenia which is unfortunately so common ; also cases 
 where the nipj)les remain undeveloped in spite of every- 
 thing that can be done during pregnancy to improve them, 
 and lastly, cases in which an inadequate supply of milk 
 which is generally also poor in quality cannot be increased 
 in quantity by suitable food and by giving the breast 
 to the child. And yet we have seen, too, that by per- 
 severance, a sufficient milk supply has been established 
 in women who were apparently delicate and not looked 
 upon as able to nurse their infants. E-ules of hygiene 
 are necessary for the mother as well as for the child ; the 
 mother's food should be abundant, and easily digestible, but 
 she should not, as so often happens, be overfed — this will 
 only cause digestive disturbances which re-act unfavour- 
 ably upon the production of milk and will not increase 
 the fat or the quantity of milk. Mental rest and the 
 indifference which is often found to an unwished for degree 
 in hired wet nurses are rare in the young women of our 
 generation, and yet are of extreme value for the child, 
 and much as I value the use of scales, and advocate 
 regular weighing of the infant, yet I cannot deny that 
 this has a disadvantage when in the hands of nursing 
 mothers whose minds are filled with teachings promulgated 
 by popular works, and who become mentally depressed 
 when the infant's weight is at a standstill or when its 
 increase in weight on any given day is below that men- 
 tioned in these books ; this mental depression is not without 
 
 426 
 
THE PREVENTION OP THE DISEASES OF CHILDREN 
 
 its influence upon the growth of the child. When the 
 physician knows that there is this nervous disposition in 
 the mother, or as soon as he discovers it, he will do well 
 to have the child weighed as seldom as possible, that the 
 weight may be distributed over longer periods, and may 
 even himself weigh the infant ; a small falsification of the 
 result in these cases comes under the category of pious 
 frauds — in short he must do what will be for the interest 
 of both child and mother. 
 
 The condition of the nipples and breasts requires great 
 attention, especially with the first child. The shape of 
 the nipple should be improved during pregnancy by con- 
 stantly drawing it out with a breast-pumj) and it should 
 be hardened by washing with spirit, because fissures of 
 the nipple often make the work of nursing the infant 
 impossible or very difficult, partly through the pain caused 
 by suckling and partly through the possibility of infection, 
 both of the mouth of the infant and of the breast 
 itself. The nipple should be washed before and after the 
 child has the breast, and there is then, as has already been 
 mentioned, no necessity for washing out the mouth of a 
 breast-fed infant. When there is suppurative infiammation 
 of the breast, I am strongly ojDposed to putting the child 
 to the breast, even though there be no apparent com- 
 munication between the abscess and the galactiferous ducts ; 
 the constant irritation caused by the suckling can only 
 increase the infiammation and may bring about the com- 
 munication which did not exist at first and expose the 
 infant to the serious risk of direct absorption of the in- 
 fected milk. In these cases it generally suffices to use 
 the other breast only, and this sometimes undergoes com- 
 pensatory hypertrophy, or if the child is old enough it 
 may be fed partly by hand ; or if it is only a few weeks 
 old a wet nurse should be recommended. 
 
 The number of meals and the quantity at each require 
 the greatest attention ; the soundness of the digestive 
 apparatus of the child depends mainly ujion a correct 
 regime, and mistakes made in this matter cause suffering 
 not only during the whole suckling period but often also' 
 
 427 
 
THE PREVENTION OF DISEASE 
 
 ill later life. A feed should be given every three hours 
 and only one breast given at each feed ; there should be 
 intervals of six to eight hours during the night which are 
 important also for the mother and her nursing powers. 
 These are the general principles and they should not be 
 departed from, in one or other direction, except in special 
 cases where the condition of the child seems to make it 
 necessary. The dyspepsia arising from overfeeding of the 
 infant, often underestimated and occurring even in breast- 
 fed infants, is the frequent cause of severe gastro-intestinal 
 trouble. Not rarely it induces the development of con- 
 stitutional maladies, and it prepares the way for other 
 diseases, and yet the point most to be emphasized here is 
 that it is j)i'eventible. These facts make it desirable that 
 the advice of the physician should be given even for the 
 healthy child ; indeed, the object of preventive treatment 
 is to restrict disease to an irreducible minimum by rational 
 living and education. To judge correctly of any of the 
 abovenamed conditions the physician must be certain too 
 when the child is suffering from insufEcient food, if breast- 
 fed. Such cases are on the whole rarer than the converse 
 cases, yet they do occur and require a very different treat- 
 ment. By weighing the infant before and after feeding, 
 by estimating the quantity of urine, the state of the faeces, 
 the distension of the abdomen, the condition of the mother's 
 breasts during the intervals between two feeds and other 
 such points, it is possible to arrive at a correct decision, 
 and according to the circumstances either increase the food 
 or change the nurse. I will pass on and consider the 
 question of suckling by a wet nurse. And I will begin 
 with a few words about ethical considerations and ob- 
 jections raised on several sides. The neglect to which the 
 wet nurse's own child is exposed, when she goes out to 
 nurse another's child, has been pointed out ; this objection 
 is, in my opinion, not ver}'- great, seeing that we do not 
 generall}^ engage a wet nurse till two or three months 
 after her deliver}^, and as it is the custom in Germany for 
 the lower clashes to begin to feed their children by hand 
 at that age there is no s^Dscial risk in weaning these 
 
 428 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 children. We may assume too that if the woman did not 
 go out as a wet nurse she would have to go out to other 
 work which would take her altogether away from her own 
 child or at any rate would take her away during the 
 daytime and her child would be no better off. There is 
 no doubt in the mind of any physician as to the fact 
 that the milk of a good wet nurse gives better results 
 than the most rational and scientific hand feeding ; on the 
 other hand, it is equally certain, for reasons "stated above, 
 that the mother's milk is far better for her child than 
 that of any wet nurse. I will briefly refer to the question 
 of the selection of a wet nurse limiting myself to points 
 which are absolutely necessary. It is evident that with 
 a wet nurse we must insist upon qualities and conditions 
 upon Avhich we should not lay so great stress if a mother 
 were nursing her own child. The wet nurse should be 
 thoroughly examined to see that she is healthy ; she should 
 be between twenty and thirty years of age, her breasts 
 and nipples well-formed, with plenty of milk. It is always 
 an advantage and in suspicious cases it is even essential 
 to see the nurse's own child and judge of its state of 
 health and development ; on the other hand, not much 
 importance need be attached to the natural disposition or 
 colour of the hair of the nurse, the diet of the wet 
 nurse must not be suddenly changed from the simple poor 
 diet to which she has been accustomed, to the rich abundant 
 meat diet of the household of which she now forms part. 
 Do not give much meat to those who have been accustomed 
 to a diet largely consisting of vegetables ; do not give 
 them too much liquid or compel them to take alcoholic 
 beverages when they have not been accustomed to take 
 alcohol. Let them work and take exercise to prevent them 
 from becoming less capable physically of nursing the child. 
 Watch carefully to see that the hours fixed for the infant's 
 meals are regularly adhered to, and on the other hand 
 take care that she gives the child no other food when she 
 takes her own meals. The mother's constant supervision 
 is needed to see that the infant is well cared for, otherwise 
 it may easily happen that instead of removing wet diapers, 
 
 429 
 
THE PREVENTION OF DISEASE 
 
 wLicli are iiiiconif or table and cause tlie infant to cry, the 
 nnrse will quiet the child by putting it to the breast — a 
 procedure which will produce those dyspeptic troubles to 
 which I referred above and which turn a peaceable nursery 
 into a pandemonium. For similar reasons the wet nurse 
 should never be allowed to go out alone with the child ; 
 her lack of knowledge induces her to cover up the infant 
 when it is out of doors and it runs a greater risk of 
 taking cold afterwards. The mother should always herself 
 bathe the child and look after the cleansing of the nose 
 and ears, otherwise harmful results may follow. In short, 
 one must not rely upon this stranger in any way and the 
 physician must impress upon the mother the great necessity 
 for supervision. 
 
 Further, the infant must never sleep in the bed with an 
 adult, not even with the nurse, partly for hygienic reasons, 
 partly because of the danger of overlaying. When possi- 
 ble the wet nurse should sleep in the room adjoining the 
 nursery, so that the air may not be necessarily contami- 
 nated, and if she is wanted at night she can be called. 
 Her physical health must not be neglected, because dis- 
 turbances of physical functions react upon the infant and 
 may cause very unpleasant disorders. In case of any 
 serious illness in the nurse, our action must be according 
 to the nature of the illness. Temporary indisposition, 
 even when of infectious nature, such as acute tonsilitis, is 
 not a sufificient reason for taking the child from the breast ; 
 the breast should still be given, but in the intervals be- 
 tween feeding the infant should not be with the nurse. 
 An illness which will be of longer duration or one which 
 is readily communicable is a sufficient reason for taking 
 the child from the breast, even though there may be no 
 experimental proof that the milk is affected ; as a rule, 
 changes soon appear in the secretion of milk which make 
 suckling impossible. On the other hand catarrhs, indiges- 
 tion and similar indispositions afford no valid reason for 
 making any change, but these ailments should be cured by 
 remedies which do not pass into the milk and so injure the 
 infant. There need be no fear if menstruation should 
 
 430 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 begin again, for even if, as Schlichter maintains, the in- 
 fant does not thrive quite so well during the menstrual 
 period and often exhibits some disturbance, always trivial, 
 yet the disturbances are quite transient. ' The recommence- 
 ment of menstruation is harmful because it makes a 
 fresh conception more possible, and the changes in the 
 milk secretion produced by conception prohibit further 
 suckling. 
 
 Without separately considering the different forms of 
 mixed diet, such as are especially preferred by the French, 
 I will at once proceed to the subject of the artificial feed- 
 ing of infants. There is danger for the infant which is 
 unwisely fed even though its food be derived from the 
 mother's breasts or from the wet nurse, but these dangers 
 are rarely great enough to imperil its life. Conditions are 
 however very different in a hand fed infant, and these 
 dangers are enormously increased. It must be clearly 
 understood, in spite of all assurances to the contrary, that 
 the artificial feeding of the infant from its birth deprives 
 it of many advantages to which reference has been made 
 above, and is also one of the most difficult and troublesome 
 problems. Cow's milk is most frequently used, and we shall 
 first consider the dangers connected with it. They may be 
 regarded from three aspects : the chemical, the bacterio- 
 logical and the quantitative. As to the chemical, not 
 only do we know the difference in percentage composition 
 between the two, but work done during recent years in 
 various directions has shown us also what are the differ- 
 ences in the elementary structure between human milk and 
 cow's milk. And now we know that cow's milk contains 
 about twice as much proteid, and about half the quantity 
 of milk sugar and more fat and more salts than human 
 milk ; the casein derived from cow's milk is far less suitable 
 for the infant than that from human milk ; and the rela- 
 tion between the nitrogenous and the non-nitrogenous 
 constituents of cow's milk is one which is far less adapted 
 to the requirements of the growing infant than that in 
 human milk. "We are also now well informed about the 
 difference in the eleinentary structure between casein from 
 
 431 
 
THE PREVENTION OF DISEASE 
 
 cow's milk and from human milk, about the constitution 
 of the different fats in milk, and the solubility of the salts, 
 and have come to the conclusion that the most careful 
 calculations and attempts to make cow's milk similar in 
 constitution to human milk must all fail because we are 
 working with substances differing chemically. Apart 
 from these facts we have in human milk a food the 
 quantity and composition of which are adapted to the 
 requirements of the child at different periods, while with 
 cow's milk we can attain only a certain average composi- 
 tion, and the infant's intestinal tract must first adapt 
 itself to be able to digest this. There are also other 
 factors : the difference in coagulability and capacity for 
 absorption of the casein, the totally different mode of 
 absorption of the fat, the absence from cow's milk of 
 certain substances, such as nuclein and lecithin, the de- 
 ficiency in iron, the great capacity exhibited by the salts 
 in cow's milk for combining with the hydrochloric acid of 
 the stomach — all these make increased demands upon the 
 digestive apparatus, and we can never tell beforehand that 
 the intestinal tract of the infant will adapt itself to these 
 conditions, and that there will not be a deficiency in the 
 materials required for building up certain tissues. For 
 these reasons, in spite of every precaution which can be 
 taken against accidental disturbances, and in spite of 
 absolute cleanliness and regularity in feeding, dyspepsia 
 often arises in children brought up on cow's milk — almost 
 a physiological dyspepsia — and lays the foundation for 
 serious gastro-intestinal disturbances which may set in 
 with astonishing rapidity and severity. Many attempts 
 have been made to lessen these dangers, and we have 
 succeeded in obtaining a number of preparations and 
 modifications of cow's milk in which the chemically in- 
 jurious effects of ordinary cow's milk have been to a cer- 
 tain extent overcome, but these products are far inferior 
 to human milk in fitness as a perfect food ; for human 
 milk gives rise to no troubles and assures the steady and 
 satisfactory development of the infant. This fact must be 
 firmly grasped, so that we can state the objections against 
 
 432 
 
THE PREVENTION OF THE DISEASES OE CHILDREN 
 
 these artificial foods, and on the other hand watch very 
 carefully for the slighest digestive trouble, and treat it 
 correctly at the very beginning. 
 
 A second class of injurious effects arises from bacterio- 
 logical infection, and here, although we have to deal with 
 a large number of opinions, we have not yet reached any 
 definite conclusion. I will rapidly pass over the fact that 
 the mother's milk and the nurse's milk are unboiled, while 
 cow's milk is frequently given to the infant after the 
 milk has been boiled, and that the boiling causes a modifi- 
 cation in the nitrogenous constituents and salts which 
 renders the milk less digestible. This cannot be avoided, 
 and Biedert's idea of getting cow's milk in an aseptic state 
 and using it unboiled is at present a somewhat impracticable 
 suggestion. The danger of transmission of tuberculosis, or 
 of foot and mouth disease, has been considerably minimised 
 during the last few years by the greater attention devoted 
 to the examination of cows by farmers and owners of dairies, 
 and by the destruction of pathogenic microbes by boiling 
 the milk, 
 
 Recently it has been proposed to so heat ^ the milk that 
 its flavour may not be interfered with. I must refrain at 
 present from giving an opinion in respect of milk so treated, 
 as I have had no personal experience of its use. Besides 
 pathogenic organisms there may be an enormous number of 
 bacteria in milk, which are derived from the dust of cow- 
 sheds, the excrements of the animals, the hands of the 
 milkers, the water for washing the milkpails, the cloths 
 used for straining the milk, and from the many utensils into 
 which the milk may be put before it reaches the consumer. 
 
 These micro-organisms sometimes cause fermentation of 
 the milk sugar with the formation of lactic acid, sometimes 
 bring about changes in the nitrogenous substances with 
 the formation of toxic products, and in other cases produce 
 injurious effects in the digestive apparatus of the infant by 
 their mere presence. 
 
 The following points are also important : the com- 
 
 ^ The author is, both here and overleaf, apparently referring to 
 pasteurization. 
 
 433 F F 
 
THE PREVENTION OF DISEASE 
 
 binatiou of free liydrochloric acid with the salts of cow's 
 milk and the loss of its antiseptic property, the formation 
 of other acids and gases in the stomach of the hand-fed 
 infant, and the loss of tone of the stomach caused by the 
 increased work and over-distension. This loss of tone 
 extends also to the intestines where it manifests itself by 
 enfeebled peristaltic action and an altered reaction of the 
 intestinal contents in children brought up on cow's milk. 
 When we consider these facts it becomes obvious that we 
 must be prepared to overcome the dangers arising from 
 this source. This has led to the introduction of processes 
 for the sterilization of milk, the details of which cannot be 
 here given ; suffice it to say that too great reliance must 
 not be placed upon these methods, that we should regard 
 with suspicion milk which has been sterilized in the cow- 
 shed, and further that the quantity to be sterilized at one 
 time should not exceed the quantity needed during twenty- 
 four hours in winter or during twelve hours in summer, 
 and it should be kept at a temperature below 45° F. before 
 it is used. As further precautions we may mention that 
 milk which has been warmed and is being kept warm 
 artificially by being wrapped in flannel or in a bottle warmer 
 should not be taken for the child when going on a long 
 journey. The feeding bottles must be kept absolutely clean, 
 and should have wide necks and no projecting shoulders, the 
 teats and milk vessels should be clean, as also should the 
 hands of those who have to deal with the milk, because 
 pathogenic germs may collect under the nails and on the 
 skin of the hands. In institutions artificial feeding is apt 
 to be followed by very bad results, and therefore in these 
 places greater stress still must be laid upon all precautionary 
 measures ; the dangers are greatly increased because of the 
 many hands through which the milk has to pass, and of the 
 possibility of infection of the milk by virulent germs from 
 the air of the wards and from suppurative processes. 
 
 I have already stated that I regard the washing of the 
 mouth of healthy breast-fed children not only as super- 
 fluous but as injurious in certain respects, but I do not hold 
 the same view as regards infants brought up by hand. 
 
 434 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 The milk j^irobably already contains some germs, and with 
 the regurgitation of food into the mouth, which is so com- 
 mon in these children, large flakes of casein become lodged 
 in the cheeks and in other parts from which they cannot be 
 easily dislodged by the tongue, thus affording a suitable 
 soil for numerous microbes ; and for this reason I consider 
 it best to wash out the mouth gently after each meal. It 
 must be done very carefully, so as to avoid injuring the 
 mucous membrane, or inducing vomiting, which is so apt 
 to occur in these infants and which would only frustrate 
 our object. 
 
 Further, injurious effects in feeding with cow's milk 
 arise from mechanical overloading of the stomach and 
 intestines. They include the ill effects of the dyspepsia 
 caused by overfeeding, together with other evils caused by 
 a food which is difficult of digestion, often contains germs 
 and is too long in the distended digestive tract. 
 
 Provided that there are the regular intervals between the 
 times of feeding, and that the mother's breasts and nipples 
 are normal, a breast-fed infant takes the breast, lets go the 
 nipple as soon as its hunger is appeased and generally falls 
 asleep. The act of sucking the breast of the mother or 
 wet nurse is, with a few exceptions, work which tires the 
 infant and induces sleep ; but it is otherwise with a child 
 fed on cow's milk. The short tubeless teats of feedino- 
 bottles, introduced in the last few years because of clean- 
 liness and almost universally used, enable the milk to get 
 into the stomach with very little effort and with great 
 rapidity. Large quantities of air are generally sucked 
 down with the milk, the feeling of tiredness after doing 
 work does not set in, a larger quantity of milk than is 
 required gets into the stomach and is more difficult of 
 digestion. The undue delay of the food in the stomach 
 and the abnormal formation of gas produce atony of the 
 walls and over-distension — conditions well known to every 
 physician. 
 
