Third annual report of the State Board of Health of the commonwealth of Georgia transmitted to the Governor January 1, 1907 [Jan. 1, 1907]

THIRD ANNUAL REPORT
OF THE
State Board of Health
OF THE
Commonwealth of Georgia
TRANSMITTED TO THE GOVERNOR january 1, 1907
A'l'I.ANTA, GA.
THE FRANKLIN-TURNER COMPANY
PIUNT.KRs: PUBI.ISHE:RS, BIND:SRS
1907

LETTER OF TRANSMITTAL.
COMMOKWEALTH OF GEORGIA, STATE BOARD OF HI!ALTH,
Exl!CDTIVE OFFICE, January I, I907.
T 0 His Excellency, Joseph M. Terrell, Govenzor of Georgia.
Sm: In accordance with the instructions of the State Board of Health of Georgia, I have the honor to here,,ith transmit to you the report of the Georgia State Board of Health for the year I906.
The Board of Health especially instructs me to call attention to the scientific work that is being accomplished in its laboratory, particularly as regards the free examination of specimens for the germs that produce disease; this work is rapidly increasing, and is beyond question having a most beneficial effect on the health of the State and will in future result in still greater good.
Since our last report we haYe been manufacturing the substance knmvn as "tuberculin." and it has been used quite extensively by physicians all mer the State for the purpose of diagnosing tuberculosis in its earliest stages. It is gratifying to say that the results haYe Leen eminently satisfactory, ancl our work along- this line \vill undoubtedly prove of much benefit. ~\s this substance has been shmvn recentlY to he of undoubted value in the treatment of tuberculosis \d1en properly used. \\"C are abo supplying it for this purpose, and it may be safely said that still g-reater benefit will be accomplished as a result of its employment in this \\ay.
\Ve would call your attention to the fact that at the last meeting of the General Assembly we were authorized

4
to install a so-called Pasteur Institute for protective treatment against rabies. Unfortunately, however, no money was appropriated for this purpose, and, as it will cost about $r,soo to properly install such a plant, I have been directed by the Boarcl of Health to defer action in the matter until further instructions have been given by the Legislature.
In some of the X orthern States eli phtheria antitoxin is also being manufactured by the laboratories of boards of health, and there is no reason why this can not also be clone by us.
If you can see your way clear to so recommend, \Ye "oulcl respectfully suggest that you ask the Legislature to so increase our appropriation as to enable us to handle this matter. and to also install a Pasteur Institute. \Vith an additional appropriation of $2,500 a year \\e believe that both of these objects could be accomplished. \Vith such an extension of our field, there is no question but that great goocl \Youlcl result, and at a much less expenditure than at present on the part of the people of our State.
Respectfully submitted,
H. F. HARRIS,
Secretary.

STATE BOARD OF HEALTHt
Commonwealth of Georgia, !906.

President ................... \Y. F. \VESTMORELAND \'ice-President ..................... CHARLES HICKS Secretary ........................... H. F. HARRIS

).lf,).IBCitS.
Dr. 'vV. \V. Owens ........................ Savannah Dr. A. P. Taylor ....................... Thomasville Dr. M. S. Brown ....................... fort Valley Dr. \V. 'vV. Stewart ....................... Columbus Dr. \V. F. 'vVestmoreland .................... Atlanta
Dr. Howard J. \Villiams ..................... Macon
Dr. R. M. Harbin ........................... Rome Dr. Samuel C. Benedict. ......................\thens Dr. Giles Hathcock ........................ Bellton
Dr. J. B. Morgan ..........................\ugusta
Dr. Charles Hicks .......................... Dublin Dr. H. F. Harris .......................... "\ tlanta

PLACE oF ::\IEETING-State Capitol, Atlanta, Ga.

TnrE OF MEETING-Tuesday follO\ving the first :\Ionday January and June, at IO A.M.

EXECUTIVE COMMITTEE.

Dr. :i\Iorgan, Chairman,

Dr. \Villiams,

Dr. Hicks,

Dr. Benedict,

Dr. Owens,

Dr. Taylor.

Bacteriologist .................. DR. C. R. ANDREWS

Clerk ....................... :i\Irss FLoRENCE FRYER

THIRD ANNUAL REPORT
OF THE
SECRETARY OF THE STATE BOARD OF HEALTH
OF 'fliE
COMMONWEALTH OF GEORGIA.

9
During the year 1906 the Georgia State Board of Health \YaS in session twice, these being the regular meet-
N itws provided for by the Act creating the Board. 0 matters of unusual interest were brought before the Board during the year, there having happily been no unusual epidemics of disease, and the general health of the State being prob,ably somewhat above the normal on account of the subsidence of smallpox, which had preyailed to a large degree for a number of years previously.
The reports of the Secretary for the year \vere as follows :
REPORT Of THE SECRE'L-\RY Of THE STATE
DOc\RD Of HE:\LTH OF GEORGIA FRO:\I Jc\.:\l~:\RY I '1'0 1\PRIL 31, 1<)06,
INCLUSIVE.
- GEX1'Ll2i1Il<:N: I ha,e the honor to submit the follmving report of the \vork accomplished since the last meeting of the Board:
:\s heretofore, the time of your Secretary bas been divided up between field and laboratory \York. It is gratifying to state that the former is rapidly on the decline, while the latter is steadily increasing.
Since the last meeting I have visited the follcmingnamecl counties: Irwin, Berrien, Chatham, :\Iontgomery, \ Vashington, Dillb ancl Dougherty. The conditions calling for these visits \YCre smallpox in three cases, cerebrospinal meningitis in one in:-;tance, and in the other cases 1 was imestigating the subject of the frequency of sprue.
Rather curiously, considering the general opposition to vaccination, smallpox is clearly decreasing, there having been reported during the four months covered by this report only about 360 cases; unfortunately, in senral instances those reporting only saicl that there \YCre some

10
cases in the vicinity, and in the absence of definite facts, no idea could be formed as to the probable number of cases.
Since the last meeting of the Board your Secretary has obtained conclusive eyidence that sprue exists endemically in Georgia. A systematic attempt has been already begun to ascertain its frequency, and this will be continued until the real facts are obtained. As the disease is curable in the earlier stages it is highly important that our physicians should recognize it, and employ the proper means to bring about recovery; perhaps a special circular on this subject could be profitably issued.
Following your instructions, I have made arrangements to begin the study of "slow-fever" in South Georgia, and haYe employed Drs. L. T. Pattillo and F. \V. Schnauss as assistants.
I have made arrangements to do the \Vork in Albany, and have hired a house already furnished in which my assistants and myself can liYe and carry on the investigation. The rent of the house is $35 per month, and I thin];: that we can manage to keep within the amount allowed us by having a cook and eating at home. It gives me pleasure to say that sewral of the railroads have already giwn us passes, and it is likely that others that have been requested to do so will be equally liberal. It is my intention to begin as soon as the disease makes its appearance. In the meantime the t\vo gentlemen already referred to are working in the laboratory here preparing culture media.

11

The following examinations have been made m the laboratory :

Doubtful. Positive. NegatiYe.

"~meba coli ............. . Actinomyces hominis ..... .

0

J

0

3

Diphtheria ............. .

2

II

Diplococcus intracellularis

meningitidis .......... .

3

45

Gonococci .............. . Tenia saginata ......... .

3

4

3

0

Tubercle bacilli ...... .

40

So

Uncinaria eggs ...... .

14

18

Widal reaction ......... .

2

7

\Vater analysis ......... .

I

Total ................ .