 The close connexion between gastric and intestinal 
 digestion and the rapid extension to the intestines of any 
 gastric disturbance may give rise to intestinal disorders 
 
 435 
 
THE PREVENTION OF DISEASE 
 
 whicli at tlie slightest provocation pass into tlie severest 
 forms of gastro-enteritis. Contrivances devised to imitate 
 tlie meclianisni of breast-feeding, sucli as long tubes with 
 valves in the stopper of the feeding bottle, or valves at 
 the sides of the bottles, answer the purpose to some 
 extent, but have the disadvantage of making it difficult 
 if not impossible to clean the apparatus thoroughly, and 
 therefore do not really help. It is better to give a 
 measured quantity of milk adapted to the age, weight 
 and size of the infant, in accordance with tables drawn up 
 by different authors, the best of which are Escherich's, 
 based upon the volumetric method. But here we are deal- 
 ing only with averages, and it becomes difficult to individ- 
 ualize for any given case. The method also is somewhat 
 complex, and would be beyond the intellectual grasp of 
 some of the women into whose hands the preparation of 
 the infant's food is entrusted. We must remember that 
 the rules for the artificial feeding of infants have to be 
 put in a form which is simple enough to be carried out by 
 any one. 
 
 I know that the preceding pronouncements will meet 
 with much criticism, especially from German readers, 
 and that my views about the difficulties and dangers 
 arising from feeding infants on cow's milk will be 
 regarded as much exaggerated. The standpoint I take 
 may be explained by the fact that my work lies in a 
 district where infants are suckled, and that I have had 
 many opportunities for observing the very great differences 
 between these results and those obtained from the methods 
 of artificial feeding described above. It is possible that the 
 greater personal experience and the greater intelligence of 
 a people who interest themselves more in this matter, and 
 the better conditions and more careful preparation of the 
 cow's milk which result from this, may make the results 
 more favourable than they are with us in the country ; 
 yet when I compare the rates of mortality among breast- 
 fed and artificially fed infants and note how insignificantly 
 these have been influenced, in spite of the great progress 
 made in the art of artificial feeding during the last decade, 
 
 436 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 I am forced to the conclusion that the statements I have 
 made are for the most part not exaggerated. 
 
 After the various preparations of cow's milk, we must 
 next consider condensed milks and the commercial pro- 
 ducts known as permanent sterilized milks. They have 
 the advantage of being free from germs when they reach 
 the consumer, but possess a number of other bad qualities. 
 Some contain a large proportion of cane sugar, others have 
 a disagreeable flavour and if used exclusively for a long 
 time are said to produce not only the ill effects common to 
 all methods of artificial feeding, but also to cause scurvy- 
 rickets (Barlow's disease). About the latter I have no 
 personal experience, as the disease is quite unknown in this 
 part of the country. 
 
 The prepared foods for children, many of which are 
 already in the market, while others are being added to the 
 list almost every year, possess some advantages. They are 
 easy to prepare, can be kept a long time, and are relatively 
 free from germs. On the other hand they are most unsuit- 
 able during the first months of life, because the child's 
 powers of absorption cannot be altered ; they tend to cause 
 obstinate constipation and often give rise to severe gastro- 
 intestinal complaints. 
 
 A rational hygiene for the first year of life, the object of 
 which is to preserve the normal condition of the digestive 
 organs of the infant and to ensure the satisfactory develop- 
 ment of the child, must include a decision as to the time 
 when a breast-fed infant should receive additional food, and 
 when it ought to be weaned from the breast. I will briefly 
 answer this question. Food should be given in addition to 
 the breast milk when failure to increase in weight or too 
 small a weekly increase of weight for some time shows that 
 the mother's milk or wet nurse's milk is insufficient. This 
 may not occur till relatively quite late, and there are many 
 children who thrive exceedingly well up to the tenth or 
 twelfth month on breast milk alone. But the commencement 
 of the second half year of life seems generally to be the time 
 at which additional food is required. How this is to be given 
 cannot further be detailed in this place, I will merely point 
 
 437 
 
THE PREVENTION OF DISEASE 
 
 out tliat a gradual and slow increase of food is more rational 
 and less dangerous tlian a sudden addition. Concerning tlie 
 choice of food — my custom is first to give a thin soup to see 
 ■whether the child can take any additional food ; later breast- 
 feeding once a day will be sufficient, and pap may be given, 
 and thus the infant is gradually weaned in the course of 
 two or three months. By this method we avoid any sudden 
 change, and further there is the possibility of returning to 
 breast-feeding if digestive disturbances make it necessary. 
 
 "What has been said about additional feeding applies also 
 to weaning, indeed the former is only to prepare for the 
 latter. The more gradually the weaning is carried out, the 
 fewer will be the dangers arising from it. We can gather 
 no physiological rule as to weaning from the development 
 of the infant ; the time for dentition is so inconstant and is 
 dependent upon so many factors that it cannot be used as 
 our guide. The same is true of the change which shows 
 that the limit for assimilation of milk sugar is passed, 
 which cannot in practice be readily enough determined to 
 serve us as a guide. That whenever possible weaning 
 should not be postponed to the hottest season of the year is 
 self evident. 
 
 I have already stated that for the additional feeding of 
 breast-fed infants, and later for the entire feeding of the 
 weaned infant, I use a suitable preparation of cow's milk, 
 soups and various forms of pap. Eggs I like to avoid dur- 
 ing the first year of life, because exact experiments have 
 shown me that diarrhoea, with very ofi'ensive motions, has 
 followed the use of eggs ; and meat, even when hashed or 
 minced, I would not give until the fourth half year of life, 
 because I have observed a number of cases of intestinal 
 irritation set up by giving meat early. These are not 
 definite rules for feeding, but merely advice one can give, 
 and parents will often without the knowledge and consent 
 of the physician fail to carry out the advice, and yet the 
 children may not suffer any ill effects. On the other hand, 
 if the parents have been told of the dangers, they cannot 
 blame the physician if ill effects do result. 
 
 It is now time to end this long chapter about diet during 
 
 438 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 infancy, and to turn our attention to the preventive treat- 
 ment, in a wider sense, of intestinal disorders. And here 
 we have two objects in view : firstly, to prevent further 
 extension of the disorder by adopting treatment at the very 
 commencement of the illness ; and secondly, by suitable 
 precautionary measures to prevent complications from 
 developing. And lastly, especially in institutions, we must 
 bear in mind the important fact that a number of these 
 disorders are very infectious, and we must do our utmost to 
 prevent the disease spreading to others. 
 
 Sufficient stress is not laid upon the fact that gastro- 
 intestinal disease in infants, even though it appear as a 
 most acute process, is not in most cases really so, but 
 develops upon a soil long prepared for it as it develops after 
 repeated slight attacks. Just as, on the one hand, it is 
 possible by keeping a careful watch over the feeding to 
 prevent the greater number of cases of digestive troubles, so 
 too it is possible by careful observation to recognize these 
 minor disturbances or alterations in the digestive process, to 
 remove them by adequate measures, and thus to prevent an 
 outbreak of more severe disease. It is evident that this 
 requires an exact knowledge of the physiology of digestion 
 in the infant, that the greatest attention should be given 
 even to the most trivial symptoms, and that we must not 
 rely upon the increase in weight alone, because the weight 
 may be quite satisfactory in children with sHght gastro- 
 intestinal trouble. The serious illness which often quite 
 unexpectedly sets in with great intensity and rapidity, and 
 resists all treatment or proves very intractable, places the 
 physician in a very difficult position, for which he is himself 
 partly to blame. We should therefore pay special attention 
 to the general appearance of the child — the play of its features, 
 the condition of the buccal mucous membrane, the number 
 and nature of its evacuations and its sleej). We should 
 note also the vomit if such occur, the state of distention of 
 the abdomen, the condition of the anal region and the 
 frequency of micturition. These various points cannot 
 here be dealt with in detail, and for further information I 
 would refer the reader to the excellent article by Von 
 
 439 
 
THE PREVENTION OF DISEASE 
 
 Epstein in the "Handbook of Practical Medicine." These 
 conditions require our most careful attention, and immedi- 
 ate treatment of them will generally prevent the threatened 
 gastro-enteritis. That this is a very grave danger in 
 artificially fed children, and that it requires greater atten- 
 tion than the physician generally bestows upon it, is 
 obvious from what has been said above. Though, at this 
 period of life, the most serious and dangerous digestive 
 disorders are the apparently acute disorders which set in 
 when the infant appears to be in perfect health, yet the 
 most troublesome ones which the physician is called upon 
 to treat are those chronic digestive disorders, the seeds of 
 which were sown mostly by improper feeding and by 
 disregard of previous premonitory and slight digestive 
 disturbances. 
 
 Next we come to cases where the disease is already fully 
 developed and where prophylactic treatment is required to 
 prevent the disease from becoming general and to prevent 
 accidental complications. To treat this subject exhaust- 
 ively would compel me to go over the entire field of the 
 pathology of digestive disorders in the infant : I shall there- 
 fore restrict myself to giving a few examples. The first 
 thing to be done is to expel the infective material from the 
 gastro-intestinal tract, or to render it innocuous, to remove 
 fermenting masses, to dilute the toxins, and to bring 
 about conditions which are not favourable to the growth 
 of intestinal microbes. These indications can be ful- 
 filled by the mechanical emptying of the stomach and 
 intestines, and by the administration of harmless liquids 
 such as tea or boiled water. It is important that the 
 mouth should be kept clean, because infective processes 
 may spread thence to adjacent cavities, to the salivary 
 glands or downwards to the oesophagus. The swallowing 
 of infected secretions should be prevented because it may 
 produce disease of the lungs. The skin needs careful 
 attention, because infectious processes often begin in the 
 skin and thence invade the body. Diapers soiled with 
 faeces or urine should at once be removed and thoroughly 
 disinfected to prevent infectious intestinal germs from 
 
 440 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 getting into other cavities and infecting them. The great- 
 est cleanliness is required as regards the hands and linen 
 and all utensils used for the child. Purity of the air in the 
 room is also important, and other similar preventive 
 measures already suggested in the earlier pages should 
 be adopted. 
 
 Very special ^precautions are needed in institutions, for 
 many of the morbid processes considered are extremely con- 
 tagious and readily spread to the greater number of the 
 children kept in the institution. There are various ways 
 in which the infection is spread, all of which should be kept 
 in mind. It is safest when possible to isolate these cases 
 completely, and to appoint special attendants for them. The 
 diapers and child's body linen should be disinfected with solu- 
 tion of corrosive sublimate and then washed separately from 
 the other linen. Each patient should have a separate ther- 
 mometer and bath. The feeding bottle and teat and all 
 utensils used in preparing the milk should be kept separate 
 from the rest. After a death has occurred from such a 
 disease the room and all its contents should be thoroughly 
 disinfected, and infected objects should be destroyed. If 
 complete isolation of these children is impossible the cubicle 
 system may be tried, which was introduced into the 
 children's hospital at Paris by Grancher. Each child suffering 
 from an infective disease is in a small cubicle separated off 
 by curtains from the rest of the ward ; all utensils used for it 
 are kept in the cubicle ; and the child is attended to by one 
 special nurse. The physician wears a linen overall, and 
 before leaving the cubicle disinfects his hands thoroughly. 
 To diminish the risk of germs being carried by the air, 
 partly directly and partly by getting into the food or 
 feeding bottles, the room must be well ventilated. The 
 air in it should be often changed ; the walls, ceilings 
 and floors should be such as can be easily washed ; and the 
 dust may be reduced to a minimum by having furniture of 
 glass and iron which can be easily cleaned, by having no 
 corners in the room, and by dusting with a damp duster. 
 These precautionary measures are not purposeless and 
 excessive. The great value of such precautions has been 
 
 441 
 
THE PEEVENTION OF DISEASE 
 
 proved by tlie results obtained in newly erected institutions 
 whicL. were planned and built and fitted up in accordance 
 with, the views above expressed. 
 
 As already stated, this chapter is devoted to diseases 
 which mostly affect children in the suckling period, and I 
 jDass on therefore to speak of preventive treatment in con- 
 genital syphilis. Syphilitic infection may be acquired by 
 the infant in various ways, namely from a syphilitic 
 wet nurse, from utensils, feeding bottles and sponges 
 used for other children who are syphilitic, from sleeping 
 with a syphilitic person, and from kissing by one whose 
 mouth is affected with the disease. Such cases belong to 
 the group of acquired syphilis, and begin with the typical 
 initial lesion and show no special modification in their 
 course at the various periods of life. Preventive treatment 
 consists of the ordinary measures for the prevention of 
 syphilis. "We can leave therefore the subject of acquired 
 syphilis and pass on to congenital syphilis, which affects 
 the infant in utero, whether it be inherited from the 
 father, from the mother, or from both parents, and consider 
 whether it is possible by treatment to prevent inherited 
 syphilis, or to prevent an outbreak of syphilitic symptoms 
 in a child born apparently healthy. Here, as I pointed out 
 in the introductory remarks, factors are concerned which 
 do not fall within the sphere of the physician's influence. 
 "We are in a position to state what has been amply verified 
 by the investigations of inquirers into this special subject, 
 namely that syphilis can by long and energetic treatment 
 be cured so completely as to leave scarcely any risk of 
 infection possible for mother or offspring. But it is seldom 
 possible to induce the man to submit to this prolonged 
 treatment before he marries. Often he conceals the fact 
 that he is diseased, barely waits even till the manifest 
 symptoms have disappeared, and then, without any precau- 
 tionary measures, by sexual connexion seriously injures a 
 young life entrusted to his care, and of an entire generation 
 some are destroyed and some are brought into the world 
 heavily handicapped. When, as is unfortunately often the 
 case, it is not possible to cure syphilis in the husband by a 
 
 442 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 long and energetic treatment, we must at least endeavour 
 to mitigate its effect upon mother and child by suitable 
 measures. There are, as is well known, several possibilities : 
 the ovum may be infected from the paternal side, and 
 abortion, premature delivery, or still birth may be the 
 result, or the child may be born with syphilitic symptoms, 
 or the symptoms may develop in the course of a few 
 weeks ; but the mother may be free from syphilis and may 
 remain free, having been made immune by the foetus, 
 according to Colles' law. In other cases the mother 
 becomes infected by the father who has recently become 
 syphilitic, later she becomes pregnant, and the pregnancy 
 ends in one of the ways just enumerated. And lastly, the 
 mother may become infected after conception has occurred, 
 and the ovum which was healthy may subsequently 
 become infected with syphilis. Further, it is important 
 in preventive treatment that we should know whether in 
 any particular case the woman is a primipara or a multi- 
 para. Unfortunately it is generally the rule that our 
 attention is first directed to the matter by a history of 
 premature or of still births, and further inquiry is then 
 made. I will now briefly refer to these various cases and 
 merely state the treatment to be adopted. 
 
 In cases where the husband has recently become infected 
 with syphilis the wife, if pregnant, and the husband should 
 both be submitted to energetic antisyphilitic treatment. I 
 advise this in all cases, even when the wife is free from 
 any syphilitic symptoms, and it is the more necessary 
 when she shows syphilitic symptoms. It is evident 
 that the wife should also be treated when after 
 conception she has become syphilitic. In cases where 
 many miscarriages and the death of children make us 
 suspect syphilis, we should look for signs of syphilis with 
 tact and caution, and should begin energetic antisyphilitic 
 treatment of both parents, even though all signs and 
 symptoms of syphilis are absent. The good results of 
 this will be obvious in the children subsequently born. 
 Antisyphilitic treatment when carefully carried out may 
 be looked upon as almost free from any possible ill effect, 
 
 443 
 
THE PREVENTION OF DISEASE 
 
 and should be used wittiout hesitation in these cases, seeing 
 the good results which follow its use. 
 
 Another question in the preventive treatment of syphilis 
 is whether a child born of syphilitic parents, and which is 
 apparently quite healthy, should be at once treated with 
 mercury, or not till symptoms of syphilis become manifest. 
 Here too we must distinguish between several possibilities : 
 if the child is born free from syphilis, and the father has 
 had syphilis but the mother has shown no symptoms of 
 syphilis during the pregnancy, we can postpone treatment 
 of the child because it does not follow that such children 
 will be syphilitic. The same holds good when the mother 
 has previously shown signs of syphilis but has remained 
 quite free from them during this particular pregnancy : the 
 child often escapes infection in such cases. On the other 
 hand we must not postpone preventive antisyphilitic treat- 
 ment when the mother has shown fresh signs of syphilis 
 during this particular pregnancy, or when she has become 
 primarily infected with syphilis during the pregnancy. 
 
 As to the feeding of a child which has or is suspected of 
 having congenital syphilis — we must, considering the 
 serious disease which is present or may appear, endeavour 
 to secure the most favourable conditions possible ; breast- 
 feeding should therefore be advised whenever possible. 
 It is obvious that the infant may only have the breast of 
 its own mother, and I consider it to be unjustifiable to ask 
 a wet nurse to undertake such a case, even when she fully 
 understands the circumstances and is highly remune- 
 rated. The want of intelligence in such people does not 
 enable them to estimate correctly the extent of the risk 
 which they run, and apart from this fact, the physician 
 cannot conscientiously make use of the favourable pecuniary 
 circumstances of a family in this immoral way — in short, 
 I feel I cannot take up too decided an attitude against such 
 a proceeding. When physical exhaustion or marked 
 anaemia, deficiency of milk, or severe syphilitic lesions pre- 
 vent the mother from nursing her child, we must resort to 
 artificial feeding, regardless of the fact that this is not a 
 favourable course for a child with hereditary syphilis. An 
 
 444 
 
THE PREVENTION OF THE DISEASES OE CHILDREN 
 
 occasional exception to Oolles' law has here and there been 
 known, and the mother does therefore run a slight risk 
 by suckling her syphilitic child and may contract a primary 
 hard sore. But such exceptions are very rare, and no weight 
 should be attached to this slight risk which a mother may 
 be expected to run for her own child. 
 
 An infant suffering from congenital syphilis is as dan- 
 gerous to its entourage as is anyone who is suffering from 
 acquired syphilis, and similar precautions must be taken 
 against the spread of the disease ; and I have nothing to 
 add to this statement. Cases have occurred in which a 
 syphilitic child is breast-fed by a healthy wet nurse, when 
 syphilis was not known or was not suspected to exist till 
 syphilitic symptoms made their appearance a few weeks 
 after birth. Such cases are not rare, and I consider that 
 the only proper course to adopt is at once to remove the 
 child from the breast, to put the wet nurse under careful 
 observation for at least six weeks, and to treat her by 
 inunction at the very first appearance of symptoms. If the 
 nurse declines to submit to this quarantine, it is the dut}^ 
 of the physician to explain what may be the possible result. 
 
 In concluding this subject I will add a few words about 
 syphilis acquired during the suckling period. Infection 
 takes place generally by feeding either from a wet nurse 
 who was not thoroughly examined, or from the use of a 
 teat or spoon previously used by a syphilitic child, or from 
 the mother infecting the milk or the cup by tasting the 
 milk when suffering from some syphilitic lesions of the 
 mouth. The prevention of such infection is by a care- 
 ful physical examination of the nurse, careful inquiry 
 into her previous health and history, and whenever possible 
 an inspection of her child ; we should never rely upon the 
 medical certificate brought from a registry office, but should 
 examine the nurse, because only then can we assume the 
 responsibility. The authorities have also an important 
 duty to perform, and this occupation of going out to nurse 
 should be strictly watched, because evils frequently arise 
 out of it, and any breach of the law should be severely 
 punished. How to prevent infection by the other ways 
 
 445 
 
THE PREVENTION OF DISEASE 
 
 just mentioned is obvious : I need only say tliat tasting 
 the milk should be forbidden, for the tem^Derature of tlie 
 milk can be estimated in other ways, and there is also 
 the possibility that other infective processes may be con- 
 veyed by tasting the milk. The risk of infection by spoon, 
 sponge and washing apparatus has already been mentioned : 
 in this respect a child suffering from syphilis must be 
 treated exactly as one would treat a child suffering from a 
 contagious disease. Infection by the genitals need scarcely 
 be taken into consideration at that tender age, but sleeping 
 in the bed with an affected person should be forbidden ; this 
 bad habit is not uncommon among the lower classes. 
 Lastly, it should be remembered that infection is convej^-ed 
 by kissing, and I must not let this op23ortunity pass without 
 uttering my emphatic protest against this widespread bad 
 habit. The physician should advise the parents to refuse 
 politely but emphatically to allow the infant to be kissed 
 when it is brought out to be shown. 
 