68

173

In connection with our laboratory work, I desire to report that I am now making tuberculin for diagnostic purposes, and if experience should show that the substance is of real value for treatment, we can easily supply all that is necessary for the physicians of our State. The process of manufacture requires some time, but is comparatively simple, and the product can be obtained at a very small cost. I was led to this step by learning on a recent visit to the various northern sanatoria for the treatment of consumption that this substance is uniformly employed for the purpose of making diagnoses in the early stages of phthisis-a matter certainly of great importance, since if it can be relied on, it will lead to the early recognition of this terrible disease at the period when it is most amenable to treatment. When employed in the proper way it was the consensus of opinion at the recent meeting of the National Association for the Study and Prevention of Tuberculosis that this substance is the most valuable of all remedial agents for consumption.

12
For some time I have been impressed with the fact that our Board could accomplish a great deal of good (and gain for itself the sympathy of the people of Georgia) by the establishment of a Pasteur Institute for the treatment of rabies. I am quite convinced that we could so arrange matters as to send from day to day the necessary material to the patient's physician, and that he could under proper instruction administer the treatment at home; this would accomplish a great good certainly, since the nst majority of people bitten by mad-dogs are poor and unable to pay for the treatment at a regular institution. If we were to establish an institute it would be the first in the world so far as I am a ware of this particular kind.
The expenses of the Board for the preceding five months have been as follows:
Expenses of January meeting:
Dr. J. B. :\1organ ........................... $2 I I 5
Dr. R. l\f. Harbin.. . . . . . . . . . . . . . . . . . . . . . . . . I3 50 Dr. III. S. Brown. . . . . . . . . . . . . . . . . . . . . . . . . . . I 5 85
Dr. H. J. Williams. . . . . . . . . . . . . . . . . . . . . . . . . 29 52
Total ................................... S8o 02
Expenses of Secretary:
January ................................... $I3 95 February ................................. 20 50 l\Iarch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 45 April . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 I I 5
Total ................................... $83 05
Salaries:
Salary of Secretary, Jan. Ist to April 30th, inclusive ................................. $666 66
Bacteriologist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333 oo

13

Clerk ... I99 98 Office Boy ............ . .. . . .... . 6o oo

Total ................................ $I,259 6-1-

January:
Incidental expenses :
Laboratory apparatus ...................... $669 04 Stamps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IO oo Vaccine points . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 55
Books for Laboratory . . . . . . . . . . . . . . . . . . . . . . I 5 oo Glass plate for table . . . . . . . . . . . . . . . . . . . . . . . . 2 52
Chemicals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 70

February:
Journals for Laboratory ................... . Plumbing ............................... . Carpentering ............................ . Statnps ................................. . Vaccine ................................ . Office supplies ........................... .

II 90
84 so
73 so
IO 00
so a~ J 5 os

March:
Vaccine Stamps

s8 52
IO 00

Total ................................ $I,039 33

Expenses were then :
January meeting of Board ................ $ 8o o2 Expenses of Secretary ................... . 83 os Salaries ............................... . 592 98 Incidental expenses ..................... . I,039 33 Salary of Secretary ..................... . 666 66

Total ................................ $2,462 04

14
January r, 1906, onrclrawn ............... $ 414 28
January rst to ~\pril 30th, inclusi\e, running expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,462 04
Paid back money borrowed, r903 . . . . . . . . . . . 2.129 69
Total ................................ $3,oo6 or A.ppropriatecl for 1906 . . . . . . . . . . . . . . . . . . . 7,500 oo Total expenses to l\Iay I. I906. . . . . . . . . . . . . . s.oo6 or
Balance .............................. $2,493 99
1\.EPORT OF THE SECRET.\RY OF THE ST.\TE DO:\RD OF HEALTH OF GEORGI.\ FRO:JI ~IAY I TO DECE::\IDER 31, I906, I:'\CLUSIVE.
I have the honor to submit the follcming report of \York clone since the last regular meeting of the Doarcl :
Dming this period the principal work accomplished by your Secretary was in connection with the inyestigation of "slo\\ fever" in South Georgia. Following your instructions. I began preparations for this work in ::\Iay. Drs. L. T. Pattillo and F. \Y. Schnauss. at considerable sacrifice to their financial interests, agreed to gi,e us their assistance. and both remained with us until the inwstigation in South Georgia \\as completed. \Ve are also indebted to :\fr. S. R Benedict for assistance cmering a greater part of this period. A great deal of credit i,; Jikc\Yise due to the hearty co-operation nf the laboratory force in !\tlanta. as they \Yere constantly employed in preparing culture media, ami Dr. .\nclrews ga ,.e much help in working out the bacteria found in manv mstances.

15
On account of the fact that Albany has a large number of railroads entering it, and as it was the most accessible point in the extreme Southern part of the State, this city was selected as the location for our sub-laboratory. On investigation it \vas at once apparent that in order to do our work properly it \vould be necessary to have a laboratory in the same house \vhere our force resided, and, though it embodied more expense than I hacl hoped or contemplated. it became necessary to rent a dwelling in which to \York. The only available house for rent \vas secured at a rental of forty ( $40) dollars per month. Through the liberality of the railroads, passes were giyen to myself and the gentlemen who assisted me. and we were thus enabled to make excursions into the surrounding territory to see patients and to secure specimens. I \voulcl suggest that the Board pass a resolution of thanks to the management of the following railroads: The Central of Georgia, Atlantic Coast Line, Seaboard Air Line, The Georgia Northern and the Albany and I\orthern Railroads.
It gins me great pleasure to announce to the Board that, according to existing views, our investigation has pronn a brilliant success. Of forty-five cases of so-called ''sJo,, fenr," typhoid bacilli \Yere isolated in nineteen, paratyphoid bacilli in nine, ancl both of these organisms in one instance.
It might occur to one unaccustomed to b;:ccteriological work that the number of cases imestigatecl \Yas small, but \vhen the size of our force is remembered, the great clisachantage under which they worked in being away from a well-equipped laboratory and the ,-ast amount of technical detail that is required to isolztte organisms under imestigation. I am sure that the fullest credit will be gi,en to the laborious \YOrk of the gentlemen upon whom the brunt of it fell. "-\s Drs. Pattillo and Sch'1auss only recei\-ecl their ;:cctual expenses of )i,ing while assisting ns, and as I knmy that they \Yere put to considerable per-

16
sonal expense during the course of the investigation, I would respectfully suggest that a small sum be appropriated for each of them in recognition of their patient work and great service to us. \Ve will issue in the course of the next few months a complete and detailed report of this investigation.
Outside of my work in Albany, I have, I am very glad to say, received very few calls to go to distant parts of the State. At one time I investigated an epidemic of typhoid fever at Raleigh, Meriwether county, and at another time I visited Jackson, Butts county, and Griffin, Spalding county, on account of an epidemic of malaria that was believed to be the result of the erection of a large clam at a point intermediate between the two cities named.
I also attended at Vvashington the Annual Conference of the State and Territorial Health Officers with the United States Public and I\Iarine Hospital Service.
I would respectfully call the attention of the Board to the fact that our books and papers are not entirely secure, nor are they safe from fire under the existing conditions. Although every precaution has been taken, it is a well-known fact that fires occasionally break out in laboratories which no foresight can prevent, and, as it is a matter of much importance to keep our books ancl records, I would suggest that your Secretary be instructed to purchase a suitable fireproof safe.
I would also like to call the attention of the Board to the fact that the entrance to our offices is in a very bad condition, and, as the only prospect of bettering this state is for us to take the matter up, it would seem to me that a small appropriation should be made for relieving this very unsightly, even dangerous, condition of affairs.
In compliance with the resolution passed at the last meeting of the Board, the Legislature passed an Act authorizing us to install a Pasteur Institute in connection

17

\\ith our laboratory, but' in a fit of absent-mincleclness, did not appropriate any money for the puqh!~C. Howe\er. as \Ye \Yill unquestionably be expected to make this addition before the next meeting of the Legislature, I \\oulcl respectfully ask that you empower me to purchase the necessary apparatus and to make the needful arrangements looking toward this encl. I am under the impression that it ~,-ill not require any considerable sum to do
this. \\.e haye continued our laboratory work, and I am
happy to say that it is still on the increase. Belo,, is giYen a detail report of the work accomplished along these lines :

DoubtfuL Positi,e. X egative.

.-\meba coli .-\ctinomyces hominis .... . Diphtheria ............. . Gonococci .............. . Diploccoccus intracellularis
meningitidis .......... . Tenia saginata .......... . Tubercle bacilli ......... . :\Ialarial parasites ....... . Lanae of fly ........... . Ascasrislumbricoides ..... . Oxyuris vermicularis ..... . Hook\vom1 ............. . \\'ida! ................. . Spirocheta pallida ....... . \\'ater analyses ..

0

0

4

IS

I6

4

3

0

3

I I7

234

I3

II

I

0

I

0

I

0

68

87

27 69

3

I

IO

I 2bh

18

Below is a statement of the financial condition of the Board:

Expenses of ::\fay meeting:

Dr. Giles Hathcock. . . . . . . . . . . . . . . . ...... $ I 2 oo

Dr. S. C. Benedict. . . . . . . . . . . . . . . . . . . .... . 14 28

Dr. W. \V. Stewart. . . . . . . . . . . . . . . . . . . ... . 20 00
Dr. H. J. \Villiams. . . . . . . . . . . . . . . . . . . .. . 17 22

Dr. \V. F. \Vestmoreland ................. . IO 00
so Dr. \V. \V. 0\Yens ...................... . 32

Dr. J. B. l\Iorgan. . . . . . . .... .

2I 6S

Total. .....

. . . . . . $I27 65

Salaries:
Secretary. . . . . . . . . . . . . . . . . . . . . . . . . ... $I ,333 34 Bacteriologist. . . . . . . . . . . . . . . . . . . . . . . . . . 666 67 Clerk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443 67 Office boy . . . . . . . . . . . . . . . . . . . . . . . . . . . . I20 00

Total .............................. $2.563 68

Expenses of Secretary :

May ..... .

. . . . . . . . . . . . . . . . $I29 45

June ................. .

. . . . . . . . . I I SO

July ................. .

. . . . . . . . . 28 00

August. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 75

September. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 75

October. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 25

December. . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I 40

Total. . . . . . . . . . . . . . . . . . . . . . . . . ...... $229 IO

l\Iay:
Incidental expenses:
Stamps. . . . . . . . . . . . . . . . . . . . . . . . . .... $
Laboratory apparatus. . . . . . . . . . . . . . . . . . . . Vaccine points...... . . . . . . . . . . . . . . . . . . .

ro oo 2 oo r 5 6-t

19

Chemicals .... Dra,vings ...... ... Tools for laboratory. . . . . . . . . . . . . ....... . Telephone paid by Dr. \Vestmorelancl ....... . Expenses "slow fever" imestigation .. .

28 70 4 00
4 40 7 20 67 30

June: Expenses "slow fever" itwestigation ....... . Telegrams ........................... . Expense mailing Secretary's report ........ . Sundries... . . . . . . . . . . . . . . . . . . . . . . ... .

122 41 6 29
40 .")''-J 13 13

July:
Stamps ..... . Vaccine ..... . Ice...... . . . . . . . . . . . . . . . . . . . ....... . Typewriter supplies. . . . . . . . . . . . . . . . . . .. . Expenses "slow fever'' innstigation ....... . Journals for laboratory. . . . . . . . . . . . . .... . Screens for laboratory. . . . . . . . . . . . . ..... . Chemicals ........................... .

IO 00
42 00 4 00 75
r6o so 6 20
27 so 17 30

August:

Type\\Titer supplies . . . . . . . . . . . . . ...... .

6o

To,vels ............................. .

6o

Laundry ............................ . IO 00

Sundries. . . . . . . ..................... . Stan1ps. . . . . . . . . . . . . . . . . . . . . . . . . .... .

4 II 10 00

Expenses "slow fever" imestigation. . . . . . .. 159 Sb

Carpenter. . . . . . . . . . . . . . . . . . . ........ . 14 9S

Amount repaid bank money borrowed quaran-

tine, I 90S ........................ . I,20-J. 00

Lithia water. . . . . . . . . . . . . . . . . . . . . . ... .

9 so

September:

Sundries ..... . Expenses "slow fever" imestigation ....... . Chemicals ........................... . Drayage ............................ .

s 3~ 122 4b 28 8r
3 6_:;

20

October: Sundries. . . . . . . . . . . . . . . . . . . ......... . Stan1ps.. . . . . . . . . . . . . . . . . . . . . . . . .... . Journal, "Out-Door Life" ............... . Expenses "slow fever'' investigation ....... .
1\ovember: Books for laboratory. . . . . . . . . . . . . ...... . Stan1ps.. . . . . . . . . . . . . . . . . . . . . . . . .... .
December: Letter-heads. . . . . . . . . . . . . . . . . . . ....... . Plumbing. . . . . . . . . . . . . . . . . . . ... . Type\uiter supplies and sundries. . . . . . . ... . Chemicals. . . . . . . . . . . . . . . . . . . . . . . . ... . Books for laboratory. . . . . . . . . . . . . ...... . Vaccine points ......................... .

4 59
IO 00 I 00
75 76
13 00 IQ 00
16 25
5 so
14 sr
19 90
6 so
IO 00

Total. . . . . . . . . . . . . . . . . . . . . . . . . ..... $2,342 32

Expenses of meeting of Board ............ . 127 6s
Salaries ............................. . 2,563 68 Expenses of Secretary. . . . . . . . . . . . . ..... . 229 IO Incidental expenses. . . . . . . . . . . . . . . . . . . .. 2,342 32
Total. . . . . . . . . . . . . . . . . . . . . . . . . ..... $5,262 75 On hand May I, rgo6 . . . . . . . . . . . . . . . . . . . . 2,493 99 Special deficiency appropriation, 1906 ........ 2,829 69
Total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5,323 68Total amount appropriated . . . . . . . . . . . . . . . . 5,323 68 Expenses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,262 75
Balance. . . . . . . . . . . . . . . . . . . ......... $ 6o 93:

21

To the Georgia State Board of Health.

GENTLEMEN: I beg to make the follmYing repun c)t the "slow fever" investigation carriecl on lry your direc-

tion during the spring, summer and autumn of the pres-

ent year. It is gratifying to report that this imestigation, \vhich,

so far as I am aware, \vas the first systematic attempt to

determine the true nature of this disease, shmYs that it

is bacteriologically in most instances, if not in all. either

typhoid or paratyphoid. I wish again to call your attention to the fact that the
actual \York of this imestigation \YZ~S carried out by Drs. L. T. Pattillo and f'. \Y. Schnauss, with the assistance for a time of ~Ir. S. R. Benedict, and that its success \\"as

largely clue to their wry efficient and e'lthusiastic ::lssis-

tance.

Very respectful!;:, H. F. H.\R!~TS.

Secrctzcrv.