 A second chronic infective disease, which may be acquired 
 through the placenta but more frequently ap]3ears during 
 the early weeks of life, is tuberculosis, and I will devote a 
 few lines to the preventive treatment of this during inf ancj^ 
 The contention long waged as to the possibility of the 
 direct conve^^'ance of Koch's bacillus from the maternal to 
 the foetal circulation has now been definitely settled by a 
 number of observations ; nevertheless such transmission is 
 extremely rare, and we are powerless to do anything by 
 treatment to prevent it. It is different in the case of 
 tubercidosis acquired after birth, and much can be done 
 even at that tender age to lessen the dangers of infection, 
 by the modern methods of isolation and the reception of 
 phthisical patients into special institutions, and other 
 similar preventive measures. The pendulum seems to me 
 to be swinging too far again in one direction, as happened 
 before, when the communication of the discovery of the 
 exciting cause of tuberculosis was first made, and the theorj'' 
 as to infection, which was formerly kept within reasonable 
 limits, now occupies the field, while the well founded teach- 
 ing about a tubercular disjDOsition, proved to be correct by 
 
 446 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 innumerable observations made on tuberculous families, 
 has passed altogether into the background. "We welcome 
 it as a step in advance in public and private hygiene, that 
 the laxity which formerly existed in connexion with the 
 disposal of tuberculous products has been removed, as a 
 result of the very useful researches of Cornet and Fliigge, 
 which showed that prevailing ideas were in part erroneous; 
 but it must be pointed out that we are apt to expect too 
 much from these precautionary measures. 
 
 A bodily condition which affords a favourable soil for the 
 bacillus plaj^s at least as important a role in the genesis of 
 tuberculosis as does the exciting cause itself, and under 
 certain circumstances an individual thus predisposed will 
 develop tuberculosis, while for others who are not thus 
 predisposed there exists not the least danger. The fight 
 against tuberculosis is not only to be waged against the 
 infection, but also against the tuberculous disposition, and 
 to ensure success must include hygienic rules for the bring- 
 ing up of children and for diet. 
 
 An infant generally acquires tuberculosis in one of two 
 ways, by the digestive or by the respiratory tract, and may 
 suffer from gastro-intestinal or pulmonary tuberculosis. 
 The former can only arise from artificial feeding, at least I 
 know of no authentic case where tuberculosis was acquired 
 through the milk of the mother or of a wet nurse. Dia- 
 gnostic tests with tuberculin, now regularly carried out, 
 have convinced us that there is much bovine tuberculosis 
 among milch cows, and there are many examples of the 
 conveyance of tuberculosis in this way. To prevent infec- 
 tion, the milk given to the child should come from cows 
 which have been proved by the tuberculin test to be free 
 from bovine tuberculosis ; the milk should be boiled and 
 never used either unboiled or heated below boiling point. 
 Infection through the respiratory tract is derived from 
 pulmonary phthisis in the mother or father or in both. 
 When speaking about suckling tuberculosis in the mother 
 was named among the contra-indications, and I must 
 emphasize this again here. If circumstances permit a wet 
 nurse should be procured, because the many digestive dis- 
 
 447 
 
THE PREVENTION OF DISEASE 
 
 turbances produced "by artificial feeding pave the way in 
 snch cliildren for the development of tuberculosis. The 
 child is infected directl}^ by the act of coughing when 
 moist particles containing bacilli get into the nose or mouth 
 of the child, or it may be infected by germs carried to it in 
 the act of kissing, or during some of the many attentions 
 which are bestowed upon it. Finally bacilli which get 
 into the dust of the room from dried sputum may infect 
 the child. Preventive measures should be directed against 
 all these sources of infection. Parents should be advised 
 to do as little as possible themselves for the child, and 
 should allow others to attend to it ; their sputum should be 
 received into a cloth which is put at once into corrosive 
 sublimate solution and then thoroughly washed in a separate 
 vessel. In this way we can best prevent infection by small 
 moist particles or by dried sputum. 
 
 Frequent washing of the hands, no kissing, no tasting of 
 the food or blowing it, are further precautions which should 
 be observed. Heubner has recently recommended the 
 establishment of special homes for the children of tubercu- 
 lous parents : these are very suitable for such cases ; the 
 child is thereby removed from the source of infection, and 
 fresh air and good feeding will tend to prevent the develop- 
 ment of a tuberculous predisposition. There is unfortu- 
 nately great difficulty in diagnosing tuberculosis in these 
 Yerj young children, and isolation of all children who are 
 attacked is therefore not possible. At this age tuber- 
 culosis generally assumes a form which is unaccompanied 
 by any external tuberculous secretion, or at most the 
 bacilli are expelled with the faeces, and a thorough disin- 
 fection of the napkins reduces the danger of infection to a 
 minimum for the inmates of the sick room or for the persons 
 around the sick child. 
 
 The influence of certain infectious diseases upon the 
 incidence or manifestation of a hitherto latent tuberculosis, 
 the measures which may be taken to prevent it, and the 
 preventive measures against scrofula, which usually 
 appears only after the lactation period, will be referred 
 
 to later. 
 
 448 
 
THE PlIEVEXTION OF THE DISEASES OF CHILDREN 
 
 From these chronic infectious diseases I pass to rickets, a 
 constitutional malady which is very common during child- 
 hood.. The first symptoms often begin shortly after birth, 
 but more often during the second halfyear of life, and 
 preveiitive measures are most effectual during this period. 
 So far we have been concerned with processes whose nature 
 is fairly clear and whose predisposing and exciting causes 
 are largely known, but now we are concerned with an affec- 
 tion whose aetiology is still quite obscure, in spite of much 
 work that has been done in this direction. If we have the 
 courage frankly to admit the fact and not confine ourselves 
 to mere assumptions, or believe that we have reached the 
 bottom of the matter when we have only considered this or 
 that factor, then it will be acknowledged that the prevention 
 of rickets is one of the most difficult problems that confront us. 
 Different authorities have variously ascribed the primary 
 cause of rickets to improper feeding, to unsuitable homes, 
 or to some infectious condition, but a very large experience 
 has convinced me that these factors influence to some extent 
 the severity of the disease and the rachitic manifestations, 
 but are not the cause of the disease itself. Many newborn 
 infants show unmistakable signs of rickets, such as general 
 enlargement of the ends of the costal cartilages, defects in 
 the ossification of the bones of the skull, curved tibiae and 
 a protuberant abdomen. This would seem to be against 
 the influence of the above-named factors and suggests some 
 hereditary cause, particularly as the parents, more especially 
 the mothers, of such children show signs of former rickets. 
 Rickets is almost unknown in some countries where infants 
 are badly fed and are in unsuitable homes, while in neigh- 
 bouring districts where the social and material conditions 
 are far better for the infant rickets is very common. I may 
 instance North Italy with its special hospitals for rickets, 
 and South Italy where rickets is scarcely known. These 
 facts do not support the theory that it is due to diet or to 
 insanitary surroundings. In Germany some 90 to 95 per 
 cent, of the children suffer from rickets at some time or 
 other of their lives, and the disease is met with in breast-fed 
 children as well as in artificially fed children, in the palatial 
 
 449 GG 
 
The PREVE^^noN of disease 
 
 homes of the rich as well as in the hovels of the poor. I 
 confess that amid favourable conditions of life the percent- 
 age of cases is lower and rickets occurs in a less severe form, 
 but experience has also convinced me that in spite of the 
 greatest care in diet, and in spite of living in fresh air, 
 symptoms of rickets have appeared, generally at the 
 beginning of the second halfyear of life. Personally 
 therefore I am of opinion that the above-named factors 
 affect the severity of the disease but are not its cause. 
 Some time ago I ventured to suggest the opinion that 
 rickets is a racial disease. I was not able to offer evidence 
 in proof of this view, and in Bohemia, where two races of 
 people live side by side, both suffer froru rickets. But I 
 made the suggestion as the result of what has been said 
 above about the geographical distribution of rickets and the 
 inadequate causes to which rickets is ascribed. I have 
 referred to this matter here, that on the one hand I might 
 give reasons why I regard our preventive measures against 
 rickets as somewhat ineffectual, and on the other hand to 
 combat statements made as to the sure results of this or of 
 that method of treatment. It is indeed evident that when 
 the child's diet and other conditions of life are improved, 
 its whole organism is fortified and rendered less liable to be 
 attacked by any disease, and I would for that reason 
 always advocate such general preventive treatment, though 
 I could not undertake to say that such a child fed at the 
 mother's breast is immune against rickets, because I am 
 almost daily convinced of the contrary. 
 
 Though little can be done to prevent rickets, yet the 
 complications can be prevented by suitable treatment. I 
 cannot refrain in this place from speaking about phos- 
 phorus, especially of phosphorated cod liver oil, which is 
 not very highly valued at the present time. Though 
 theoretically its action is doubtful, and though possibly it 
 only attacks the rarefaction of the bones and leaves 
 untouched the essential rachitic changes, yet its effect in a 
 very large proportion of cases is excellent, indeed its effect 
 upon the severe nervous symptoms of this disease might 
 almost be termed magical, and I should not like to be 
 
 450 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 without this drug. By giving phosphorus we can in a 
 comparatively short time prevent those complications which 
 are to be feared, complications affecting the respiratory and 
 digestive organs, the blood-building structures and central 
 nervous system, and in this respect phosphorus is a most 
 valuable prophylactic. To sum up briefly, I would first 
 endeavour to modify the future attack of rickets by suitable 
 diet and mode of life, and at the first sign of rickets would 
 begin this phosphorus treatment, provided that the drug is 
 well borne by the infant, and this is mostly the case in 
 infants, though not invariably. One word about institu- 
 tions for sea baths and brine baths, so many of which 
 have been established in recent years, and have been said 
 to give excellent results. They certainly are of some 
 value, because the methods there carried out tend to check 
 the progress of the rachitic process, and cause a rapid 
 consolidation of the osseous structures, and thus counteract 
 the extensive curvatures so frequently met with. And in 
 this way they are a valuable addition to treatment by 
 phosphorus. 
 
 Acute infective diseases will be described in a later 
 chapter. They are not common during infancy. The child 
 is less often exposed to infection during this period of life, 
 and there are therefore no special preventive measures 
 against these diseases at this age. It remains for me to 
 consider a few disorders which may possibly be prevented by 
 suitable measures. Mastitis in infants is the most important 
 of these : it is often met with during the first weeks of 
 life, and deserves special notice, not only because it is a 
 painful disorder which may become the starting point of 
 a general infection, but also because it may lead to partial 
 destruction of the mammary gland, which in girls is so 
 important an organ later in connexion with maternal 
 functions. A firm stand should be taken against the 
 custom of squeezing the infant's breast : this is a practice 
 which fails to accomplish its object and remove the se- 
 cretion ; on the contrary it increases the secretion by the 
 mechanical irritation, and at the same time exposes the 
 infant to the danger of infection by dirty hands, from the 
 
 451 
 
THE PREVENTION OF DISEASE 
 
 adjacent skin, or from secretion wliich has been squeezed 
 out and covers tlie nipple. This infection -may give rise to 
 deep-seated suppurative inflammation of the breast which 
 never occurs when the breasts have been left untouched, 
 covered only by a dry or wet dressing. "When there is a 
 mammary abscess it is imjDortant as a prophylactic measure, 
 especially in girls, that the abscess should be opened by an 
 incision parallel with the mammary ducts, that is by an 
 incision radiating from the ni23i3le, to avoid a transverse 
 division of the lactiferous ducts which might lead to the 
 formation of cysts. 
 
 The other infections which may proceed from the skin 
 and its glands and their prevention have already been 
 mentioned. I have still to consider a few affections of the 
 mouth in connexion with the digestive organs. Psoriasis 
 linguae is a very trivial affection, probably never giving 
 rise to serious disturbances, and I can dismiss it in a 
 few words. My personal impression is that this condition 
 is never met with except in children fed with the bottle or 
 using one indiarubber teat for a long time. I have never 
 been able to confirm the statement made of a relation 
 between this affection and tuberculosis. We cannot too 
 strongly condemn the use of rubber teats to soothe babies. 
 "When we remember that these indiarubber teats are gener- 
 ally first moistened by the mother Avith her own saliva, and 
 then put into the child's mouth, it is really astonishing 
 that affections of the infant's mouth are not more common. 
 This harmful custom is one of the most widespread in the 
 nurser}^, and it is comparatively easy to do away with. 
 
 Aphthous stomatitis is an affection against which pre- 
 ventive measures are most effectual. Its connexion with 
 foot and mouth disease of cattle is maintained by many, 
 and though not definitely established yet it is advisable 
 not to use the milk of cows affected with this disease, 
 and on the other hand to boil the milk thoroughly and 
 thus destroy any germs of this disease which may have 
 got into the milk. Further, the infant affected with 
 aphthous stomatitis should be isolated, and all articles 
 used by it should be carefully disinfected. Lastly, the 
 
 452 
 
THE PREVENTION OF THE DISEASES OF OHILDREN 
 
 .1 Ifpctimi sliould he prompt I3' ami energeticalh^ treated to 
 prevent tlip injurious pffects of complications, such as 
 diseases of the e^^es and of the lungs, which are serious 
 and may be prevented. 
 
 The same is true of ulcerative stomatitis, which may be 
 a primary affection caused by infection of the mouth with 
 the cocci of pus, and may thence spread to the skin, or it 
 may be a secondary affection conveyed to the mouth by 
 the infant's fingers, from impetigo of the face or of some 
 other part of the body. Prompt measures should be taken 
 to prevent the spread of such an impetiginous dermatitis. 
 An endeavour must be made to prevent the infant from 
 scratching the eruption and infecting its fingers.; and con- 
 versely, v/hen the affection begins in the mouth, we must 
 prevent its extending to the skin and must heal it promptly. 
 
 Finally, in this chapter I must mention certain manipu- 
 lations which in nnskilled hands and with unsuitable 
 instruments may cause injury. I refer to enemata. It is 
 a very bad custom which prompts the nurse to show her 
 skill by giving at once an enema, though there be no 
 indication for it. Often she uses an unsuitable instrument 
 or one which is not free from danger, and preventive treat- 
 ment which covers the entire range of the disease of chil- 
 dren must guard too against injuries which may be thus 
 produced. Ulceration, haemorrhage, fissures, even intus- 
 susception, may be produced, and it should be a rule that 
 no enema be given except when prescribed by the doctor, 
 and he should superintend the giving of the first enema 
 and should see that the instrnment does not consist of a 
 syringe with a hard nozzle, but merely of a tube, a tap 
 and a soft rubber catheter, which can inflict no injury 
 nor allow of any force being used. 
 
 Certain affections of the respiratory tract in this period 
 of life require special treatment, partly because of their 
 special significance and partly that they maj^ be prevented. 
 Coryza is the chief of these, quite a trivial affection in older 
 children but serious in the sucking infant, for it is a 
 hindrance to sucking, as the nasal cavities are blocked and 
 breathing interfered with, and it may also be the starting 
 
 463 
 
THE PEEVENTION OE DISEASE 
 
 point of infections which j)ass clown the respiratory tract. 
 Infectious catarrhs caused by mechanical irritation of the 
 nose with sejDtic objects have already been mentioned, and 
 the method to be adopted in cleaning the infant's nose was 
 described. It still remains for me to refer to " catching 
 cold" and to say a few words about it. It would be a 
 mistake to begin to harden the body at this period of life, as 
 some would have us do. The great hyperaemia of the skin 
 in the first weeks of life, the inability to regulate the heat 
 formation and the very small amount of movement make the 
 infant very susceptible to all sudden changes of temperature 
 and often are followed by violent and quite unexpected 
 reaction. One natural result of this is that we protect the 
 infant very carefully from "taking cold " and from unfa- 
 vourable conditions of the weather ; do not allow it to be 
 carried out except on fine and still days when there is no 
 wind, and do not let it be too long out of doors ; do not 
 have it covered over in the summer, nor allow the tempera- 
 ture of the room to rise too high or fall too low. The heat 
 of the bath water is checked by a thermometer, and is only 
 gradually lowered during the later months of the period of 
 infancy. These precautions generally suffi.ce to prevent 
 colds with their serious sequelae in infants. If the infant 
 has a cold very great care and good nursing are needed to 
 prevent bronchitis and broncho-pneumonia, which are very 
 dangerous conditions in the infant and readily follow the 
 cold. The transition between the simple cold and these 
 conditions is often hardly noticeable, and the slightest 
 neglect may give rise to bronchitis. We must utter a 
 warning then against these colds, and every cold must 
 be regarded as serious in the first months of life. The 
 infant should be kept in the room till the cold has quite 
 gone, and should be most carefully shielded from taking 
 any fresh cold even indoors. 
 
 "What has been said about coryza applies still more to 
 bronchitis, which even in its mildest form, and limited to 
 the larger bronchial tubes, is a serious and very trouble- 
 some affection demanding the greatest attention. Most 
 cases of broncho-pneumonia which seem to be simple are 
 
 454 
 
THE PREVENTION OF THE DISEASES OE CHILDREN 
 
 really tlie result of neglex3ted catarrli of the air passages, 
 and might be prevented by proper care. Additional pre- 
 cautions are required in institutions where the disease 
 assumes a very infectious character from the crowding of 
 sick children in badly ventilated rooms, and where the 
 poison increases in intensity as it passes from child to child. 
 The isolation of such cases and careful disinfection are 
 required, the principles of which have already been given. 
 As a further precaution which should not be neglected, an 
 infant suffering from coryza and bronchitis should not be 
 bathed too soon, as this is apt to aggravate the condition. 
 Secondary pneumonias and their prevention have already 
 been mentioned in so far as thej arise during infancy. 
 True croupous pneumonia is comparatively^ rare during 
 this period of life, and we can do but little to prevent 
 it except by the precautions which should be taken in in- 
 stitutions against any danger of infection, to which refer- 
 ence has already several times been made. 
 