SYNOI\YMS: Typha-malarial fc<'cr; si!!Zp!c cont;nucd fever; remitttcn t malaria fcecr; TVil!acoochcc lt'i'Cr, con tinzted fever; bilious fever; t;;phm'd fever.
From the above list of names, by \\hich this disease has at times been designated, it will be seen that there has been in the past most divergent views as to its causation and real nature. l\Iany physicians living in the S\vampy regions of southern Georgia maintain that this affection is lmt a severe form of malaria, while others of equal capacity and intelligence are quite as positive tbat it is a 111ild form of typhoid fever; there are not \Yanting still others equally as capable \Yho hold that the malady is neither one nor the other, but is a separate and distinct disease. These varying views 1-:ave been maintained by their several advocates probably since the settlement of the country, bnt proof of their tmth has been. so fctr ;t'

22
[ am aware, based only on the clinical aspects that the disease presents, and, more recently, on blood examinations for the malarial parasite.
The subject is then seen to be at present in a hopelessly confused state-there being no possibility of an .1greement being reached except by actual proof of the truth of one of these opinions by the demonstration of the causation of the disease in question. \Vith this object in view, the present investigation was undertaken.
It is much to be regretted that our working force was so small that it was out of the question to se<;ure full and complete clinical data in the cases of "slow fever" that we have investigated. The material for our work was collected over a wide area embracing the entire southwestern portion of the State. In a number of instances specimens were sent us by the physician in charge-the localities from which they were gotten being too inaccessible for any of us to make a personal visit to the patient-and in such cases we necessarily had to depend on data obtained from the medical man in charge; this accounts for the lack of clinical records in several of our cases. It was likewise true that in not a few instances the patients were, on account of ignorance, but little disposed to aiel us in our work, and it was only with the greatest difficulty under such circumstances that specimens were obtained. Charts were distributed among the physicians with the request that records be made of the clinical course of the disease in their several patients, but, as in nearly all cases, these had to be left in the hands of the patient's family to fill out, practically no records of any value were secured. It should, however, be understood that our prime object was to discover the etiology of the disease, and I consequently felt that everything else should be sacrificed in order to determine this: it is gratifying to say that this has been accomplished according to accepted bacteriologic standards.
nur heartiest thanks are clue tc the f0llowing gentle-

23
men for their enthusiastic cooperation-carrying us to see patients and furnishing us with specimens oftentimes at great personal inconvenience to themselves. \Vithout their assistance this investigation would have been impossible, and the State Board of Health and the people of Georgia are unquestionably due them a debt of gratitude for their unselfish aiel:
Drs. P. L. Hitsman, A. H. Hitsman, \V. L. Da,-is and L. E. Welch. Albany, Ga.; A. L. Crittenden, E. C. McCurdy and A. F. \Veathers, Shellman, Ga. ; I. A. Bush,
J. L. Brown and J. ~1. Spence, Camilla, Ga.; J. L.
_-\dams and \V. 11. Richardson, Iron City, Ga.: F. B. Gregory and A. G. Fort, Lumpkin, Ga.; S. S. Gaulden and \V. Mathe\\"s, Quitman, Ga. ; 0. G. Cranford and
J. R. Cranford, Sasser, Ga.; H. T. Simpson and vV.
T. Simpson, Smithville, Ga.; A. P. Taylor, Thomasville, Ga.; C. B. Harrell, Doerun, Ga. ; vV. A. vValker, Cairo, Ga.; D. Q. Dallas, Pavo, Ga. ; R. H. Stovall, Vienna, Ga.; Lee L. Robinson, Naylor, Ga.
The thanks of the State Board of Health are likewise due to the follo\Ying named gentlemen, who most kindly furnished the members of this commission with passes over their respective roads. The finances of the board were so limited that this investigation could not have been undertaken witho~t the aid given us in this way, and it is but meet that the public should be made aware of this expression of their interest in the general welfare of the people of this State. The gentlemen by whom
these passes were given were Major J. F. Hanson of the
Central of Georgia Railroad, T. M. Emerson, president of the Atlantic Coast Line Railroad Company; Alfred Walker, president of the Seaboard Air Line Railway;
J. S. Crews, vice-president and general manager of the
Albany and Northern Railway. and C. Vv. Pidcock, presi-
dent and general manager of the Georgia Northern Rail\Yay Company.

24

"C"nfortunately it is impossible to go into the literature of this subject, as there is no accessible library from which the necessary data could be secured.

CLINICAL HISTORY.-For the purposes of convenience, the cases studied will be divided into four series, depending upon the bacteriological findings.

SERIES I. Cases in which the typhoid bacillus was demonstrated.

Stmts 2. Cases in which the paratyphoid bacillus "as obtained.

SERIES 3 Case in ,,hich both typhoid and paratyphoid bacilli \Yere demonstrated.

SERIES 4 Cases in which neither of these orl!al11SlllS \Yere found.

SERIES I. Twent\-three cases "ere seen.

Date of Ouser~'ation-T,vo of the patients \Ycre seen in June, t\vche in July, three in ~\ugust, and six in Sep-

tember.

Date of Onset-The disease in four of the cases began

in June, eight in July and three in August; in eight

cases no records were obtained.



Stage of the Diseasc-Tvw of the patients \Yere seen in the first, bvo in the second, five in the third, t\'o in the fourth, three in the fifth, and one in the sixth \Yeek of the disease; in eight cases no data were obtaineel.

Race-Of these patients eighteen m~re \Yhite and fi,e

\Yere negroes.

Sex-Fourteen \Yere male and nine female.

N ativifJ-All were Americans except one, who was a native of Germany.

Agc-T\YO of the patients were under ro years of age, seven between ro and 20, six between 20 and 30, one between 30 and 40, two between 40 and 50, and one bet\Hen so and 6o; in four instances the ages \Yere not obtained.

'25
Ocwpation-Se,en were farmers, se,en school children, three \vere house\\ives, one was a drummer, one a laborer, one a merchant, one a school teacher, one a pressing club operative, and one a child.
Previous His tor)' as Regards F e~1er-1'hree of the p01tients had previously had "slow fever," one had had typhoid, one malaria, and in fifteen instances there was no previous history of fevers; in three cases no records \\ere obtained.
Clzills-ln three cases the onset of the disease was manifested by chills, and in one chilly sensations; in eighteen instances no chills occurred, and in one case there \vas no record.
H eadache-ln the beginning nineteen suffered from headache, while in three cases this symptom did not occur; in one instance no record was obtained.
Pa:in in Bad: and Limbs-Thirteen of the patients had pains in the back and limbs, \vhile in nine this \HS not obserYCcl; in one instance there is no record.
Thirst-During the early stages of the disease se,en suffered from thirst to a clecidecl degree, while this symptom in two other cases \vas present, hut n0t ;o n~arkecl; in thirteen cases the thirst \vas not increased, and in one case there is no record.
Appetite-In nine cases the appetite \vas good, while in twelve anorexia \Yas obsenecl; in one case no recorrl \vas obtained.
Bmcels-ln fourteen instances the patient suffered from constipation and in four from diarrhea; in three cases the bowels \Yere regular, ancl in two instances there is no record.
Distention of Abdomen-SeYen showed a distention of the abdomen to a considerable degree, \Yhile in two other instances this symptom was present, but not so marked ; in t\nhe cases the abdomen \vas not distended; in two cases we haye no record.

Tenderness in Right Iliac Fossa-Tenderness in the right iliac fossa \Yas marked in eight cases, and slight in one; in thirteen it was not observed, and in one case we have no record.
Nose-Bleed-Two suffered from nose bleed in the early stages, while in twenty cases this symptom was not pbserved; in one instance \ve have no record.
Fever-Unfortunately our records of the temperature of these cases are exceedingly imperfect; in no instance have we a chart showing the daily variations. At the time the patients were seen the physician in attendance was always asked as regards the variations of the temperature since the beginning of the disease, and below is given the data thus secured:
Of two cases seen during the first week the temperature had varied from 100 to 103; in both instances there were remissions ; in five cases seen in the second week the temperature was said to have been in one instance 104.5, while in another case it had been clown as low as 99.2 ; in all remissions in the fever occurred, but there were no intermissions; in three cases seen in the third \veek the temperature had varied from 99 to 104.5; in one instance the fever was intermittent, but in the other two only remissions were observed; two cases were seen in the fourth week the temperature having varied from normal to 103.2; in one of these cases the fever was intermittent during the first and second week, but later only remissions occurred ; one case was seen in the fifth week the temperature not having been over 101, according to the physician in attendance; the fever was remittent; in two cases seen during the sixth week the temperature had varied between 101 and I05; in both instances remissions were present.
Rose Spots-Rose spots were observed in seven cases, but were absent in sixteen.
NenJous Symptoms-In ten cases nervous symptoms were pronounced, while thev were ahsent in eleven : in t\vo no records were ohtainerl.

27
Lungs-In twenty cases the lungs showed no abnormality, while in three we have no record.
H cart-In one case there was a systolic murmur at the apex, while in nineteen instances the organ appeared to be normal ; in three cases no records were obtained.
Spleen-In nine cases the spleen was decidedly enlarged, and in three slightly so; in eight the organ appeared to be normal in size, and in three there is no record.
Liver-In four cases this Yiscus appeared to be decidedly enlarged, \Yhile in three it was only slightly so; in thirteen cases it '';as negative, and in three instances no records were obtained.
Lymph Nodes-In seyen cases the lymph nodes were enlarged generally, while in one instance the swelling was confined to the neck, and in two cases to the inguinal regions; in ten these bodies were negatiYe, and in three cases no records were obtained.
B load-The difficulties under which this investigation was carried on precluded systematic examinations of blood in all instances. Smear preparations were, however, obtained in all cases, and stained by the Romanowsky method. The malarial parasite was not demonstrated in any of the cases.
The hemoglobin was estimated in nirie instances with the result that it was between 6o and 70 in one, between 70 and 8o in three, between 8o and 90 in three, and between 90 and IOO in two cases; no examinations were obtained in fourteen instances. It is noteworthy that in those cases where the hemoglobin was comparatively low the disease had existed for a number of weeks.
It is much to be regretted that in none of these cases were either the red or white cells counted.
Differential Counts of White Cells-Differential
counts of white cells were made in four cases-the ayerage results being as follows: Small lymphocytes, 20.3 per

cent.: large iymphnc_.-~t-~.

cent.: p(iyiiJrplw-

nuckar leuk(C\tc,_ (,', pc: , :.1 , eusinophile. I.j per

cent.

.Jg:.;!utinuti<J' : ,sls-.\~':_:;llltinaii 111 test:; \\"ere nndc

in tig';rcct: ,;:,es \':ith the result that ten \Yen.' p<)Siti,e

an'., c: ne,;ttile. \\bile one,,-~; qt:c,<i-nahlc: in fi,e

i" . . , "' c:-;:a~ninati(>ns \rcre made.

f; <1' ,') i!f'f'/y-Tn fourteen GlSCS the patie:lt 's drink-

11''. ,--ncr came from ~urface \\ells. \rhile 111 three in-

-:::ilCC.' ic ,.-a~ supplied from artc~ian \rcl!:;: in si:--: C1SC"

nr' rCciJ-, ]s \\ere olJtaine.J.

S:,\'/1.1'--Tn "nh nne C:tSC' ',\as the h, >11S: in \'.hiclJ f1c

p:1tien: Ji,ed screened: in ~ixtcen 0thers nn a!lempt lt:td

lccn m:-uic to carrY "l'' :tis great hygienic JliTCillt i, rn

:<~~in't di<ea'c in ,.,-;t;

tatc.s. Tn six itlsta:Jcc' n'

l"("(t ~rd~ \\"Ci"C nllt~tiL, 1.
ri1.: 1 !{,.w!!::-Oi !>~ hntit_,-thrce patient,, one died:

t111i .rttnl;-,tcl~ it \\'a.s imp:>s,:ihlc to obtain a p,,q-n;nrtem.

The :cmainin!..: t\\enty-t\\n marie une,entfnl rec:>\-crie'.

\\ ith tile except inn nnl~- that in one C;tse the p;tticnt \\"hen

last he;trI frr>m still cnmpbined of insomnia ;mel rleai-

nc S'-the htter prnhahly being- the re.~11lt ni the arlmini'-

trat-ion of hr~c doses of quinine, with \\ hich the'c pa-

tiC'nt;-; ;-,!c nftcn treated.

Tt is interest in!-': tn note that f, 'llr oi 1k'C p:1ticnts

li1ed in th: same hnu.;;e, ;tnd \er~- r11ri~m-h n1ic nf the

c:1~es in \rhich the parat~11hoirl hacillus \\":lS fn,md al,o;o

cl\\elt in the same house.

nactrri(J/(Jgica! rindiugs-The typlli1id lncillm "a"

f, 11nd in the urine in fifteen. in the !Jf, Jt)d in 'i';. and in

the feces in t\\n imtances; in n~1e case the org1ni'n1 \\"as

i,o;nbted from both blood :1nrl fecc;-; and in an ,i]wr fr<"rlll

the urine and feces.

Sr.Rrts .., Xine cases \\'ere seen. D.It, (Jf Q[,_,r;<'7/ion-Sew:n cases \\ere seen m July. one in .\ugnst and nne in September.
Dat, i'f Onsrt-The clise:1se in one of these cases he-

~ub1tnaiinne.d\

pril, th in one

ree in Jun instance.

e

,

iour

in

July;

no record \\as

Stage of the Disease-T\YO cases were seen during the second, one during the third and three during the fifth week of the disease; in one instance the patient \Yas seen during the second month and in another during the third; in one instance no data \vere obtained.

Race-All of these patients were \\bite.

Se.t"-Six \vere female and three \\ere male. Nativity-Ail were Americans.

Age-One was under ro years of age. three \\ere from ro to 20, two from 20 to 30, ancl t\VO from 30 to 40; in one instance no record was obtained.

Occupation-Two were schoolgirls, one \vas a school teacher, one a housewife, one a farmer, one a carpenter, and one was a child; no data \vere secured in two instances.
Previous History as Regards Fevers-Five of the patients had had malarial fever, one had had typhoid ana one had had "slow fever"; in two cases no records \vere obtained.

Chills-In two cases the disease began with pronounced chills, in six this symptom was not present; m one case no record was obtained.

Headache-Seven had headache; one did not. Pain in Limbs-In four cases this was present ancl m four absent; in one instance no record was secured. Pain in' Back-This was complained of in fiye instances; in three it was not observed, and in one no record \vas secured. Thirst-Thirst was pronounced in four cases, ancl in four it was not present; in one instance no data were secured. Appetite-In three the appetite was good, and in five poor; \Ve have no record in one case.