 In conclusion I must briefly mention preventive measures 
 against the ill effects of certain operations undertaken for 
 cosmetic reasons or as religious rites. I mean the piercing 
 of the ears of girls and the ritual circumcision of Jews. 
 The vanity of the female sex does not permit us to do 
 away with ear piercing, but it should at least be done with 
 greater antiseptic precautions than is generally the case. 
 The needles used should be thoroughly disinfected, for it is 
 often very difficult to clean the instrument which is used, 
 and the silk should be boiled or soaked in an antiseptic, so 
 that the obstinate eczema, inflammation and even erysi- 
 pelas spreading from the pierced spot may be of less frequent 
 occurrence. Apart from the inconvenience and risk of 
 these complications, they may render the operation of no 
 effect. It would be wisest to postpone piercing the ears till 
 girls are older ; they will then experience the pain of this 
 operation undertaken to satisfy their vanity, and it will 
 also be possible to do the operation more aseptically. 
 Ritual circumcision is a sad remnant of a fanaticism of 
 past. ages; it was sanctioned also as a hygienic measure in 
 the tropics and amid the want of cleanliness of oriental 
 
 455 
 
THE PREVENTION OF DISEASE 
 
 peoples; but this necessity no longer exists, and one ought 
 to have courage to do away altogether with this barbarous 
 and often dangerous operation. In the instruments em- 
 ployed and in the operation as it is performed by the lay- 
 man, no regard is paid to the modern methods of the 
 treatment of wounds ; and apart from this there are other 
 dangers arising at this tender age from a wound which is 
 not covered by a dressing and is exposed to the neighbouring 
 secretions. In several cases I have seen a fatal result from 
 haemorrhage and from erysipelas which started from the 
 preputial wound, and the custom, which is not common in 
 Grermany, of sucking the wound and sprinkling it with 
 wine held in the mouth, may introduce into the infant's 
 body septic germs and even the germs of syphilis and of 
 tuberculosis, as has been recorded in literature. The be- 
 lief that this operation is a preventive measure against 
 phimosis and balanitis, and also later against venereal 
 infection, cannot be seriously entertained. The number of 
 cases of these diseases is always relatively small, and thej 
 are very amenable to careful treatment and aseptic precau- 
 tions. Another objection is that the results of the opera- 
 tion performed for ritual reasons often need subsequent 
 surgical treatment, and lastly, the numerous cases of genital 
 infection in Jewish youths show plainly enough that the 
 mutilation has been useless in protecting against venereal 
 infection. 
 
 I now turn to — 
 
 PREVENTIVE TREATMENT IN EARLY CHILDHOOD 
 
 In the introductory remarks when I sketched the jDlan 
 to be followed in these pages, I pointed out that other 
 causes play a part in the diseases common to this period of 
 life, and as instances I enumerated the changed diet and 
 way of life of children, their greater independence, their 
 intercourse with playmates, and their frequent contact 
 with the ground. Up to this age preventive treatment 
 was directed mainly against digestive troubles and all else 
 seemed to fall into the background, but now prophylaxis 
 has to face a group of maladies which we include under the 
 
 45fi 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 lerm uf acute iiil'(-'cii(His disease, and their prevention is an 
 important duty for the physician. The rapid growth of 
 organs favours the reception of infective germs at certain 
 parts of the body and requires other preventive measures. 
 Games ; animal and vegetable parasites in the soil, in 
 certain kinds of food and in drinking water ; fruit, sweets 
 and confectionery which are not always quite wholesome — 
 all these factors must not be underrated and require care- 
 ful consideration. During the later, years of this period of 
 childhood the child begins to go to school, and is exposed 
 there chiefly to the risk of catching contagious diseases and 
 therefore special precautions have to be taken. These 
 infectious diseases are the most serious and the most 
 common, and I will therefore commence by speaking of 
 their prevention. 
 
 Scarlatina. — The measures required to be taken against 
 the infectious diseases to prevent their spread, are deter- 
 mined by several factors. First, we must be clear about 
 the way in which the infection is conveyed, and secondly 
 about the period during which infection may be trans- 
 mitted. It is most important to determine the diagnosis 
 as early as possible, because experience has shown that 
 many of these affections are less infective in the initial 
 stages than in their later stages. Further, it is desirable 
 that we should be able to recognize the specific organism, 
 the presence of which in the dwelling room of the sick child 
 or on the articles used by the child may help us to ascertain 
 the source of infection and enable us to judge when infec- 
 tion is at an end. Unfortunately some of these postulates 
 are still impossible, others presuppose a special training, 
 possessed indeed by the experienced physician but not by 
 the parents under whose observation the children generally 
 are at the commencement of the illness. Insufficient 
 medical supervision of schools, on the other hand, often 
 makes it possible for a child to continue to associate with 
 the other children of that school, though already suffering 
 for one or more days from well marked premonitory^ signs 
 of an infective disease. The want of sufficient strictness in 
 seeing that such infectious diseases are at once notified, 
 
 457 
 
THE PEEVENTION OF DISEASE 
 
 and tlie endeavours made to elude this notification by certain 
 classes of the population, lead to serious consequences, and I 
 will give a few examples of everj^day life. A milkman, 
 regardless of the fact that several of his children are suffer- 
 ing from an eruption with fever, continues to serve his 
 customers without taking any precautions ; he fills the 
 milk-can in his house, attends to some small want of his 
 sick children, and then, without washing his hands, goes on 
 with his occupation as milkman. Then, again, washer- 
 women take in washing which they wash in their infected 
 houses, and, without changing their clothes, or in any way 
 cleaning themselves, go into other houses to deliver the 
 washing. Another frequent source of infection is the 
 general provision shop, where, in the room behind the shop, 
 children with some infectious disease may be nursed, and 
 when the shop door opens, the shopkeeper comes out from 
 the sick room and, with hands unwashed, proceeds to sell 
 bread, fruit, or vegetables to the customer, I have selected 
 these few examples, though in our daily life there are many 
 others. The knowledge of these is important, and we 
 should not be content with strict care in the notification of 
 these cases, and with the disinfectant measures prescribed 
 by the law, but in every case which cannot be explained, 
 and where the child has not come into contact with other 
 children, we should prosecute the search for the cause, 
 because only in this way is it possible to remove it. In 
 former years children's hosjDitals suffered much from 
 infection in the hospital, for children who were taken 
 thither for some other illness often sickened and developed 
 an acute exanthem, or, if admitted for one infectious dis- 
 ease, contracted another. Now. however, rooms for doubtful 
 cases are provided, a careful inspection of the children 
 brought up to the hospital is made, and the immediate 
 separation of those showing suspicious symptoms is effected. 
 Separate isolation pavilions for the various diseases here 
 under consideration have been built, and the patients and 
 staff isolated from the remainder of the institution. These 
 precautions have reduced the danger to a minimum and 
 have proved how much can be done by such measures. It 
 
 458 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 is obviously, too, the duty of every j)liysiciaii in private 
 practice to take precautions so that he may not be the 
 means of conveying any infectious disease ; the order of the 
 visits to his patients should be suitably arranged. Similar 
 infectious cases should be visited in succession, and infec- 
 tious patients should generally be seen at the end of his 
 round ; his hands should be thoroughly disinfected both 
 before and after his examination of each patient ; he should 
 put on a linen overall which reaches down to his boots 
 and is kept ready for him in the anteroom — or when this 
 is impossible, he should take off his coat and hang it up 
 outside the sick room, and should afterwards change his 
 clothes before continuing his daily round- — and, finally, he 
 should avoid touching the little patient more than is 
 necessary. All these precautions can be carried out very 
 easily and will considerably diminish the risk of infection 
 being conveyed by the doctor. Having mentioned these 
 general rules, I pass on to consider special preventive 
 measures against scarlatina. 
 
 The diagnosis of scarlatina in its initial stage is not 
 easy : generally the child sickens suddenly with high 
 fever and vomiting, and these symptoms should make 
 us suspect scarlatina and keep the patient isolated. Yet 
 there are cases in which the initial symptoms are very 
 ,slight and are overlooked by the parents, and the 
 physician is only called in when the scarlet fever is 
 already fully developed. And, lastly, there are cases 
 in which the symptoms are so slight that the disease 
 is not recognized by those around the child, and the 
 child is allowed to go out and even to school. Let us 
 suppose a favourable case in which medical help is called 
 in at the very earliest symptoms. We should at once 
 proceed to examine the throat, for this should never be 
 omitted in a child, and see whether a rash is present and 
 the tonsils swollen. If there is a possibility of the disease 
 being scarlatina, the child should be isolated. My experi- 
 ence proves that this course will always save the brothers 
 and sisters from becoming infected at the initial stage, and 
 careful antiseptic precautions will protect them from later 
 
 459 
 
THE PEEA^ENTION OF DISEASE 
 
 careful antiseplic precautious will protect them from later 
 iufectiori. lu less favourable cases where medical aid is 
 uot sought till the exauthem is develoj)ed, immediate 
 separation of the other children from the patient will often 
 prevent infection and should therefore at once be carried out, 
 and when lack of room in the house does not permit this, 
 the child should be transferred to a fever hospital. The 
 safest way of all is to remove the healthy children from the 
 house and place them with other families where there are 
 no children. "When this cannot well be done, it is best to 
 wait till the incubation ]3eriod is over before deciding to 
 send the brothers and sisters to another house, otherwise 
 there is the danger of infection being carried. In a large 
 house where it is possible completely to cut off all com- 
 munication between the sick room and the rest of the 
 house, we may carr}^ this isolation out at home, but we must 
 always bear in mind that it is after all but a half measure, 
 as all parents do not 230ssess sufficient self control to keep 
 away for weeks from their other children who are living 
 under the same roof ; yet this complete isolation of the 
 mother who is nursing the sick child is absolutely essential. 
 The father m.a,y possibly be allowed to go into the sick 
 room if he puts on an overall in an anteroom away from 
 the other children, and then before returning very carefully 
 cleanses his face and hands in a separate room. I have 
 already enumerated the precautions to be taken by the 
 phj^sician, and it only remains for me to describe the pre- 
 cautions to be observed with the other children and their 
 schools. "When these children remain in the same house as 
 the sick child, they should be kept away from school and 
 not allowed to return till the illness is over and the rooms 
 have been thoroughly disinfected. "When the brothers and 
 sisters, after a bath and the disinfection of their clothes and 
 belongings, have been sent to another house, they should be 
 kept away from school for the extreme incubation limit, 
 namely about twelve days : they may afterwards return to 
 school provided they do not in any way come into contact 
 with any of the surroundings ' of the sick child, and only 
 see their father according to the rules laid down. The 
 physician should see the children before he gives leave for 
 
 460 
 
THE PREVENTION 01^ THE DISEASES OF CHILDREN 
 
 them to return to school. Tliose mild oases of scarlatina 
 which run their course with scarcely a symptom and very 
 slight rash are very unfavourable cases so far as the con- 
 veyance of infection is concerned, and for several days or 
 during the whole of the illness the cliild gets about and 
 may spread the infection over wide areas. We are power- 
 less to do anything in such cases, especially among certain 
 classes of the population, and the only way in which the 
 disease can be prevented from spreading in schools through 
 such cases would be to appoint physicians to the schools. 
 This important prophylactic measure has already been too 
 long delayed to the injury of the children. 
 
 Lastly I must mention forms of scarlatina known as 
 scarlatina without eruption, which are not uncommon and 
 which present great difhculties in diagnosis. It is gener- 
 ally mistaken for diphtheria which also requires isolation 
 and disinfection, and, as the course of these cases is 
 generally severe, the danger of spreading infection in itself 
 is not great in these abortive cases. Still it is important to 
 arrive at a correct diagnosis and this can usually be done 
 by the aid of bacteriological examination. I should like 
 also here to j^i'otest against the proposal made by some 
 physicians, that when a child has a mild attack of scarla- 
 tina its brothers and sisters should be allowed to be with 
 the sick child that they may also have a mild attack and 
 thus become immune against scarlatina. Every experi- 
 enced observer is aware of the uncertainty of this insidious 
 disease and knows that the severest forms may be conveyed 
 by a slight case of the disease; and, further, that one attack 
 does not necessarily protect against a second. There is 
 therefore no justification for such a procedure. 
 
 The germ of scarlatina is unfortunately still unknown, 
 and this is to be regretted when we have to decide upon 
 the measures which are effectual for disinfection after 
 scarlatina and the period necessary for isolation. We 
 know however that the sloughing of the throat which so 
 often accompanies scarlatina is the effect of secondary 
 infection by ver^^ virulent streptococci, and, further, that 
 these play an important role in causing complications. 
 
 4G1 
 
THE PREVENTION OF DISEASE 
 
 The question arises, how long is it jDOSsible for the iufection 
 to be conveyed by the patient, and how long by a third 
 person or by articles which have been nsed by the patient ? 
 There is no donbt that scarlatina is most infectious in the 
 eruptive stage and while the throat and nose are the seat of 
 special inflammation, and that the degree of contagiousness 
 diminishes towards the desquamation period. The state- 
 ment made in book after book that the disease is spread by 
 letters sent by the scarlatina patient and infected by the 
 scales shed by the skin requires proof. My impression is 
 that the contagion of scarlatina is a fugitive one, and 
 begins to disappear directly the skin peels and the 
 epidermis begins to be regenerated, and that it is then to a 
 great extent harmless. Nevertheless one would not dis- 
 infect the room used by the patient until all scales have 
 been completely removed from the skin by frequent and 
 prolonged baths and soap and water, and as we cannot 
 begin to bathe even an uncomplicated case before the fourth 
 week, the disinfection will have to be postponed to about 
 the beginning of the fifth week. The traditional rest in 
 bed for six weeks is unnecessary when the course of the 
 disease is normal, and I shall I think meet with no oppo- 
 sition today when I plead for thorough ventilation of the 
 sick room, a frequent change of body linen and bed linen, 
 which after being used should be put into a solution of 
 corrosive sublimate for twelve to twenty-four hours and 
 should afterwards be separately washed. The hands and 
 face of the child should be washed at least once daily with 
 warm soap and water. Great importance must be attached 
 to the care of the mouth, not only because many of the 
 secondary infections which may proceed from the mouth 
 can thus be considerably limited, but also because we can 
 reduce the contagiousness by washing away the secretion 
 poured out by the mucous membrane of the throat and 
 nose. In every case in which there is any sore throat, 
 we should wash out the mouth several times a day ac- 
 cording to the severity of the affection, using plenty of 
 lukewarm boiled water or a mild antiseptic and passing 
 
 462 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 part of tlie fluid through the nose to remove any secretion 
 which is there. Personally I attach little value to injec- 
 tions of carbolic acid into the tonsils ; it is very difficult to 
 do when the doctor is alone or has only the help of the 
 mother, and moreover children are so very susceptible to 
 carbolic acid that I prefer to avoid its use. I attach 
 much more importance to well rubbing the skin during the 
 entire course of the disease and especially during the 
 desquamation period with fat, using some pure form of 
 fat which will not undergo decomposition : in this way we 
 can best prevent the flakes of peeling skin being scattered 
 in the form of dust. When the time has arrived for the 
 disinfection of the rooms, one room should be first dis- 
 infected and prepared to receive the convalescent patient 
 and his new or thoroughly cleansed clothes. The bedding 
 must be exposed to the action of steam, and in every large 
 town there are special places where this is done ; carpets 
 and curtains which were in the sick room should be cleaned 
 by the same process ; the floor and walls should be washed, 
 and for this purpose I use a solution of corrosive sublimate 
 of one in 1,000. Toys, picture books, vessels for eating and 
 drinking which have been used by the patient should be 
 destroyed ; cupboards should be opened wide, their contents 
 spread out in the room, and all be then exposed for twenty- 
 four hours to the vapour of formaldehyde. Since Schloss- 
 mann and Flligge have both stated that formaldehyde at 
 a dry heat becomes altered, I have now for about eighteen 
 months used steam at the same time, which is produced by 
 a kettle of water heated by a spirit lamp and placed 
 beside the disinfecting apparatus. The rest of the rooms 
 should then be disinfected, the anteroom and the kitchen, 
 and for these a steaming for about six hours suffices. 
 When these precautions have been taken, in no case of 
 mine have any of the brothers and sisters taken the infec- 
 tion on their return home, and it has always fortunately 
 been possible for me by adopting the preventive measures 
 described above and by isolation of the sick room to limit 
 the disease to the child attacked. 
 
 I have still to mention the preventive treatment of the 
 
 4G3 
 
THE PREVENTION OF DISEASE 
 
 complications which occiip}'^ au important j^lace in the path- 
 ology of scarlatina. The frequent and thorough cleansing of 
 the mouth and nose, as also of the skin, has been mentioned; 
 the same careful treatment is necessary for the genital 
 organs, especially in girls, for they not rarely become the 
 seat of catarrhal processes and even of noma. Other 
 points belong rather to the field of therapeutics proper and 
 do not fall within the scope of this work, and I will there- 
 fore add only a few words as to the preventive treatment 
 of the nephritis. It is too optimistic to believe that it is 
 always possible to prevent nephritis by strict milk diet 
 combined with rest in bed ; the frequency of renal compli- 
 cation depends very much more upon the character of any 
 given epidemic than upon what the patient does after the 
 eruption has passed away, and I have often seen no nephritis 
 develop in children of the lower classes who were sent out 
 into the open air directly the fever had ceased and who 
 were given a mixed diet, while it developed in other chil- 
 dren who were kept in bed at a uniform temperature and 
 were placed on a strict milk diet. I do not mean that milk 
 diet and a plentiful supply of non-stimulating liquids are 
 valueless, for I am convinced that even where nephritis 
 eventually sujDervenes, it runs a milder course when this 
 prophylactic regime is carried out than when such precau- 
 tions are omitted, but I would not place too great reliance 
 upon them, and often they are very difficult to carry out on 
 account of the child's aversion to them. In severe cases 
 with threatened heart failure, small pulse and other serious 
 symptoms, fear of an impending nephritis need not deter us 
 from giving alcohol and other stimulants temporarily for 
 such symptoms. I have often given alcohol without any 
 subsequent injurious effect upon the kidneys. It is not 
 necessary, I think, to explain that special and careful 
 nursing and food are required during convalescence from 
 scarlatina, and that care must be taken that the patient 
 does not catch cold. 
 
 Next I pass to the prophylaxis of measles. Its contagion is 
 also unknown, but from the results of clinical experience we 
 can state that it is far more communicable than that of scarla- 
 
 4G4 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 tina. The contagiousness of measles is at its maximum 
 during the initial stage of the catarrh of the mucous mem- 
 branes and the development of the rash ; and as it was not 
 possible till recently to make a certain diagnosis at this 
 early stage, epidemics of measles generally spread widely 
 and rapidly, so that we seldom saw a child which had not 
 taken the infection during one or other epidemic. When. 
 in the families of princes, measures were taken to seclude 
 the children and thus keep them from all possibility of con- 
 tact, they developed the illness later, when the duties of 
 their station in life necessitated their coming into contact 
 with the people. During the various epidemics of measles 
 in Prague — some of them very extensive epidemics which I 
 had the opportunity of observing — I was not once able to 
 prevent the brothers and sisters of the child from contracting 
 the infection however early they were isolated, that is at 
 the commencement of suspicious catarrhal symptoms. By 
 causing the healthy children to be removed from the 
 infected house, I found that I merely took the disease 
 into another house, and came finally to the fatalistic con- 
 clusion that I must be content with half measures, and 
 restrict myself to keeping the children away from school, 
 and letting all care be taken when they went out for walks 
 during the twelve or fourteen days of the incubation period, 
 but as I said before I did not succeed in keeping the brothers 
 and sisters free from infection. A few years ago Koplik, 
 an American, pointed out a tolerably certain prodromal 
 sign of measles, namely the appearance of spots, which have 
 been named after him, upon the mucous membrane of the 
 cheek and gums some five or six days before the eruption 
 of the exanthem and before the beginning of the catarrhal 
 symptoms, and it may thus be possible for us to isolate such 
 cases early enough, that is before there is any risk of infection, 
 and in this way we may check the spread of this disease. 
 Since hearing of Koplik's observations I have only seen one 
 slight epidemic of measles, and I can state that I was able 
 in a few cases to isolate the patient early enough, and so 
 prevented the infection from spreading to the brothers and 
 sisters. I attach less value to the prodromal sign given by 
 
 465 HH 
 
THE PEEVENTION OP DISEASE 
 
 Meimier, wlio states that tliere is a distinct loss in weight 
 during the incubation stage in children about a week before 
 the eruption appears, although the child seems otherwise 
 well. Apart from the fact that it is not always easy in private 
 practice to obtain this information, though it can be done in 
 hospitals, such variations in weight in children may be due 
 to other causes and are so inconstant that but little value can 
 be attached to them. Koplik's sign, on the other hand, almost 
 constantly appears in measles ; it is absent in other infectious 
 diseases, can be readily observed at once even by one who 
 is not very experienced, and the diagnosis can be made by 
 simple inspection of the mouth. I ought to state that so far 
 as my experience of this sign has gone, and it is not yet an 
 extensive experience, there seems to be some prognostic 
 value in this sign, and that the severity of the disease bears 
 a direct relation to the number of spots in the mouth. 
 
 Measles is most infectious during the stage of the com- 
 mencing catarrh and the rash, but it very quickly loses its 
 contagiousness, and in uncomplicated cases danger of infec- 
 tion is over in a few days. The contagion is not so readily 
 conveyed by a third person as it is in other contagious dis- 
 eases, and I do not believe that the infection is carried in 
 letters, nor do I consider that the toj^s of the child are any 
 serious source of infection. In most cases infection is 
 through direct contact with a patient suffering from 
 catarrh, apparently a bad cold with some catarrh of the 
 eyes, and only as the epidemic begins to appear do we 
 recognize the nature of the case. From what has been 
 said, it would seem unnecessary to be so strict in the disin- 
 fection of the house as after scarlatina. It is sufficient if the 
 bedding is disinfected, the room washed with corrosive 
 sublimate solution, the books and toys thoroughly cleaned, 
 and the sick room well aired ; the other rooms should be 
 well cleaned, and after two or three baths the child may be 
 sent to school. The case is otherwise when there has been 
 severe bronchial catarrh giving rise for some time to infec- 
 tious secretion, which may cling to various parts of the 
 room used by the patient ; disinfection should then be 
 carried out in exactly the same way as was described for 
 
 466 
 
THE PREVENTION OE THE DISEASES OF CHILDREN 
 
 scarlatina. Tlie same liolds good for broncho-pneumonia 
 complicating measles ; tlie child must be kept away from 
 his companions of the same age, and the house will require 
 thorough disinfection. Physicians and parents and all who 
 have any intercourse with the sick child should observe all 
 the precautions described above. Children who have 
 run the risk of infection should be kept away from school 
 during the incubation period, and we should take care 
 that they do not come into contact with other children 
 when they are out for walks or at games. The compli- 
 cations and after effects of measles depend to some ex- 
 tent upon the character of the affection, nevertheless 
 prophylactic measures in various directions are very effi- 
 cacious. Owing to the strong tendency to affections of 
 the respiratory mucous membranes cold must be carefully 
 guarded against, and good ventilation of the room pro- 
 vided. An even moderate teraperature, a moist atmo- 
 sphere kept up by a steam kettle, frequent change of the 
 air of the room during which the child should be taken 
 into an adjacent and equally warm room or should merely 
 be well covered up, according to the season of the year, are 
 the best precautions against these complications. It is 
 important to wash out the mouth and nose several times a 
 day, and to change the linen daily or more often if neces- 
 sary. Great caution is required in deciding when the first 
 bath should be given ; young children who seem almost 
 well and have but very little cough are difficult to keep 
 in bed, and we are sometimes in rather too great a hurry in 
 these cases, and bad results follow. I never allow the child 
 to be bathed till the cough has completely ceased for two or 
 three days, and the mucous membrane of the mouth has 
 assumed its normal condition and the skin shows but very 
 slight trace of any pigmentation left by the rash. The 
 room must be warm in which the bath is to be given, the 
 bath water not under 95° F., and the child must be put to 
 bed directly afterward for several hours : it is therefore best 
 to give it in the evening before the child goes to sleejD. All 
 these are small but im23ortant matters, "We must not be in 
 too great a hurry in letting the child go out for the first 
 
 467 
 
THE PREVENTION OF DISEASE 
 
 tinie, especially wlien the season of the year and tlie weather 
 are nnfavonrable. The combination of measles with whoop- 
 ing congh is rightly looked upon as grave, especially as 
 epidemics of measles and of whooping congh seem to stand 
 in some close relation to one another, and each of these dis- 
 eases seems to predispose to infection by the other. The 
 preventive measures will be given under " "Whooping Cough," 
 and I would therefore refer the reader to this later section. 
 
 Lastly, I have to mention the connexion of measles with 
 tuberculosis, which under certain social conditions and with 
 hereditary predisposition assumes a serious form. I need 
 only in this place point out how often a hitherto latent 
 tuberculosis of the bronchial glands becomes manifest under 
 the influence of measles, and as a prophylactic against it 
 all children suspected of a tendency to tuberculosis should 
 be anxiously guarded from infection, but it is often very 
 difficult in practice. Frequently, too, we see that a patient 
 suffering from measles and living in a phthisical environ- 
 ment develops tuberculosis from patches of broncho- 
 pneumonia. It is exactly for these cases that Heubner's 
 excellent idea is so useful, of providing special homes for 
 children who are predisposed to tuberculosis or who are 
 exposed to the danger of infection from tuberculosis, and 
 in certain special cases we should advise that this should be 
 done, although in ordinary cases of measles we should avoid 
 sending the child to a hospital, knowing that this does not 
 favourably influence the course of measles. It is not my 
 task to describe in detail the preventive measures which 
 should be carried out in the hospital, and I will merely say 
 that the wards for measles should be so arranged that it is 
 possible to isolate patients suffering from pneumonia or from 
 tuberculosis in S23ecial well ventilated rooms, and to avoid 
 crowding patients together in large and densely filled wards. 
 
 Rubeola (or '' German measles ") is closely related to 
 measles and is often classed with measles. It differs 
 from measles in the catarrh being absent or slight — the 
 difference upon which most stress must be laid — and in 
 the absence of Koplik's spots, and observations of epidemics 
 of rubeola justify us in regarding this affection as a dis- 
 
 468 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 ease sui generis. Its contagion is unknown, but it appears 
 to be very transient and it possesses its greatest power 
 of infection during th.e eruptive stage. The small amount 
 of secretion from the mucous membranes makes the period 
 during which there is danger of infection a very short 
 one and the milder measures of disinfection described in 
 the previous paragraph suffice to prevent the spread of 
 German measles. In uncomplicated cases — and rubeola 
 generally runs a simple course — the patient may safely be 
 sent to school ten days after the eruption, after he has had 
 two or three baths. The brothers and sisters should be 
 kept under observation till the incubation period of twelve 
 to fourteen days is passed. Conveyance of the disease by a 
 third person or by utensils used by the patient need scarcely 
 be considered. 
 
 For the prevention of smallpox, we have in Jenner's 
 vaccination, as the brilliant results in Grermany show, a 
 method which enables us completely to stamp out this devas- 
 tating and disfiguring disease. It is much to be regretted 
 that all civilized states do not yet enforce compulsory 
 vaccination and revaccination of their inhabitants, and are 
 content often with less strict compulsory vaccination. In 
 Austria a certificate of successful vaccination is required 
 when the child goes to school, and primary vaccination or 
 revaccination of recruits for the army is also compulsory. 
 It is noticeable in these cases that the instinct of the 
 people anticipates the care of the government for them, and 
 physicians, at least in the towns, meet seldom with any 
 opposition to vaccination, but it is rather welcomed. We 
 owe it principally to this fact that even in Austria the 
 number of cases of smallpox steadily decreases, and for 
 years at a time there may be no smallpox to treat. But if 
 smallpox is really to be stamped out by vaccination, then 
 more stringent laws are necessary, non-compliance with 
 which should be severely punished. Every child should be 
 vaccinated in the first year of life, and the vaccination 
 should be repeated at intervals of not more than ten years. 
 Great importance should be attached to this revaccination, 
 as our military results prove the protection against small- 
 
 469 
 
THE PREVENTION OF DISEASE 
 
 pox lasts only a certain time, and primary vaccination alone 
 is therefore only a lialf measure. 
 
 At tlie jDresent time we have not yet reached the point 
 when we may pass variola by, and we must therefore briefly 
 consider preventive measures required in the treatment of 
 smallpox. Of the three stages in the course of a smallpox 
 case — the eruptive, the suppurative and the desquamative 
 stage — the latter is by far the most dangerous so far as con- 
 veyance of infection to others is concerned ; the unknown 
 organized virus shows great power of resistance, and even 
 when dry in the crusts left by the pustules is still virulent for 
 a long period. The desquamative process often lasts for 
 several weeks, and as a j^reventive measure j^atients should 
 not be permitted to come in contact with the outer world 
 till all the spots are completely healed and the crusts have 
 been completely destroyed. To hasten the drying up of the 
 vesicles and as far as possible prevent their further exten- 
 sion, baths are used with the addition of some mild anti- 
 septic. The attendants and the physician should be revac- 
 cinated, and before leaving the sick room, which should 
 not be entered without previously putting on a linen 
 overall, the hands and face and even the beard should be 
 thoroughly washed with soap, and disinfected with alcohol 
 and sublimate, in order to remove and make innocuous the 
 small scales which may adhere to these parts. It seems to 
 me to be necessary too to take a bath and to change one's 
 clothes before visiting other patients. Utensils used in the 
 sick room should not be carried into other rooms, but should 
 be washed in a place specially set apart for this purpose. 
 We should not omit disinfection of the patient's faeces and 
 urine ; for the variolous process is known to affect also the 
 mucous membranes of the intestinal and urogenital tract, 
 and these excretions may also be infectious. Lime is best 
 for this purpose. When the disease is past, the whole house 
 must be rigorously disinfected, all things used by the 
 patient should be destroyed by burning when possible, 
 and the remainder, and bedding, carj^ets, and curtains, 
 must be disinfected by steam. The furniture should be 
 washed with a solution of corrosive sublimate, the floor 
 
 470 
 
THE PREVENTION OF THE DISEASES OE CHILDREN 
 
 and walls slionld be likewise washed and afterwards 
 repainted or repapered ; special care slionld be taken to 
 destroy the crusts formed by the pustules, and this is best 
 done by bnrning. Lastly, the honse should be disinfected 
 by formaldehyde with steam, or by giycoformol ; it should 
 then be aired for several days, and un-revaccinated inmates 
 should not be permitted to return to the honse until they 
 have all been satisfactorily revaccinated. 
 
 I have still to mention the cases where a pregnant woman 
 is attacked with smallpox, and the measures required to be 
 taken. When pregnancy is iiot far advanced expulsion of 
 the ovum generally occurs, but when pregnancy has nearly 
 run its full course there are several possibilities. The child 
 may be born during the incubation period of smallpox, is 
 still susceptible to vaccination but sickens in spite of it — 
 and I can call to mind such a case in the Foundling Hos- 
 pital where vaccination and smallpox pustules developed 
 side by side ; or the child may be born having an eruption 
 of smallpox pustules or remnants of them, and this child is 
 naturally not susceptible to vaccination ; or it may in utero 
 have become immune against smallpox and against vaccin- 
 ation without itself having been ill. Nevertheless it is 
 obviously our duty to vaccinate these children directly 
 after birth, and carry out all necessary precautions as 
 mentioned above. Lastly, it may happen that the mother 
 sickens only towards the end of gestation, and that the 
 child is born during the desquamative stage or during the 
 mother's convalescence : in these cases either the child may 
 be immune, as is proved by the fact that vaccination does 
 not take, or the vaccination takes and the infection of the 
 newborn infant may be prevented. 
 
 In conclusion, a few words must be said about vaccina- 
 tion, which has become comparatively easy since the use of 
 human lymph has been given up, and the objection to 
 vaccination raised by anti- vaccinators because of its liability 
 to convey syphilis no longer holds good. The soundness of 
 the animals from which the vaccine lymph has been obtained 
 is always tested by an autopsy on the body of the animal, 
 made before the lymph is sent out. In obtaining the lymph 
 
 471 
 
THE PREVENTION OF DISEASE 
 
 the vaccinated surface is kept clean by dressings, by steri- 
 lizing all instruments used for the oj)eration, and by otlier 
 similar precautions ; and freedom from germs in tbe lympb 
 is secured by the prolonged action of glycerine : as a re- 
 sult there has been a great decrease in the number of cases 
 of infection with microbes, especially with staphylococci. 
 Further rules are that asepsis should be observed when vac- 
 cinating ; the child's skin should be previously well cleaned 
 with soap and brush, ether or alcohol. A piece of cotton 
 wool should be interposed when blowing out the lymph from 
 the tube, the glass plate upon which it is received should be 
 disinfected, and the instruments should be boiled. When 
 the pustule develops we must cover it with a suitable dress- 
 ing which should not be discarded till the wound has healed. 
 
 Varicella is generally a very trivial affection and the pre- 
 ventive measures against it are simple. The contagion soon 
 loses its virulence and infection is easily prevented. When 
 the pustules have dried up, a few baths with the addition of 
 some mild antiseptic and the use of plenty of soap suffice to 
 render the patient non-infectious. In disinfecting the 
 rooms it is sufficient to use the simplest measures above 
 mentioned. The brothers and sisters should be kept away 
 from school till the incubation period is over, that is for 
 about fourteen days. Certain precautions should be observed 
 in view of complications ; the mouth must be kept very 
 clean to prevent infection spreading from the eruption on 
 the mucous membrane, and the urine should be tested in 
 case nephritis should supervene. These are the principal 
 precautions needed. We should avoid sending patients into 
 hospital because experience has shown that varicella may 
 then run a severer course, and gangrene of the pustules and 
 secondary infections arising therefrom make the prognosis 
 far worse. Lastly, I must not omit to mention that we 
 ought to make a correct diagnosis, as much mischief may 
 be caused by mistaking a mild or abortive form of smallpox 
 for chickenpox. 
 
 I proceed now to speak of the preventive measures against 
 diphtheria. The discovery of the exciting cause of diph- 
 theria, the Klebs-Loffier bacillus, about the specific action 
 
 472 
 
THE PEEVENTION OF THE DISEASES OF CHILDREN 
 
 of wliich there can be no doubt, has enabled us to demon- 
 strate the existence of the disease, and to devise sure pre- 
 ventive measures. The fact that Behring and his pupils 
 have given us a specific cure for diphtheria, and the pos- 
 sibility of obtaining at least a temporary protection against 
 diphtheritic infection by using this protective serum, are 
 considerations which place our modern preventive treatment 
 of diphtheria upon a strictly scientific basis, and when 
 rightly used it is followed by very good results. We know 
 the great vitality which is possessed by the bacillus of 
 diphtheria and we know that it may be spread not only 
 through contact with the patient but also through the air, 
 by the most diverse objects, such as toys, imperfectly 
 washed fruit, and bread, through soiled hands, and through 
 the secretion of the nose and throat of healthy persons 
 who are apparently immune against diphtheria. We 
 must briefly then consider all these possible sources of 
 infection, and adopt commonsense preventive measures 
 against diphtheria which embrace them all. During 
 epidemics of diphtheria we should avoid getting articles 
 of food from houses in which are patients suffering from 
 diphtheria, and the authorities should not allow the sale 
 of food, and especially of milk and bread, by persons 
 whose children have suffered from diphtheria till after 
 the house and shop have been thoroughly disinfected. 
 There would be great difficulties in such measures, but I 
 am convinced that without them we cannot prevent the 
 spread of diphtheria. It is essential, too, that milk 
 should be boiled directly it is delivered at the house and 
 set aside to cool, bread should be well scraped, fruit 
 should be peeled or cleansed, and vegetables should be 
 thoroughly washed. It is much more difficult to prevent 
 infection by persons who, without themselves being ill, 
 harbour the virulent germs of the disease in the nasal 
 cavity and throat. Often, as in the cases rejDorted by 
 Escherich in which the infection was spread by a 
 nurse, it is by a mere chance that we find the source 
 of the infection, and we must therefore carefully weigh 
 all possibilities and endeavour to arrive at a con- 
 
 473 
 
THE PEEVENTION" OF DISEASE 
 
 elusion by tlie help of bacteriological examinations. The 
 child suffering from diphtheria and all its surroundings, 
 those whose duty it is to nurse the child as well as all 
 things which are used for the child, require very special 
 care. The precautions by way of disinfection which have 
 already been described in detail in previous pages must 
 be strictly observed. It seems to me important that we 
 should make sure by examination of cultures that the 
 disease is of a diphtheritic nature, this being of the 
 greatest importance both as regards the treatment of the 
 disease and the subsequent measures to be taken. I do 
 not deny that there are certain obstacles in the way of 
 introducing this method into general practice, but these 
 must be removed. The brilliant results obtained in places 
 where it is carried out are the best guarantee for the 
 correctness of these statements. Another equally im- 
 portant point is that a child, though convalescent after 
 diphtheria, and this may be in a few days when serum has 
 been early used, harbours virulent diphtheria bacilli for a 
 long time in its throat, though the mucous membrane is 
 apparently normal, and also in its saliva, and in this way 
 infection may be spread. We should therefore, before dis- 
 pensing with further isolation, examine the mouth of the 
 child for these bacilli, and by gargling with solution of cor- 
 rosive sublimate, mopping out the throat with this antiseptic, 
 and in other similar ways, endeavour to render innocuous 
 any bacilli which still remain. When for other reasons 
 it is not possible to do this, isolation of the child must be 
 strictly carried out till we are sure that the throat is quite 
 clear, and this often takes several weeks after the exudation 
 has gone. This point is also of the greatest importance 
 in relation to the return of the child to school. 
 