00
Do~'els-The bowels were regular in four cases, irregular in one and loose in two instances; in two no records were secured.
Distension of Abdomen-This symptom \vas observed in two cases and was absent in six, and in one instance no record was secured.
Tenderness in Right Iliac Fossa-In two cases tenderness was present, but in six it was absent, ancl m one no data were obtained.
Nose-Bleed-This symptom was observed in three cases, and was absent in fiye, and in one instance no record was secured.
FCLcr-Our temperature records, as \Yas the case \vith typhoids, are of a very meager character, and are merely a report of statements of the attending physicians as to the variations in temperature up to the time the patients were seen by us. The data given us are as follows: The temperature had been 100 to 104. in two cases seen during the second week; 104 in a case seen first in the third week, 105.5 in one instance seen during the fifth week, 99 to 105 in h\o cases seen during the sixth week, 102.5 in one case seen during the tenth week and 103 in a case seen during the twelfth week. All of these cases had shown more or less pronounced remissions, but in only one instance where the patient was seen during the tenth week was there any record of the temperature having been intermittent.
It will be observed that the fever was quite as high and persistent in these cases as in the typhoid.
Rose Spots-In seven cases rose spots were absent, and in one instance it is possible they may have been present. We have no record in one case.
Nervous Symptoms-The nervous symptoms were pronounced in two instances, and slight in two others: in four nothing of the kind was obsened. The records in one case were lacking.

31
Lungs-In eight cases the lungs were negative, and in one case no record was obtained.
H cart-The heart appeared normal in eight cases, and in one case no records \Yere secured.
Spleen-The spleen was enlarged in five cases, but appeared normal in three. No data were obtained in the other case.
Liver-'this organ appeared enlarged in one case and normal in seven; we have no record in one case.
Lymph Nodes-These bodies were not enlarged in seven cases; in two no data were secured.
Blood-Our records are likewise here exceedingly unsatisfactory, there having been no systematic examinations made of the blood.
In one instance only the \Yhite cells were counted, the number being 7,8oo.
In one case the hemoglobin was 6o per cent. during the second week, and in another 70 per cent; in one case in the sixth \Yeek it was 6o per cent.
Dtfferential Cou~zts of White Cells-Differential counts were made in three cases with the following a\erage: Sniall lymphocytes, I 5-5; large lymphocytes, 7 7; polymorphonuclear leukocytes, 76. I; eosinophile, 7
Agglutination Tests-Agglutination tests were made in two instances with negative results. In seyen cases this examination was not made.
Water Supp/'y-In six cases the patient's drinking water came from surface wells, while in one instance the water -vvas supplied from an artesian well; in two instances we have no records.
Screens-In seyen instances no screens were used, and in two the records are lacking.
Final Results-Eig-ht of these patients recovered and one died. In the fifth \Yeek one of the::;e patients developed phlehitis. and in one instance marked emaciation followed the fever.
Bacteriological Findings-The paratyphoid bacillus

32
was isolated in four cases from both urine and feces from the feces alone in two cases, from the urine alone in two cases and from the urine and blood in one case. It is noteworthy that with only one exception the bacilli were of the type A.
SERIES 3 Only one case was observed. This patient ,,as seen in September and was convalescent at this time. The date of onset was not obtained. The patient \vas \Yhite, a female, an American, a schoolgirl and \vas ten years of age. The patient had never had fever previously. There were not present in the beginning chills, headache, pain in back or limbs, or nose-bleed. The appetite \Yas good. There were thirst, constipation, distention of abdomen and tenderness in the right iliac fossa. At the time the patient was seen the temperature was running
ros from I04 to with occasional intermissions, according
to the report of the attending physician. No nenous symptoms were noted. The heart, lungs, liver and spleen were normal. The lymph nodes were enlarged. \Vith the exception of a \Vidal test, which was positive. no examination of the blood was made.
No records were obtained as to the water supply, nor as to whether the house in which the patient lived \vas screened.
Both typhoid and paratyphoid bacilli were isolated from the urine; the later organism belonged to the A type.
SERIES 4 Twelve cases were seen.
Date of Observation-Three cases were seen in July, four in August and five in September.
Date of Onset-The disease in four of these cases began in June, six in August, and two in September.
Stage of the Disease-One of these patients was seen during the first week, seven during the second week, three during the third week and one in the sixth week.
Race-Nine of the patients were white, and three were negroes.

33
Sex-Six were male and six were female. Nativity-All were Americans. Age-One patient \vas under 10 years of age, two between ro and 20, five between 20 and 30, two between 3o and 40, and one between so and 6o; the age of one was not given. Occupation-One was a woodsman, two were laborers, three were farmers, two were housewives, one was a child, one a schoolgirl, one a bookkeeper, and one was a
cook. Previous History as Regards Fevers-Four of the pa-
tients had had malaria, one typhoid fever, and one continued fever; five had never had fevers, and in one case no record was obtain_ed.
Chills-In five instances the disease was ushered in with a chill; this did not occur in the other seven cases.
Headache-In the beginning eleven suffered from headache; in one this was not observed.
Pa1in in Limbs-In nine cases this symptom was present, and in three absent.
Pain in Back-This was complained of in ten cases, but in two instances was not observed.
Thirst-Thirst \vas pronounced in nine cases, and in three cases was absent.
Appetite-In two cases it was good, and in ten poor. Bowels-Four of the patients were constipated, and in three instances the bowels were loose; in five of the cases the movements were regular. Distention of Abdomen-This symptom was observed in five cases and absent in seven. Tenderness in Right Iliac Fossa-This was observed in five cases, but was absent in seven. Nose-Bleed-This occurred in one case, and was absent in eleven. Fever-As in both Series r and 2, our fever records are very unsatisfactory in these cases. The data secured were as follows: The temperature had been 104.6 in
3bh

34
one case during the first week, from 103 to 104.4 in fi\'C cases seen during the second week, from 101.5 to 105 in five cases seen during the third week and 106.6 in one seen during the fourth 1nek. In one of these cases the fever was intermittent from the outset, but remittent later. and in one other instance was intermittent; all the rest only shmved more or less pronounced remissions,
Rose Spots-In nine cases rose spots were absent, and in three instances it was questionable as to whether they were present or not.
Nervous Sjmptoms-N ervous symptoms \Yere pronounced in six cases, and absent in six.
Lungs-In nine cases the lungs were normal, and in three no records were secured.
Heart-The heart was apparently normal in nine cases, but intermittent in one; in two no records 1\'ere secured.
S plecn-This viscus was enlarged in seven and normal in three cases; records were lacking in two instances.
Lhcr-The liver was somewhat enlarged in three cases and negati\'e in six; in three instances no records were obtained.
Lymph Nodes-In three cases the lymph nodes were enlarged, and in seven they appeared to be normal ; no data were secured in three instances.
Blood-A hemoglobin estimation was made in s1x instances, the figures running between 6o and 95 per cent. There was no marked relationship between the quantity of this substance prese11't, and the length of the disease. the highest and lowest figure having been observed in cases in the third week.
No counts were made of either the reel or white cells.
Differential Caunts of the White Cells-In four instances differential counts of the white cells were made with the result that the average number of cells were as follows: Small lymphocytes, 17.5; large lymphocytes, 8.2: polymorphonuclear leukocytes, 72.6, and oesinophile, 1.7.