 As to the brothers and sisters it is advisable to remove 
 them from the house directly after the illness has declared 
 itself ; generally it is possible by this early isolation to 
 keep them from becoming infected, and it is essential 
 that they be kept under observation so that at the very 
 first appearance of symptoms they may be submitted to 
 the serum treatment. When it is impossible to separate 
 
 -474 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 tliem tlius completely from tlie infected cliild I inject a 
 small dose of Beliring's serum sufficient to render tliem 
 immune against diphtheria, and in some cases I have 
 followed the same course with the attendants upon the 
 child. In this way we can remove all fear of infection 
 for a few weeks and the sick room can be disinfected. 
 The return to school of the brothers and sisters of the child 
 must be strictly forbidden, especially as the incubation 
 period of diphtheria varies within such wide limits that 
 we cannot definitely state any exact period. Any inter- 
 course of the healthy children with the attendants upon 
 the sick child should be wholly avoided where possible, 
 or should only be allowed when all due precautions are 
 taken : that is, there should be no close contact and the 
 clothes should be changed. Among preventive measures 
 calculated to prevent possible complications I give the 
 foremost place to the early use of the serum. Its use in 
 more than a hundred cases in private practice, some of them 
 in consultation with other physicians, has convinced me that 
 only in this way can we make sure that the disease shall 
 run its course without complications and disturbance. The 
 results in hospitals have been less uniform : they generally 
 do not come under treatment till a much later stage. It is 
 then impossible to neutralize the changes wrought by the 
 bacillus or its toxin. During the last few years I have 
 seen no case complicated with albuminuria or nephritis 
 and no paralysis, and since using this valuable serum there 
 has not been any rash. "We should not omit to wash out 
 the throat regularly ; appetite returns earlier when this 
 is done and any microbes which would produce secondary 
 infections are best removed by this method. In hospitals 
 where no provision is made for treating dijohtheria separately 
 we should adopt preventive inoculation as introduced by 
 Heubner and persuade all patients to undergo the opera- 
 tion ; the value of this prophylactic is shown by the total 
 disappearance of infection in the institution. 
 
 As in most of the acute infectious diseases, so too in 
 whooping cough, the exciting cause of the disease is still 
 unknown : much work has been done in this field during 
 
 475 
 
THE PEEVENTION OE DISEASE 
 
 recent years but the results liave been so contradictory as 
 to be of no value yet for practical purposes. Of the three 
 stages of the disease — the stage of prodromal catarrh, the 
 convulsive stage, and the stage of decline — the first is the 
 most dangerous, not I think because of its greater in- 
 fectiousness, but because the disease has not yet been 
 diagnosed and close intercourse with other children has 
 not been forbidden. Diagnosis in this initial stage would 
 be of great service in preventing pertussis, and I venture 
 to suggest that we should look with suspicion upon every 
 cough the severity of which is disproportional to the 
 physical signs and which is not relieved by sedatives, and 
 should isolate such children. Though some authorities do 
 not consider the paroxysmal stage to be contagious yet 
 this is surely an error, and I would urge isolation of the 
 patient with whooping cough until complete cessation of 
 the cough. The difficulty of isolation is greatly increased 
 by the fact that we have to do mostly with patients who 
 do not keep to their room or their bed but go out, especi- 
 ally in the fine seasons of the year, against the wish of 
 the physician. Certain special precautions are required 
 that the j^atient may have open-air treatment and at the 
 same time that the danger of conveying infection to others 
 may be reduced to a minimum. I would recommend that 
 certain parts of parks should be reserved and laid out 
 for such children, that special conveyances should be used 
 to bring patients living at a distance, that j^arents or 
 attendants accompanying the children — who are often so 
 thoughtless about this matter — should be advised to take 
 the child aside at the apj^roach of a paroxysm of coughing 
 and to see that the expectoration is received into a cloth 
 which can later be thoroughly disinfected, or else that 
 the expectoration is at once covered over by earth. This 
 method is not always practicable, especially when the 
 paroxysms are followed by severe vomiting and the food, 
 mixed with infectious mucus from the larynx, cannot be 
 got rid of so easily ; nevertheless much can be done by 
 removing certain bad habits, such as drawing the mucus 
 out of the mouth of the child with the fingers, smearing 
 
 476 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 it on the clothes, and holding the child up against the 
 body during the paroxysm. Similar precautions should 
 be taken too at the various watering places and summer 
 resorts to which children with whooping cough are taken. 
 And here too it would be advisable to set apart certain 
 places where such patients with their attendants would 
 only be received and where the houses, the walks and the 
 entire arrangements of life could be adapted to the needs 
 of such children. These are very desirable precautions and 
 would most effectually prevent the spread of the disease. 
 In railway travelling special carriages should be set aside 
 for such children and indeed for all persons suffering from 
 contagious diseases ; these should be such as can be easily 
 disinfected, and each carriage should be thoroughly cleaned 
 after every journey. Lastly, it should be mentioned that 
 it is best to avoid treating children with whooping cough 
 in institutions on account of the risk run of developing 
 secondary infections. Thorough disinfection of the house 
 in which a case of whooping cough has been is essential. 
 The child should be kept away from school till the cough 
 has completely ceased. As to the brothers and sisters they 
 should be removed from the house, and should not be 
 allowed to go to school unless they have already had 
 whooping cough or until they have had no intercourse 
 whatever with the patient for about a fortnight, this being 
 the incubation period. Children at the breast should also 
 be removed from the house, for although there is certainly 
 some immunity against pertussis in a child who is suckled, 
 yet when it does take the disease it has it in a very severe 
 form which often ends fatally. 
 
 Conveyance by a third person is possible, especially 
 through expectoration clinging to clothes or toys or utensils 
 used by the sick child, and it can be prevented by suitable 
 precautions, such as changing the clothes before visiting 
 the other children, thorough cleansing of dishes and vessels 
 used for eating and drinking, and by destruction of the toys 
 at the end of the illness. 
 
 A few words must here be said about the prevention of 
 complications which may be very severe even when the 
 
 477 
 
THE PREVENTION OF DISEASE 
 
 disease has run a mild course. The coincidence of epidemics 
 of pertussis and measles, reference to which has already- 
 been made, demands serious attention, because these diseases 
 have a bad influence one on the other and favour the 
 development of tuberculosis. At such times we should 
 therefore exercise extra care to prevent infection. The 
 open-air treatment of pertussis is an additional precaution : 
 every physician knows the fact, though the explanation 
 of it is not yet forthcoming, that the number of paroxysms 
 of whooping cough is far smaller in the open air than 
 indoors. I attribute also to this factor the good results 
 supposed to follow a change into the country, and we 
 should therefore send the children into the open air as 
 much and as long as possible. But we must not forget 
 that these patients are thereby exposed to the risk of 
 taking cold and of developing complications of the respir- 
 atory tract which may be very serious. The child should 
 therefore be permitted to be out of doors for long only 
 in the warm season of the year and on dry days when 
 there is no wind, but in autumn and in winter he should 
 only be out in the afternoon when the sun is shining. 
 The advice now often given that the child ill with whoop- 
 ing cough should be carried out in the open air even 
 when the disease is complicated with pneumonia is, I 
 consider, very dangerous. 
 
 When speaking about measles I pointed out that measles 
 and whooping were peculiar in that they render a child 
 very susceptible to the infection of tuberculosis, or may 
 render active some latent tendency to tuberculosis, especially 
 of the bronchial glands. "Wherever there is an hereditary 
 disposition or whenever there is much risk of infection 
 extra care is required to prevent the tubercle bacilli from 
 gaining a hold. It is best at once to remove the child out 
 of these infected areas, and if tuberculous disease of these 
 glands is already present we must secure the most favour- 
 able conditions possible by getting the child into the 
 country and by proper diet, in order to render the attack 
 of whooping cough as mild and as short as possible. In 
 the dieting too we have some prophylactic opportunities : 
 
 478 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 frequent vomiting reduces tlie pliysical strength of the 
 child and makes it less able to resist secondary infections ; 
 in these cases, as indeed in all cases of pertussis, the child 
 should have frequent meals, most of them consisting of 
 fluids or gruel ; the meals should be taken shortly after 
 a paroxysm of coughing in order that there may be an 
 interval for the partial absorption of food before the next 
 attack. 
 
 In the infective diseases which so far have been de- 
 scribed, the infection was conveyed chiefly by direct contact 
 or inhalation or through a third person or through some 
 object ; but in typhoid fever it is somewhat different : the 
 patient has become infected by eating or by drinking infected 
 substances which contain the specific bacillus, and other 
 modes in which infection may be conveyed are of secondary 
 importance only. Most often the infection is through 
 drinking water made impure by having become mixed with 
 the excreta from a typhoid patient, or through unboiled 
 milk containing the bacillus, through badly washed veget- 
 ables or unpeeled fruit. It is only rarely that a person 
 becomes infected directly by the secretions and excretions 
 of the patient. The aetiology is more obscure in those 
 cases where an infant at the mother's breast is attacked 
 with typhoid fever though neither the mother nor the 
 wet nurse has, or has had, the disease. I have several times 
 seen such cases in Prague, which has the evil reputation as 
 a typhoid fever locality. "We can only surmise that the 
 bacillus was in the water used for washing the breasts 
 or in the bath water, or that the bacillus reached the 
 finger of the nurse in some way and was conveyed to the 
 child's mouth when the nurse was attending to the child. 
 The preventive measures against such sources of infection 
 are obvious : boiled water alone should be used for washing 
 the breasts or for the child's bath, and the hands should be 
 well washed before touching the child. If there is a case 
 of typhoid fever in the house the patient should be isolated 
 and every care be taken to prevent the infection being 
 conveyed to the infant. If the child is being artificially 
 fed the main point is the thorough boiling of the milk, 
 
 479 
 
THE PREVENTION OF DISEASE 
 
 and only boiled water should be used to dilute tbe milk. 
 In the ]3eriod of early childliood additional measures are 
 required : drinking water, especially in towns where there 
 is much typhoid fever, should always be boiled and filtered 
 or replaced by a mineral water ; all food given to the 
 child should previously have been well cleaned, and this 
 is especially the case with fruit, which should be peeled 
 or thoroughly washed. Especially during epidemics one 
 must be careful about children who like to play with 
 earth, and one should prevent the child putting its fin- 
 gers to its mouth before they have been washed. "When 
 the disease is present the chief aim must be to disin- 
 fect the faeces and urine to prevent spread of the 
 infection ; the excreta should be disinfected by the ad- 
 dition of lime ; the linen should be separately washed, 
 having previously been put into a solution of corrosive 
 sublimate ; the hands of those who are attending the 
 patient should be carefully cleansed and disinfected with 
 corrosive sublimate, soap, alcohol and ether. By observ- 
 ing these precautions it is generally possible to prevent 
 the brothers and sisters from becoming infected, and with 
 suitable home arrangements they may be allowed to go 
 to school, especially as the very slow development of 
 typhoid fever would make it possible to take them away 
 from school in time. 
 
 Among ]3reventive measures we must include the making 
 of a correct diagnosis of typhoid fever and this, as every 
 experienced physician knows, is very difficult at the begin- 
 ning of the illness. "We should therefore avail ourselves 
 of every possible means of diagnosis, make cultures from 
 the faeces and urine, and apply "Widal's test : where 
 circumstances do not permit of this being done in the 
 physician's own laboratory, the sanitary authorities should 
 provide facilities which would enable this method of 
 examination to be added to the other methods for the 
 diagnosis of infectious disease. If the State imposes upon 
 the physician the duty of notification of infectious disease 
 it should also on its part place every available method for 
 the diagnosis of disease at his disposal, free of charge and 
 
 480 
 
THE PREVENTION OE THE DISEASES OF CHILDREN 
 
 without taking up much of his time : this is indispensable 
 in the interests both of public and private hygiene. 
 
 It is necessary now for me merely to mention the pre- 
 vention of complications. The mouth must be kept 
 thoroughly clean as it is often the site of numerous bacteria 
 which may excite secondary infections ; great care must 
 be given to the care of the skin ; the genito-anal region 
 should be kept clean. A large amount of fluid should be 
 given to the patient, and the diet should be ample and such 
 as not to give rise to irritation of the intestinal tract. Great 
 importance should be attached to deciding upon the time 
 when the patient may get up and when solid food may 
 again be given ; too great haste may be the cause of much 
 mischief. So far as one can make general rules for these 
 cases, I never allow a patient to get up before the com- 
 mencement of the second week after the temperature is 
 quite normal. I allow solid food to be given at the same 
 time, and a week later I permit the patient to go out in the 
 open air in good weather. 
 
 Epidemic parotitis, or mumps, runs a very favourable 
 course in childhood, and cases complicated with orchitis 
 are much more rare than in adults. This consideration 
 induces some authorities to suggest that measures 
 should not be taken to prevent children from acquiring 
 this infection, because infection during childhood will 
 render them immune against infection later in life when 
 the disease runs a more severe course. "When speaking 
 of scarlatina I pointed out that we are not justified 
 in adopting this course, and for mumps I would simi- 
 larly urge the isolation of the patient, the disinfection 
 of all articles used by the patient, keeping the patient and 
 his brothers and sisters away from school, and thorough 
 disinfection of the house when the disease is over. These 
 principles I have already laid down in detail. It should 
 be remembered that the infectiousness of mumps begins 
 with the prodromal stage and lasts during the whole 
 course of the disease, and the incubation period extends 
 over two or three weeks. 
 
 During the last ten years Europe has repeatedly been 
 
 481 II 
 
THE PEEVENTION OF DISEASE 
 
 visited by widespread and in parts by very severe forms 
 of influenza. It may attack cliildren during all periods of 
 child life, and its very rapid spread and infectiousness, 
 make its prevention a difficult task. 
 
 It is a very dijSicult matter, especially in cases where 
 the mother or wet nurse has influenza ; taking the child 
 from the breast does not save it from infection, and on the 
 other hand exposes the infant to the risks run by changing 
 its food, and many an infant has succumbed. From the 
 experience gained in the three epidemics of influenza which 
 have visited Prague since 1890, I am of opinion that isola- 
 tion of the patient is of very little value ; it is generally 
 not possible to isolate these cases till too late, and the 
 disease spreads so rapidly and by so many ways over whole 
 towns and regions that it is quite impossible to attack 
 them all, and it is better to look on with a certain fatal- 
 ism. At all events I do not advise that children should be 
 sent away from the infected house, which would only still 
 further spread the malady, neither do I advise that a 
 change should be made in the feeding of an infant at the 
 breast unless the disease is running so severe a course as to 
 influence unfavourably the secretion of milk. It appears 
 to me to be of much greater importance to prevent second- 
 ary infections proceeding from the mouth and nose, and 
 most of these are caused by streptococci. These infections 
 are often seen in children, and they are of bad prognosis, 
 whereas the prognosis of the disease itself is good. Regu- 
 lar washing out of the throat and nose with lukewarm 
 boracic acid solution seems best to prevent these infections. 
 Large numbers of people are attacked at a time, and it 
 seems therefore advisable in the case of school children 
 that the school should be closed to prevent at least this 
 source of spread of infection. I am not able to say whether 
 disinfection of the room or rooms in which the patient has 
 been is of any value ; the attempt might be made. I did 
 not myself make it, because in the families to which I was 
 called all the members generally sickened in such rapid 
 succession that subsequent disinfection of the house ap- 
 peared unnecessary. 
 
 482 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 My experience in miliaria is limited, and extends only 
 to a slight epidemic ■which occurred in an outlying district 
 of Prague. The infectious nature of these cases was but 
 slight : isolation of the patient in one room sufficed to pre- 
 vent the brothers and sisters from becoming infected, and 
 disinfection of the sick room sufficed to destroy the ap- 
 parently short-lived germs. But from communications 
 made by various authorities I gather, that in some epi- 
 demics of miliaria the disease runs a very severe course 
 and is highly infectious, and in such cases it is obvious 
 that far more stringent preventive measures are required. 
 
 Glandular fever was first described by Emil Pfeiffer, but 
 some do not consider it a special disease. I have only seen a 
 few doubtful cases of it, and am therefore not able to give 
 any personal experience in regard to its prevention. 
 Prague, so fertile a soil for the various infectious diseases, 
 does not, judging from the observations of myself and my 
 colleagues, offer a favourable soil for this disease. 
 
 Physicians who have had exj^erience with glandular 
 fever state that it is not highly infectious ; they recom- 
 mend that the patient be isolated, and on recovery the 
 throat and nose should be washed out several times, and 
 a few baths containing some antiseptic should be given 
 before the child is permitted to associate with other 
 children. 
 
 The remaining diseases comprised in this group are 
 Asiatic cholera and malaria. I have not seen a case of 
 either of these among children, and must refer the reader 
 elsewhere. 
 
 Tetanus is an infection which may be met with here 
 and there during the period of infancy and during early 
 childhood. In the former period the infection usually 
 enters by the umbilical wound, and prevention lies in strict 
 asepsis. During early childhood the bacillus usually gets 
 into the body from the earth, and infection is prevented 
 by guarding the child from all dirt and by carefully disin- 
 fecting any small injury the child may meet with. When 
 the disease is epidemic, as last year at the Prague Lying- 
 in Institution, it is extremely diffi.cult even by the most 
 
 483 
 
THE PREVENTION OE DISEASE 
 
 thorough, disinfection to get the upper hand of the tetanus 
 bacillus, as may be seen from the fact that after leaving 
 the wards empty for a long time and thorough cleansing 
 of them, sporadic cases nevertheless occurred when they 
 were again used. In such a case, having regard to the 
 doubtful results obtained by treatment with antitoxin, it 
 seems to me best to adopt preventive inoculation of all 
 pregnant patients taken into the institutions and all 
 patients already confined, a method which might also be 
 extended to the children. 
 
 Hydrophobia is an infectious disease not very rare in 
 early childhood, and I can remember seeing a number of 
 young children who were patients at the Paris Pasteur 
 Institute in the year 1886. The preventive treatment car- 
 ried out by Pasteur, which is begun during the incubation 
 period, is now practised in the institutes of preventive 
 medicine in various countries, and is so well known as to 
 need no further description. Another method of preven- 
 tion is to forbid the child having anything to do with 
 domestic animals, which often are a source of danger too 
 in other ways. 
 
 Next I turn to chronic infectious diseases of early child- 
 hood and their prevention. Tuberculosis must be first con- 
 sidered. The conditions of infection and the course of the 
 disease are somewhat different at this period of life from 
 those of infancy. In an earlier paragraph relative to 
 tuberculosis I pointed out the dangers which are run when 
 children hereditarily predisposed to tuberculosis and very 
 susceptible to the contagion are allowed to live with their 
 parents who are already phthisical : in such cases it would 
 be best to follow Heubner's suggestion, and put the children 
 into a special institution. This unfortunately often 
 cannot be done, and other preventive measures too against 
 tuberculosis are very difficult to carry out in practice. 
 Often it is absolutely impossible to prevent close inter- 
 course between parents and children : to educate tuber- 
 culous patients, and get them to observe due caution in the 
 disposal of their expectoration and to avoid using vessels 
 in common with others for eating and drinking, are tasks 
 
 484 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 often beyond the power of the physician to accomplish, 
 thongli their importance is very eviflent and of special 
 value for those who are scrofulous. At present I see but 
 scant possibilities for such thorough preventive measures, 
 and we shall have for some time to come to be content 
 with removing a part only of these dangers. 
 
 I will now briefly describe these measures. Experience 
 teaches us that a large number of children belonging to 
 tuberculous parents have caseation of the bronchial lymph- 
 atic glands, the clinical diagnosis of which is not very 
 easy, but which we may assume with tolerable certainty 
 to be present when there is enlargement of many of the 
 cervical glands, especially of those lying along the anterior 
 border of the trapezius, which, as I have often verified by 
 ■post mortem examinations, are continuous with the chain 
 of infected lymphatic glands in the hilum of the lung. I 
 attach less value to interscapular dulness, or to weak 
 breath-sounds of one lung produced by narrowing of the 
 chief bronchus by pressure upon it of the surrounding 
 lymphatic glands, and the diagnostic aid of tuberculin 
 injection I consider too dangerous for use in children. 
 Some of these children do not develop either a local or a 
 general tuberculosis ; in other children the swelling of the 
 lymphatic glands is the result of disease elsewhere, such as 
 chronic intestinal trouble, nevertheless I regard these en- 
 larged glands as a symptom which should make us suspect 
 tuberculosis, especially when there is a family history of 
 tuberculosis and the children show any other signs of the 
 disease. The greatest care is required in these cases. 
 
 There are several precautionary measures to be taken : 
 all sources of irritation of the lungs, especially that which 
 follows a cold, should be avoided ; the children should be 
 guarded against changes of weather, should be much in 
 the fresh air, and spend the fine months of the year in 
 some healthy district, avoiding however all places fre- 
 quented by phthisical patients, and selecting a spot where 
 there is sea air or where there are brine baths. The 
 tendency of some infectious diseases, especially of measles 
 or of whooping cough, to bring out a latent tuberculosis, 
 
 485 
 
THE PEEVENTION OF DISEASE 
 
 makes it our duty to guard sucli cliildren from those diseases 
 which excite tuberculosis. They should therefore be kept 
 away from children's ordinary j^l^-Jgro^^i^cls, should be 
 watched when out for a walk, should be guarded from all 
 that would necessitate general intercourse with other 
 children, and should not be sent to school till they are 
 older, because the risks are then fewer, as most children 
 have the infectious diseases in early childhood. Careful 
 diet, excluding all food that might convey tuberculous 
 virus, and care of the physical health are essential. These 
 children are not fit subjects for strong measures in harden- 
 ing the body. All this is naturally possible only for those 
 in the better circumstances of life ; for the poor and 
 wretched the only prospect lies in government help in the 
 future. 
 
 Another class of cases which must here be considered 
 contains those in which scrofulous symptoms are present, 
 I will not here enter upon the question of the relation be- 
 tween scrofula and tuberculosis, but merely state that 
 personally I regard scrofula as affording a favourable soil 
 for the development of tuberculosis. It seems to me 
 immaterial whether this is the correct view or whether 
 scrofula is of a directly tuberculous nature. Experience 
 teaches us that with suitable treatment scrofula may be 
 perfectly cured, and that children who have had scrofula 
 may grow perfectly strong in later years, showing not a 
 trace of the former scrofulous diathesis. The suscepti- 
 bility to tubercular virus disappears when these scrofulous 
 symptoms disappear, and this suggests one line along which 
 preventive treatment may go. The advantage of this 
 treatment is not for the rich alone; and poor people are 
 able to send their children to hospitals which have 
 been established at seaside places through private benevo- 
 lence. It were to be wished that the government would 
 actively take the matter in hand, as is done in France, be- 
 cause the question is one concerning the health of the 
 rising generation. 
 
 It can be shown even in childhood that there exists a 
 close correlation between the heart and the lungs in children 
 
 486 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 with a tuberculous predisposition, and this suggests 
 another line of preventive treatment which may be followed. 
 I have already said that such children should not be sent 
 to school, this prevents the risk of their infection with 
 infectious diseases, but it is well for other reasons too to 
 keep the child from school. Sitting still for hours at a time, 
 the homework, want of movement, and the faulty position 
 assumed in reading and writing, are conditions which tend 
 to prevent the efficient expansion of the lungs and the 
 effective working of the heart, and these make it still more 
 easy for Koch's bacillus to develop in a body predisposed to 
 tuberculosis. Suitable gymnastic exercises are of value, 
 but should not be begun too early, not till after the sixth 
 year, and should be limited to "free " movements and dumb- 
 bell exercises to increase the size of the thorax and raise 
 the respiratory capacity of the lungs. Thus we possess a 
 number of preventive measures by which one who is 
 apparently likely to die or to become chronically ill may 
 be transformed into an individual capable of taking his 
 part in the battle of life. 
 
 As regards syphilis in early childhood, the measures 
 already given when speaking of syphilis acquired in in- 
 fancy should be adopted. It should be added that sleeping 
 with unknown persons should be forbidden, as is not un- 
 common among the lower classes ; and even at this early 
 age syphilis may be caused by sexual abuse. 
 
 Before proceeding to speak of measures required to pre- 
 vent disease of the various organs of the body, it seems 
 well to say a few words about the care of children and diet 
 at this period of life, so far as this is concerned with the 
 prevention of disease. As to the bath, one should begin 
 towards the later months of infancy to discontinue the 
 daily bath and limit the baths to two a week in the period 
 of early childhood and in winter to one a week. The fact 
 that the child gets about much more necessitates very care- 
 ful watching of its movements, and all water which is 
 derived from a suspicious source, as is the general case in 
 Prague, should be boiled before being used. The tempera- 
 
 487 
 
THE PREVENTION OF DISEASE 
 
 ture of tlie bath in the second year should not be below 85*^ F., 
 and later, so far as the ordinary bath is concerned, the tem- 
 i:)eratnre should be only very gradually reduced, and should 
 not during early childhood be below a minimum of 70° F. 
 
 It is otherwise with bathing in the open, and in fine 
 weather particularly at the seaside it is permissible to bathe 
 in water at a lower temperature : but I would not permit 
 children to bathe in the open before the end of the third 
 3^ear, and I would not permit them to learn to swim before 
 they are eight j^ears of age. 
 
 This question leads me next to consider the subject of the 
 hardening of the body, about which we are so often asked 
 for advice. I cannot say that I am personally impressed 
 with its advantages, and the course of years has not con- 
 vinced me that such children show any greater degree of 
 power of resistance to disease. To begin very early with 
 such measures I consider to be a direct disadvantage, and 
 my own opinion is that they should never be begun before 
 the fourth year, should then be very gradually adopted and 
 carried out with common sense. The temjDerature of the 
 bath should be slowly reduced and the bath may be followed 
 by an application of cool water or a douche. The child may 
 be rubbed down with cold water before going to bed, or if 
 this stimulates the child too much, it may be done after 
 getting up in the morning. Suitable clothing should be 
 pro^dded and the woollen vest and hose may be disused. 
 Certain customs which have arisen from vanity or from 
 lack of understanding, such as wearing short socks in 
 winter and leaving the calves of the leg bare, I consider 
 erroneous and often injurious ; and so also on the other 
 hand the coddling of children and the anxious dread of 
 every breath of air and the wearing of much warm clothing 
 may all lead to injurious results. The hapj)y medium is 
 required in all these matters, and Spartan customs should 
 be avoided, for they are not adapted to the climate of Ger- 
 many with its abrupt changes of temperature. 
 
 With regard to the mouth, the treatment should be differ- 
 ent to that required in infancy. In the baby the shallow 
 toothless oral cavity with the short alveolar processes, in which 
 
 488 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 tlie food (mostly liquid) remains a very short time may, especi- 
 ally under certain conditions previously mentioned, require 
 very special and careful treatment. In cliildhood regular 
 daily care of the mouth is required. It should be cleansed 
 daily with a soft brush and piece of linen soaked in a weak 
 antiseptic solution, and later it is necessary to gargle 
 with a similar solution after every meal. It seems to me 
 of great importance to accustom the child early to have 
 its throat inspected ; this makes it possible at onoe to 
 recognize any disease which may commence in the throat 
 and makes it also much easier for the physician to examine 
 and treat the throat. The painful struggle with a howling 
 child which has possibly been previously threatened with 
 the " doctor " should be spared us, and the use of force, such 
 as holding the nose till the mouth is opened and using a 
 gag, should be had recourse to only in extremity. The 
 care of the teeth should be commenced with the milk teeth, 
 and as any carious cavity may become the habitat of 
 numerous microbes, it should be stopped to make it harm- 
 less. As to the nose, I consider that washing out of it is 
 only necessary when there is some infective process ; at 
 other times it is sufficient to wash the easily accessible 
 parts. The same holds good for the ears, which the child 
 likes so much to handle at this age, and which therefore 
 often become affected with inflammations of the external 
 meatus, or stopped up with cerumen or foreign bodies. 
 
 We must never omit to inspect and to cleanse the 
 genitals : conditions (especially balanitis and vaginal 
 catarrh) associated with the irritation of itching often 
 produce masturbation which one is almost powerless to 
 remove when once it has developed. Intestinal parasites 
 too, especially threadworms, may wander into the vagina 
 and by mechanical irritation cause pruritus, leucorrhoea 
 and similar conditions, the cause of which may be over- 
 looked. Inspection of these parts is therefore advisable. 
 
 In regulating the life of such children we should aim at 
 letting them be out of doors as long as possible when the 
 weather permits, and when they can walk they should be 
 permitted to take plenty of exercise. The amount of walk- 
 
 489 
 
THE PEEVENTIOX OF DISEASE 
 
 ing permitted to chiklreii just learning to walk or to rickety 
 children must be limited. When the child soon tires and 
 cannot run well the chief cause, in my experience, is to be 
 found in flat foot caused by rickets and generally combined 
 ■with genu valgum. When we have convinced ourselves. 
 after inspecting the child when it has been stripped, that it 
 is suffering from rickets and the bones are still soft, walk- 
 ing should be forbidden ; but in other cases it is sufficient 
 to order suitable pads for the boots, and they should be 
 worn also in the house till the foot has become normal in 
 form. 
 
 Certain details need mention as to the child's bedding, 
 and as to carrying the child about. A firm mattress and 
 a low and firm pillow are best ; the child should lie on its 
 back in bed and be lightly covered over ; these precautions 
 will tend to prevent rachitic curvature of the spine. The 
 child should take very little liquid with the last meal and 
 the bladder should be emptied before going to bed ; these 
 are the best preventive measures against nocturnal enuresis. 
 To prevent the development of scoliosis the child should not 
 be carried on the same arm alwaj^s ; indeed it should never 
 be carried for long, but should be taken out in a perambu- 
 lator. 
 
 As to sleep, it is most important that the child should 
 sleep long and undisturbed ; till the end of the third year 
 of life it should have several hours' rest in the morning and 
 afternoon. After three years of age, only in the afternoon, 
 and this should not be discontinued till it is five or six 
 years of age. The child should be put to bed early and all 
 exciting games or tales should be avoided which may dis- 
 turb sleep and cause night terror and similar conditions. 
 
 Their toys should be as simple as possible, free from 
 all poisonous materials, and so shaped that the child 
 cannot injure itself with them ; we should, too, be careful 
 where they come from, as they may be carriers of in- 
 fection. 
 
 Although games out of doors are very desirable, yet 
 much coming into contact with the earth should be avoided 
 as much as possible ; different germs and the eggs of 
 
 490 
 
THE PEEVENTIOX OF THE DISEASES OF CHILDREN 
 
 intestinal parasites, such as the ascaris lumbricoides, may 
 get on to the fingers from the earth, and as children often 
 have the habit of putting their fingers in the mouth, the 
 germs may thus obtain entry into the body. 
 
 As to diet, the principal food up to the end of the second 
 year should be milk, and variety can be obtained by suit- 
 able combinations of milk foods, soups and eggs. Through- 
 out childhood milk should be given to the child to drink, 
 I like to avoid the addition of any coffee or tea because of 
 their stimulating effects : but I permit cocoa or chocolate. 
 Meat should not be given before the fourth half-year of life, 
 and it is well not to give any meat till the child is two 
 years of age. It should be given only once a day, and I 
 prefer the different kinds of white meat and fish without 
 bones, which can all be given to the child hashed, with or 
 without the addition of eggs. Before the complete develop- 
 ment of the milk teeth meat should not be given except very 
 finely cut up, otherwise the morsels which are but slightly 
 masticated undergo decomposition in the intestine and 
 cause diarrhoea. I must protest strongly against giving 
 children raw meat : the dangers of raw meat outweigh its 
 advantages, for ova or intermediate stages of intestinal 
 parasites or other organized causes of disease and the toxins 
 produced by them get into the child's body through the 
 raw meat. For the same reason no meat should be given 
 to the child which is not quite fresh or which has been 
 insufficiently boiled or roasted ; it should not be eaten 
 merely smoked or steamed. 
 
 Among beverages alcohol must be avoided in every form ; 
 though I do not fear its use as much as do total abstainers, 
 who paint its effects in too dark colours. Though cases of 
 acute or of chronic alcoholic poisoning in chiMhood are 
 curiosities rather than practical difficulties, yet we can 
 trace a decidedly harmful influence of alcohol upon the 
 nervous system, and we should not early accustom a child 
 to take a substance to which so many human beings later 
 in life fall victims. For this reason and also because, when 
 they are at table with adults, children have things given 
 them which are indigestible, it is best to keep children 
 
 491 
 
THE PP.EVENTION OF DISEASE 
 
 away from the meal table of adults until the little ones 
 may eat what is on the table, that is until they are four 
 years of age. 
 
 A few words must also be said as to the regulation of 
 children's lives. The tendency of the present day to hurried 
 living influences childhood too, and when we recall to 
 memory our own early years we are often astonished 
 at the games and picture books placed before children, 
 for they give ideas to the young children which formerly 
 were not given till much later. Even their entertainment 
 of friends has taken a form which appears to be a reproduc- 
 tion on a smaller scale of the dinner parties of adults, and 
 the children are overloaded with very indigestible food and 
 evince a certain affectation in their intercourse which often 
 lays the foundation for the affected manners so often seen 
 in girls and which may be the germ of a later hysteria. 
 But other ill results, especially the spread of infectious 
 diseases, also follow this social intercourse among children, 
 and I would therefore urge from the purely medical 
 and prophylactic aspect of the subject, and entirely omit- 
 ting the educational aspect, that the intercourse of children 
 with other children should be restricted to a few well 
 known playmates. 
 
 Another bad custom which is unfortunately very common 
 and should be avoided as liable to cause ultimate mischief 
 is the overburdening of their minds by tasks of memory 
 intended to show their intellectual forwardness. The 
 minds of children are sufficiently burdened with the daily 
 increasing number of impressions which come to them 
 without the addition of the task of learning poems by heart. 
 
 Lastly I must speak of the home, and point out the 
 injurious effects of rooms with insufficient air and light, 
 the removing into newly built houses, especially during 
 winter, and the proximity of stables to the house, factors 
 which have an undeniable influence upon the mortality of 
 children. 
 
 The evil effects of schools upon the health will be more 
 minutely detailed under the disorders peculiar to later 
 childhood. 
 
 492 
 
THE PREVENTION OF THE DISEASES OF CHILDKEN 
 
 I pass un to consider the jDreventive treatment of the 
 diseases of the various organs of the body during early 
 childhood, and begin with the resj)iratory tract, including 
 the affections of those jiarts which are common to the passage 
 of food and air, the mouth and pharynx. The various forms 
 of tonsilitis come first in importance : they begin with the 
 commencement of the second year of life, and are most 
 common in the period of early childhood. Colds and infec- 
 tious influences assist to cause them ; in the so-called 
 chronically recurring exudative forms there is also an here- 
 ditary factor ; the condition of the mouth and teeth must 
 also be taken into consideration and preventive treatment 
 adapted to these various causes. One should avoid coddling, 
 particularly the wrapping up of the throat with warm 
 scarves. The children should be guarded against sudden 
 changes of temj^erature, especially at school, where during 
 the intervals the children are often sent out of the over- 
 heated classrooms into the cold corridors. The mouth and 
 teeth should be carefully cleansed, and carious teeth should 
 be stopped. All cases of tonsillitis are infectious, and such 
 patients should be isolated ; the short duration of the con- 
 tagion makes further measures unnecessary, but we must 
 wait till every trace of the throat affection has disapi^eared 
 before allowing the child to return to school. To avoid 
 complications, some of which run a very serious course, the 
 nose and throat should be well washed out with large 
 quantities of weak antiseptics, but I have very little opinion 
 of the effects produced by gargling. The children should 
 learn to gargle early so that the mouth is kept thoroughly 
 clean, but in cases of illness I do not consider it necessary 
 to worry them much with it. Cellulitis and retropharyn- 
 geal suppuration, which is not rare at this age, need timely 
 incisions to prevent the pus from going lower. Removal of 
 the tonsils is advised by many, esj)ecially in chronic forms 
 of the affection, but I do not consider that the o^^eration is 
 indicated unless the tonsils are so large as to obstruct 
 respiration. I am not of opinion that this ©ijeration, which 
 has dangers of its own, is a sure means of preventing a 
 recurrence of the tonsilitis ; indeed I have often seen a 
 
 493 
 
THE PREVENTION OE DISEASE 
 
 reciuTence on the scar surface. The same is true for the 
 slitting up of the follicles and other methods undertaken 
 for the same object. It seems to me suitable here to speak 
 about hypertro23hy of the pharj-ugeal tonsil (adenoids), and 
 removal of this tonsil to prevent disturbances which may be 
 caused by its hyj)ertrophy, and I cannot withhold the 
 opinion that we are apt to operate too much. In a large 
 majority of cases the increase of adenoid tissue is only 
 temporary and later disappears, or the development of the 
 nasal cavities removes any disturbance caused by the 
 adenoid growth, and one often sees cases in which no good 
 effect has resulted from the operation, or the old symptoms 
 reappear after a time. Whether this occurs because only 
 part of the pharyngeal tonsil has been removed or because 
 the adenoid tissue has been reformed I am not able to say, 
 though I can vouch for the correctness of the observations 
 recorded above. In these cases I would therefore counsel 
 patience and first attempt a cure with astringent lotions 
 and with astringent powders applied to these parts, and 
 have recourse to operation only when serious obstruction to 
 nasal respiration urgently demands relief. The reflex 
 theory ascribes a number of nervous phenomena to hyper- 
 trophy of the pharyngeal tonsil and overgrowth of the 
 posterior ends of the turbinate bones. I can merely state 
 that I consider these assertions somewhat exaggerated, and 
 would point out that such children are known to have a 
 predisposition to neurasthenia ; therefore the psychical 
 effect of any operation upon them should also be taken 
 into consideration. 
 
 For the prevention of bronchitis and broncho-pneumonia 
 at this period of life, all that was said in a previous para- 
 graph about these affections applies also to this period, but 
 "taking cold " is at this age a more frequent cause of these, 
 and requires special care. In previous sections we have 
 considered how far it is 230ssible to prevent those affections 
 of the respiratory tract which often accompany the various 
 infectious diseases and seriously affect the prognosis. Once 
 more I would contrast the bad influence of treatment in a 
 hospital, and the crowding of patients into badly venti- 
 
 494 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 lated wards, with the excellent results of adequate ventila- 
 tion in smaller rooms, and the frequent change of the 
 patient from room to room. 
 