35
Agglutination Tests-In one case the result was positive, and in three negative; no records were secured in eight instances.
Water Supply-In eight cases the water supply was from surface wells, and in four instances no records were secure_d.
Screens-The houses in which the patients lived were not screened in eight instances; in four the records were lacking.
Final Results-All of these p~tients had uneventful recoveries.
ETioLOGY.-As was before stated, the prime object of our investigation was to ascertain the etiology of this disease. Opinion as to whether or not \Ye have succeeded will depend entirely upon our views as to the accepted ideas concerning the causation of typhoid and so-called paratyphoid fe\'ers. As 1s well known, the etiologic relationship of the typhoid bacillus to typhoid fever has never been put to the crucial test of human experimentation, and as typhoid fever does not occur in the lower animals, final proof of this connection is yet wanting. This is equally true of. the so-called paratyphoid bacillus. :0Jotwithstanding this lack of final proof, a vast majority of bacteriologists agree that these organisms really stand in a causative relationship to typhoid .and paratyphoid fever respectively. If this view be correct, there can be nb dot1bt of the success of our labors, and although the organisms were found in only 733 per cent. of all cases investigated, it seems in the highest degree probable that if these germs in reality produce the disease in question, more careful and thorough examinations would have demonstrated their presence in all of the other instances. At all events the typhoid and paratyphoid organisms were isolated in practically three-fourths of the cases under inv~stigation, and agreeably to current views, there could be no further doubt as to the real nature of the fever in

36
those instances in which the organisms were found. It is certainly true, whatever views we may hold, that the isolation of these germs in such a large percentage of cases is extremely interesting, and more or less significant.
As has been stated above, typhoid and paratyphoid bacilli were demonstrated in 733 per cent. of all cases investigated; of these the typhoid organism was found in 56. I per cent., the paratyphoid in 20 per cent., and a mixed infection in 2.2 per cent. of cases.

,_
.I..
...,

v
I
'
~(
I
\

,,-:'

'~-::J~

,,

Jv) ~--l

1!.

'~I

I I
\I
... I

TYPHOID BACILLI.
As is well known, the isolation of the typhoid and paratyphoid bacilli, particularly from the feces, is a matter of great difficulty. Unfortunately there is a most close relationship between these bacteria and the colon bacillusso close that it seems to me there can be no question that they are varieties of one and the same organism. Morphologically, and in their staining reactions, it is impossible to distinguish these bacteria one from another, it being only by careful cultural experiments that this can be

37
accomplished. This very close resemblance has lead to a vast deal of work with the idea of devising some method or methods by which it would be possible always to differentiate these bacteria. Thus we find that the earlier investigators laid great stress upon the fact that the typhoid bacillus usually grows in a colorless film on potato, while the colon bacillus produces a thick grayish pa!licle. Much also was made of the fact that as a rule the colon bacillus produces indo!, '"hile the other organism does not. A striking peculiarity of the colon bacillus is the fact that it produces gas in media containing sugars-a peculiarity which it does not share with the typhoid bacillus. For a time considerable stress \Yas laid upon the fact that in media containing iodide of potassium the colon bacillus usually develops much more rapidly than does the typhoid, but recently this method of differentiation has not been so much employed. Among the other peculiarities of these organisms, upon which the earlier writers relied to differentiate them are the facts that typhoid bacillus is usually somewhat more slender than th~ colon bacillus, that its flagellze are generally more numerous, that they produce less acid, and that their growth is usually not so rapid as is the case with the other organism; the colon bacillus coagulates milk in which it grows, but the typhoid bacillus does not do this. Unfortunately it has been shmvn that these ,arious methods for differentiation of the organisms in question can not be entirely relied upon, as it now and then occurs that the colon bacillus will show some of the peculiarities of the typhoid organism, and cmwersely, the latter germ not infrequently exhibits characteristics that are supposed to be peculiar to the other.
\Vithin recent years highly successful attempts have been made along the line of preparing special culture media, the object of which was to isolate these bacteria by means of the chemical substances that they produce. Chief among these is the culture medium invented by Drigalski and Conradi ( r). This medium \Yas imagined

38
on account of the well-known fact that in the presence of both carbohydrates and nitrogenous substances the colon bacillus produces acids from the former, while the typhoid bacillus breaks the albuminous material into products that give an alkaline reaction. This medium contains chrystal violet, which is supposed to hinder the development of other bacteria that might be present in the material under examination.
The Drigalski-Conracli medium, \Yhen made according to the directions of the originators, \Yas found to g; 1 e somewhat inconstant results. Following the suggestims of Terburgh (2), we han modified the method of preparing this medium as follows:
2 litres of bouillon-(3 pounds of beef to 2 litres of water.) 20 g. (I per cent.) peptone siccum Witte. 20 g. (I per cent.) nntrose. IO g. (o.s per cent.) salt. 6o g. (3 per cent.) agar. 30 g. (r.s per cent.) lactose (C. P.)
After the solution in the autoclave is complete th(;; medium is made faintly alkaline to litmus, 4 c.. c. of a ro per cent., sodium hydrate solution and 20 c. c. of an aqueous chrystal violet (B. Hochst) solution ( I-IOoo) are added, and the whole is sterilized; 36 c. c. of a sterilized solution of litmus prepared by pouring boiling water over pulverized ordinary commercial litmus is then added.
The alkalinity of this medium should, at least, be 0.04 per cent. of pure sodium hydrate.
Typical colon bacilli, on account of the large quantity of acid that they produce, turn the medium red in the immediate vicinity of the point where the growth occurs; the acids do not diffuse to any considerable degree owing to the great proportion of agar that the medium contains. The typhoid colonies do not develop so luxuriantly as the colon and are more transparent; the medium in their immediate neighborhood remains blue. From the foregoing it is seen that where the two organisms develop in

CO RADI-DRIGALSKI PLATE.

LEFT, TYPHOiD BACILLI.

RIGHT, COLON BACILLI.

39
a characteristic way, differentiation between them is extremely simple.
Another culture medium which is quite, if not more, satisfactory than that of Drigalski-Conradi for the sep-
aration of the two organisms in question is that of Emro
( 3). It, like the former medium, depends for its value on the production of considerable quantities of acids by the colon bacillus, and the detection of the colonies by the change in color produced in the culture material upon which the organism grows. The medium as slightly modified by us is prepared as follows :
To 1000 c. c. 3 per cent. neutral nutrient agar. ro g. (r per cent.) of lactose. roc. c. (r per cent.) of roper cent soda solution are added.
The whole is sterilized and is then mixed with so c. c. of
a I per cent. watery solution of basic fuchsin. Then 25 c. c. of a sterile IO per cent. sodium sulphite solution is added, and the whole well shaken, and the medium at once poured into sterile Petri dishes. When cold it has a faintly pinkish tinge.
The reason that the above modification was clevisecl was on account of the fact that we found that the medium again became red if sterilized after decolorization by the sodium sulphite.
The alkalinity of this medium is generally between .::-.I to o. I 5 per cent. pure sodium hydrate with litmus paper as an indicator.
It is particularly necessary in preparing and preserving this medium to give attention to the following details:
I. The lactose should be pure. If adulterateJ with cane sugar the typhoid bacillus also produces acids which renders its differentiation from the colon bacillus very difficult.
<. The sodium sulphite solution must either be kept in a well-corked bottle or should be freshly made.
3 The culture medium must be preserved in the dark, as light causes it to gradually turn reel.