 Disorders of the digestive tract do not occupy so im2Dortant 
 a position in early childhood as they did in infancy ; the 
 chief principles which must now guide us in the prevention 
 of these diseases are to give a suitable diet as described 
 above, to avoid giving meat too early, to exclude bad food 
 or very indigestible food, and to prevent the overloading of 
 the stomach which is so apt to occur in children at this period. 
 Plenty of vegetables and cooked fruit are the best means 
 against the obstinate constipation so common during this 
 period of life, A further necessary precaution is to remove 
 the stones from fruit, and to avoid giving any food which 
 cannot be reduced in size by mastication ; such articles act 
 as foreign bodies in the intestines, and may lodge in the 
 vermiform appendix and set up appendicitis. Lastly, 
 preventive treatment against entozoa must be considered. 
 I have already pointed out the important factor of playing 
 with earth, of eating raw or imperfectly cooked meat, and 
 of contact with domestic animals. I have only to draw 
 attention to auto-infection by the children themselves, who 
 put their dirty fingers into the mouth and thus convey 
 the ova of worms into the body where the ova then 
 develop ; there is also the possibility of the transference of 
 these ova from child to child. On the one hand, strict 
 cleanliness is essential ; on the other hand, caution in the 
 intercourse between such patients and their playfellows. 
 It is opportune here to mention the common custom among 
 the public of giving anthelmintics, especially preparations 
 of santonin, as a preventive. I must protest against this 
 custom, and also against the assumption that frequent pick- 
 ing of the nose is a sure sign of worms. Anthelmintics 
 should only be used when worms are passed or their eggs 
 are found in the faeces, and then only by medical prescrip- 
 tion. The free sale of anthelmintics to the public by 
 chemists I consider an abuse. 
 
 Among diseases of the genito-urinary organs, the most 
 important is vulvo-vaginitis, which may occur in epidemic 
 
 495 
 
THE PREVENTION OE DISEASE 
 
 form aud be very widespread and difficult to control, 
 especially in hospitals and institutions. In a former para- 
 graj)li I pointed out the prophylactic measures to be taken 
 against spread of the disorder, and against the risks of 
 infection through the mother : besides these infections 
 through accidental contact, we must bear in mind too at 
 this age the possibility of infection of the genitals of 
 children by the malpractices of individuals suffering from 
 gonorrhoea, There is a possibility of spreading the disease 
 by baths used in common. Epstein has pointed out the 
 dangers of public baths in this respect. These children 
 may also spread the affection at school. Preventive treat- 
 ment should aim at removing all these possible sources of 
 infection. These patients should be isolated, care being 
 taken that their linen and other articles used by them are 
 separately washed ; sleeping with strangers should be 
 avoided, the children should be kept away from school ; and 
 girls taken into hospital should be examined, and all suffer- 
 ing from vulvo- vaginitis should be at once isolated. It is 
 imj)ortant too occasionally to examine the secretion micro- 
 scopically so that the nature of the case may be definitely 
 diagnosed and the duration of infection ascertained. 
 
 In boys balanitis is frequent at this age and may be 
 prevented by cleanliness. It is not only an unpleasant 
 condition, which causes pain and urinary difficulties in such 
 boys, but observation has convinced me that it may also be 
 the cause of nocturnal enuresis, and the itching associated 
 with the condition often gives rise to masturbation. The 
 preventive measures are obvious : the glans should be fre- 
 quently washed, some simple ointment may be applied, and 
 any phimosis treated. 
 
 The most important of the diseases peculiar to this period 
 of childhood have now been mentioned, in so far as their 
 course can be influenced by preventive measures, and I 
 now proceed to describe 
 
 THE PEEVENTIVE TEEATMENT OF DISEASES OF LATER 
 
 CHILDHOOD 
 
 To prevent repetition I shall leave out of consideration 
 
 496 
 
THE PREVENTION OF THE DISEASES OF CHILDEEN 
 
 those diseases which in their invasion, coiu'se and preven- 
 tion cannot be separated from those of early childhood. 
 Nevertheless aU the principles previously laid down must be 
 borne in mind, and they can be carried out more easily now 
 that the child is more intelligent and self dependent. These 
 diseases are influenced to some extent by school life and 
 work, the want of exercise and fresh air necessitated by the 
 increased demands made by education, and further by a 
 new factor, "• nervous contagion," which now appears and 
 demands our attention that it may be adequately treated 
 and prevented. The physician and the teacher should 
 work hand in hand, but the physician is unfortunately 
 often unable to act effectively, and the requirements of 
 education and of hygiene are often opposed, and the influ- 
 ence of the physician in the school is less than could be 
 wished. But so far as it is possible efforts should be made 
 to prevent mental overstrain and to check the injurious 
 mental and physical effects which are attributable to educa- 
 tion. Prophylactic measures to ensure the normal healthy 
 development of children are as important as the prevention 
 of infective diseases and of digestive, respiratory and 
 similar disorders. The question can be treated only very 
 briefly here, and for details I must refer the reader to works 
 on school hygiene, but for the sake of completeness they 
 cannot be altogether omitted in this book. 
 
 Apart from spreading infectious disease, school life may 
 exert a bad influence in various ways upon the physical 
 and mental development of the child. The danger is less 
 in the lower classes, the short school hours, the small amount 
 of homework, the fact that reading and writing are only 
 being begun and the innate restlessness of the child prevent 
 these injurious effects from appearing. But in the later 
 years, even at a primary school, there are too many hours 
 spent in sitting at school, and too much close work for the 
 growing eye, its homework keeps the child too long at 
 the table, and its need for physical movement and fresh air 
 are not sufficiently regarded. xAdd to this the ill effects of 
 insufficient light, the overcrowding of the schoolroom, the 
 faulty postures in sitting, the bad print of schoolbooks, and 
 
 497 KK 
 
THE PREVENTION OF DISEASE 
 
 the incorrect position in writing, and we liave a number of 
 disturbing causes wHcJi must be briefly considered. Myopia 
 is very common in sclioolcliildren, and increases as the 
 child goes from class to class : it is caused by an excessive 
 effort at accommodation, and it is also harmful for the eyes 
 and therefore it should be prevented by appropriate means. 
 Among these may be mentioned good illumination for every 
 seat, suitable blackboards which do not reflect light and so 
 strain the eyes, well printed schoolbooks, suitable hand- 
 writing upright and large, a correct length of the lines and 
 distance between the lines, and the avoidance of artificial 
 light which strains the eyes. These are to some extent 
 already attained in schools with modern equipment and with 
 specially drawn-up rules ; but in the home these matters do 
 not yet receive proper attention, and the physician should 
 see that at home too the child has an apj^ropriate place in 
 which to work, and that it is not occupied too long with 
 book work. 
 
 Another injurious effect resulting from school and home 
 education is curvature of the spine, caused by badly con- 
 structed seats, together with a wrong posture in writing 
 and too long continued writing. Though in most places 
 nowadays care is taken to place a child at a suitable distance 
 and on a bench which is adapted to his size, and the upright 
 style of handwriting now taught tends to make the child 
 sit straight, yet the long hours which a child is kept at 
 writing undoes a part of the good thus accomplished, and 
 this is made still worse by the large amount of homework 
 which the children have to do, generally on badly con- 
 structed tables and in bad postures and in insufficient light. 
 One should therefore insist u]pon the child having a suitable 
 desk at home, which is placed so as to be adequately supplied 
 with light, and one should watch the number of hours given 
 to homework, as the physician is the best judge as to the 
 amount of mental work which a given child can do without 
 injury to itself. 
 
 School headaches, anaemia and epistaxis are caused by 
 remaining long in closed and often overcrowded rooms and 
 by the constant exercise of mental energies along this one 
 
 498 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 channel only, and they are often accompanied by loss of 
 appetite and by insomnia. In this conflict between the 
 requirements of education and of physical health it is often 
 very difiicult to convince parents that the latter is more 
 important, and they point out that the child will be out- 
 stripped by its competitors, Nevertheless in a few bad 
 cases I have insisted upon a whole year of school life being 
 given up, and have employed this solely in building up the 
 physical health which had been neglected, and I have never 
 had cause to regret this course. It is the physician's duty 
 to see that the child's hours of sleep are not curtailed, and 
 all work after supper should be forbidden. When the 
 intellectual capacity and ability of the child are insufficient 
 to enable it to do the homework during the daytime, the 
 work must be left undone, and it may be necessary to inter- 
 rupt the education for a time. Out-of-door exercise, 
 gymnastics and field games are the most effectual antidote 
 to the ill effects of much sedentary work. During the few 
 hours given to recreation the mind should be allowed to 
 rest, exciting books, theatres, and such amusements should 
 be forbidden. The child's walks out of doors will supply 
 it with new and fresh experiences. Unfortunately, especi- 
 ally in the higher schools as already said, we are scarcely 
 able to make our influence felt against this common over- 
 strain of children's minds, but nevertheless we must exer- 
 cise a careful supervision and must put a veto upon this 
 education of a child when we see that its health will be 
 seriously injured thereby. 
 
 As regards the diet of children at this age when they 
 dine with adults, all indigestible food must be avoided, the 
 food should be simple, all alcoholic drinks should be 
 excluded as they only tend still further to increase the 
 cerebral hyperaemia already existing. The child should go 
 to bed early, and should be kept from the social entertain- 
 ments and recreations of adults. 
 
 Hysteria, of which we see many serious cases even at this 
 early age, is steadily increasing. The disease is caused partly 
 by the great demands of school life, partly by our modern 
 manner of life. Its preventive treatment is in education, 
 
 499 
 
THE PREVENTION OE DISEASE 
 
 and it should be remembered that its characteristic mani- 
 festations are often passed on to susceptible companions of 
 the same age, and in this way the most remarkable school 
 epidemics arise by '' nervous contagion." It is therefore 
 advisable to keep such children from school. 
 
 The same remarks apply to chorea, which is so common 
 at this age. Teachers ought to be more familiar with the 
 initial stages of chorea than they generally are ; they 
 would then cease to blame and punish such children and 
 aggravate the disease. Here again the need for school 
 physicians is evident. 
 
 Night terror requires certain preventive measures : rest 
 of the brain for some time before going to sleep, and the 
 avoidance of mental work, of exciting books, or tales which 
 stimulate the imagination of the child, are the chief points to 
 be observed. From the standpoint of aetiology much more 
 importance should I think be attached to such symptoms 
 when associated with a weak constitution, anaemia and over- 
 strain, than to the hypertrophy of lymphatic tissue in the 
 pharynx or to nasal affections. 
 
 Finally I would add that the holidays of these children, 
 short as they are, should be used to remove injurious effects 
 which have arisen during the school year and to strengthen 
 the body to meet the new demands which will be made 
 upon it. All mental work should therefore be forbidden 
 during the holidays, and all that is possible should be done 
 to improve the physical health of these children. For this 
 purpose they should have moderate exercise and plenty of 
 nourishing food, but should not be taken for long tiring 
 walks or mountain tours, as so often happens when fathers 
 take with them their half grown up children. 
 
 I come now to the last part of my subject, to the so- 
 called 
 
 PKOPHYLAXIS IN TEEATMENT 
 
 This section concerns us physicians most intimately, and 
 I would head it with "wo/^ nocere^ The great progress made 
 in therapeutics during the last decade is reason enough 
 to make us hold views other than the negative ones of 
 
 500 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 former times ; on the other hand we must guard against 
 going to the other extreme and make use of measures of 
 which we are not quite certain and which are not altogether 
 free from danger. We should keep clearly before us the 
 measures and modes of treatment which are best adapted 
 for any particular period and those which should be avoided. 
 And lastly, the children entrusted to our medical care, 
 whether in private life or in hospitals, must not be regarded 
 as subjects for doubtful experiments. "We should always 
 well consider whether the satisfying of scientific curiosity 
 may be of disadvantage to the sick child. These are the 
 limits within which so-called curative prophylaxis should 
 work. 
 
 To give a few examples. Opium and its derivatives, 
 morphine, codeine, belladonna and hyoscyamus, should be 
 avoided during the first year of life, since even after very 
 small doses serious symptoms may appear. In the treat- 
 ment of gastro-intestinal disorders we can obtain much 
 better results by mechanically emptying the digestive tract 
 and by appropriate dietary regulations than by internal 
 remedies, and these should therefore be restricted to the 
 utmost. Infants seem to be particularly susceptible to 
 certain drugs, such as potassium chlorate and naphthalin, 
 while they tolerate relatively large doses of other drugs, 
 such as the expectorants ipecacuanha and senega. Salicylic 
 acid and salicylates are not always tolerated ; mercury and 
 potassium iodide, on the other hand, when properly given, 
 leave no unpleasant after-effects. Much depends too upon 
 the mode of its exhibition. With many drugs the most 
 effectual and harmless method is to administer the drug 
 internally in the liquid form, and I may mention, besides 
 those already referred to, the various drugs used in digestive 
 disorders, such as hydrochloric acid, lactic acid, sodium ben- 
 zoate, magnesium benzoate, and bismuth salicylate. With 
 other drugs cutaneous application is best : for instance, 
 salicylic acid and especially mercury, which is so well 
 tolerated when thus administered, while it readily sets up 
 diarrhoea when administered internally. I would also 
 strongly recommend a trial of the new " merkolint " method 
 
 501 
 
THE PREVENTION OF DISEASE 
 
 for hereditary syphilis in infants. Subcutaneous injection, 
 very useful in later childhood, is not suitable during the 
 first year of life, and abscesses readily form at the site of 
 the puncture. Caution must be observed too in the use of 
 antiseptics. Experience has shown that carbolic acid is 
 very badly tolerated by infants, that iodoform sometimes 
 gives rise to skin irritation, while corrosive sublimate in 
 weak solution, not over two parts in 1,000, can be used 
 with perfect safety. I altogether refrain from giving 
 internal antipyretic remedies during childhood, at least in 
 the way formerly practised. On the other hand I can 
 strongly recommend lukewarm baths and wet compresses, 
 not so much because of their antipyretic power as because 
 of their soothing effect. A cold bath may readily cause 
 collapse, and should be watched by the physician. I avoid 
 it altogether, and have elsewhere stated my reasons. Even 
 wet compresses may do harm, either by giving rise to 
 eczema or by causing exfoliation of the epidermis as I have 
 seen in delicate children. A new drug should be used with 
 great caution, and at first only in smaller doses than 
 recommended. Enthusiasm combined with a lack of judg- 
 ment which after a few hasty and insufficient observations 
 lauds the beneficial effects of new preparations should warn 
 us to be cautious. For washing out the stomach and 
 bowel the temperature of the liquid should be exactly 
 taken ; too much fluid and too rapid injection of it should 
 be avoided. Personal experience has proved to me that the 
 addition of resorcin and tannin is best avoided. A further 
 precautionary method to be observed in infancy is to give 
 the drug in very small doses and to get the cumulative 
 effect of it, and whenever possible to select the liquid form 
 of the drug, and to avoid during the first months of life any 
 addition of material capable of undergoing fermentation, 
 such as the very favourite syrups. 
 
 In later childhood too it is best to avoid treatment of 
 fever by drugs, which after all can only modify an inci- 
 dental symptom of the infection, but cannot in any way 
 influence the course of the disease ; rather indeed, when 
 given in large doses and when badly tolerated, it will give 
 
 502 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 rise to serious cardiac symptoms. Among antipyretics 
 antifebrin and antipyrin in large doses are often not ■well 
 borne, but cause vomiting or rashes. Quinine too cannot 
 be extensively used because of its taste and the difficulty 
 of disguising it, and the administration of these drugs in 
 pill or wafer is only possible for older children. The most 
 convenient antipyretic is phenacetin, which is almost taste- 
 less, and small doses of it, one to three grains, are 
 sufficient to bring down the temperature for a few hours 
 without unpleasant after effects. Of the external methods 
 for reducing temperature during the second period of child- 
 hood I prefer wet packs and lukewarm baths, while in 
 later childhood I use a bath which is gradually cooled down 
 or a cold douche. But here too moderation is required. 
 The slight reaction of most children after high tempera- 
 tures, together with the fact that the severest infections 
 often run a course with but slight rise of temperature, 
 considerably limit these indications and only justify us in 
 adopting these measures when there is hyperpyrexia, 
 serious implication of the sensorium or great nervous 
 unrest. 
 
 I have already protested against the casual use of worm 
 powders, and I would here caution against the "cures" for 
 tapeworm, especially as the greater number of cases of 
 poisoning by Filix mas are met with in childhood. Such 
 drugs should only be administered by the direction of a 
 physician who lives near the patient. 
 
 Anaesthesia by chloroform is often induced for diagnostic 
 purposes or to remove an excitable condition in restless 
 children, and I cannot too strongly protest against this 
 course. Only when there is some vital reason for inducing 
 anaesthesia, such as the diagnosis of a tumour or appendi- 
 citis, does it appear to me justifiable ; in other cases I 
 consider its use an unpardonable thoughtlessness which 
 may have serious results. 
 
 Indeed the use of such heroic methods of examination as 
 have been introduced into hospitals of late years to clear up 
 certain scientific contentions should be restricted within 
 wise limits, and experiments upon human beings, especially 
 
 503 
 
THE PREVENTION OF DISEASE 
 
 upon cliildren wliose consent cannot be asked, should be 
 narrowed down to the utmost. Among these methods are 
 the withdrawal of large quantities of blood for various 
 didactic reasons and dieting methods by which healthy- 
 young children are supplied with insufficient food for days. 
 No permanent injurious results have been observed, or at 
 least they have not been recorded, fco follow this experi- 
 mental work, but it scarcely seems to me wise to wait till 
 then. Our experience in the domain of the conveyance of 
 syphilis and of the inoculation of healthy individuals 
 with gonococci shows plainly enough that the utility of 
 such methods is not j)roportionate to the dangers incurred. 
 
 Neither can I speak enthusiastically about lumbar 
 puncture, which has become a favourite method during 
 recent years. It is certainly a valuable addition to our 
 knowledge to have gained information in this way about 
 the pressure within the skull under normal and under 
 pathological conditions, and the amount of albumen present 
 in cerebro-spinal fluid and of the bacteria, yet I cannot 
 maintain that the diagnosis of the various inflammations 
 which affect the central nervous system has been furthered 
 by this method of research. And as to the therapeutic 
 value of this method we feel a little sceptical about the 
 assertions of its enthusiastic advocates. At any rate when 
 we consider the risks of a possible infection of the spinal 
 canal and other possible evil results, it would seem essential 
 that this method should only be carried out in hospitals 
 where there is adequate assistance, and that the physician 
 should send into hospital every child who is to be treated 
 by this method. 
 
 Recently too the question of intubation in private 
 practice has been raised, and I would take this opportunity 
 of saying that this course can only be regarded as justifi- 
 able and free from serious risk when it is possible to 
 arrange for continuous and adequate medical aid for the 
 child during the first few days. 
 
 I will refrain from further detail, as I wished only to point 
 to the directions in which caution should be exercised by 
 physicians in the treatment of children entrusted to their 
 
 504 
 
THE PREVENTION OF THE DISEASES OF CHILDREN 
 
 care, and did not intend to discuss individually every 
 method and every drug employed. With increasing years 
 and experience we become more moderate, and learn to avoid 
 certain therapeutic measures which formerly, with the 
 zeal and sanguine nature of youth, infatuated us. With 
 this I will end my remarks, which have already taken up 
 almost too much space, but my apology for the length of 
 this section is the importance of preventive measures in the 
 most susceptible period of life, when they are most service- 
 able in the development, education, hygiene and treatment 
 of children. And though there are many omissions in these 
 pages, yet I have I think considered all the means by which 
 it is possible effectually to prevent the diseases of childhood. 
 I hope that the study of aetiology will soon give us a deeper 
 insight into those pathological processes which are still 
 unexplained, and will enable us to meet them with greater 
 knowledge and better results than hitherto, and thus prevent 
 disease and the spread of disease, and secure for the rising 
 generation the conditions of life required for their robust 
 and normal development. 
 
 505 
 
*^<u