40
When colon bacilli are planted on this medium the colonies grow rapidly and color it very red; over their surfaces a metallic luster quickly appears which is highly characteristic of these organisms. The typhoid colonies are small, have a transparent appearance and only show a faint pinkish color.
In r903 Lentz and Tietz (4) discovered the fact that malachite green, when added to the customary culture media, possesses the important property of more or less hindering the development of the colon bacillus, while the typhoid organism is relatively unaffected; this property of malachite green is particularly important where investigation of the feces are being carried on, but unfortunately the results depend very greatly on just the proper degreeof alkalinity in the medium. On this account we were not particularly successful with this method, and, as the same object could be attained more satisfactorily in other ways, we did not continue the use of the medium throughout the course of our investigations. It seemed to us by no means so certain as the method of Ficker and Hoffman ( 5), in which the growth of the colon bacillus is hindered by the presence of caffeine in the medium; this method is certainly very serviceable, and we believe more reliable than the one just referred to.
Perhaps the best of all the media for the detection of typhoid bacilli in badly contaminated material, such as feces, is the method of Gaehtgens (6), which is a combination of the procedures devised by Endo. and Ficker and Hoffman. In this method caffeine in the Endo medium hinders the development of the colon bacilli while the color reactions differentiate these organisms from the ty1)hoid and paratyphoid bacilli. The medium is prepared by simply adding 0.33 caffeine to the Endo agar solution already referred to.
It might be mentioned at this point that \Ye have useo 1Yith entire satisfaction the bent glass rods recommended by Drigalski and Conradi ( 7) for planting on plates the organisms under investigation.

EN DO PLATE.

LE FT. T YPHOID BAC ILLI.

R IG HT . C OLON BAC ILL I.

41
'J'hey consist of glass rods about 20 em. in length, and an arm about 3 em. long bent at right angles to it at one end. The material to be examined is rubbed up well with water in a sterilized mortar. The culture is then made by inserting the small arm of the glass rod in the mixture, removing with a shake the excess of liquid sticking to it; and it is then drawn lightly over the surface of the medium in the Petri dish.
Where it is wished to make cultures from the blood, the method recommended by Conradi (8), is undoubtedly of great value, supplanting, in our opinion, the earlier procedure of Schottmueller (9), who first called attention to the value of bacteriologic examinations of the blood in the diagnosis of typhoid eyer. This procedure is based upon the fact that the bile has a decided action in preventing the coagulation of blood, while the bacilli grow excellently in a mixture of these two substances. The method is carried out as follows: To ox bile ro per cent. each of peptone and glycerine is added, and after sterilization ro c. c. of the solution are measured off in as many tubes as may be desirable. Blood is then obtained from the patient by \\'ithclrawing it from a vein with a syringe, or, as Conradi prefers, from the ear; o. 5 to 2 c. c. are sufficient. The blood is added to the bile solution and put in the incubator for about sixteen hours. If typhoid bacilli be present their number very greatly increases. Cultures are made from this mixture on any of the media by means of which it is possible to determine the true characteristic of any growth that may be present.
In the first instance, then. where it is desired to isolate typhoid or paratyphoid lncilli, \\'e would recommend that in the case of the feces either the methods of Gaehtgens or Drigalski-Conradi be employed; where .\\'e are dealing with urine. either of these methods. OF the Enclo process, may be adyantageously used; finally where we wish to examine the blood \Ye make a preliminary culture of Conradi bile medium, and then subsequently identify

42
either of the orgamsms in question m case they are present.
Among the methods that have been especiaiiy devised for the purpose of differentiating colon from typhoid baciiii after isolation may be mentioned the foiiowing:
Escherich ( ro) first called attention to the fact that the colon baciiius coagulates milk----.:a property which t:'! not shared with it by either the typhoid or paratyphoid organisms. Paratyphoid B alkalinizes this medium after the sewnd \Yeek, and causes the milk to become clear.
,\nuther important differential test was that describe1l by Chantemesse and \iVidal (I r) who showed that the colon baciiius ferments lactose with the production of gas, while the typhoid bacillus does not do this; Schottmueller's paratyphoid baciiius A resembles in this particular the typhoid organism, while the type B, like the colon baciiius, disengages gas.
It was also shown by these authors that glucose reacts to the typhoid and colon bacillus exactly as does lactose. As regards the paratyphoid organisms, however, the two substances are not entirely similar since both the A and B types possess the power of decomposing the former.
~vfany writers early called attention to the fact- that the various bacteria possesses the property of changing the reaction of culture media. Among these may be mentioned Buchner (I 2), \iVeissner (I;)), Cahen (I 4 ), Loeffler (IS), and Behring (r6), but it was Petruschky ( I7) who first recognized the great significance of this fact in connection with colon and typhoid baci11i. He uses as a differential medium whey, to which a sufficient amount of purified litmus has been added to distinctly color the medium. On this the typhoid bacteria grow without producing any alteration of color, but the colon organism quickly changes the culture material t 1 a decidedly reddish hue.
A modification of the last two tests devised by Wurtz ( I8) is very convenient. It is based on the fact that no

43
gas or reddening of the medium occurs when the typlwid bacillus grows in litmus-lactose agar, while both of these results occur during the development of the colon bacillus. Paratyphoid B produces more or less gas in this medium. while the A does not.
As has long been known, the production of indol in albuminous media is highly characteristic of the colon bacillus, while this substance does not result from the growth of the typhoid organism; the paratyphoid is this respect resembles the typhoid bacillus. The test usually employed for the demonstration of indo! is that devised by Baeyer ( I 9), and recommended by Kitasato ( 20) for the purpose of differentiating the typhoid from the colon bacillus; 2s modified by Salkowski ( 2I), it is carried out as follows :
To the bouillon culture I c. c. of o. 02 per cent. of sodium nitrite solution and a few drops of concentrated sulphuric acid are added, and if indol be present the mixture assumes a reddish color.
Still more delicate is the reaction discovered by Ehrlich, and published through his pupil, Proescher ( 22) ; this test depends upon the fact that solutions of par3dimethylamiclobenzalclehycle are colored reel in the presence of indo!. The test is carried out as follows by Boehme ( 23), who first called attention to its value from a bacteriologic standpoint:
Two solutions are employed:
(I) Paraclimethylamiclobenzaldehypcle . . . 4 g.m. Alcohol ( 96 per cent.) ............ 380 c. c. Hydrochloric acid (concentrated) ... 8o c. c.
(2) Potassium persulphate saturated watery solution.
To IO c. c. of the bouillon culture to be tested 5 c. c. of solution No. I are added, and then 5 c. c. of solution No. 2; the whole is well shaken, and if indo! be present it assumes immediately an intensely red hue.
Erdmann and Wintemitz (24) have shown that proteinchrom is produced by the typhoid bacillus in media

44

containing albumins, while this substance does not result

from the growth of the colon organism. The bacterium=

under investigation is planted in peptone bouillon, and

after two days the culture is treated with a sufficient

quantity of acetic acid to render it sour. Bromine or

chlorine-water is then added drop by drop, and if pro-

teinchrom be present there results a deep reddish-violet

color. These writers prefer chlorine to bromine-water.

They call attention to the fact that the former may be

easily prepared by adding hydrochloric acid to a watery

solution of chloranated lime. This test was positive four

and negative six times out of our ten examples of para-

typhoid bacilli.

One of the most satisfactory methods for differentiat-

ing between the colon bacilli and the typhoid and para-

typhoid organisms is the modification of Rothberger's

( 25) neutrar red procedure devised by Scheffler ( 26).

The medium is prepared by adding 0.3 per cent. of grape

sugar, and r c. c. of a concentrated watery solution of

neutral red to roo c. c. of nutrient agar. The culture ma-

terial is sterilized and put in tubes, and stab cultures

made in the usual way after cooling. In from twenty-four

to forty-eight hours the medium which before '"as of a

dark cherry-red tint becomes partially decolorized and

as5umes a very characteristic gr~enish fluorescent hue if

colon bacilli be present; there are also numerous bubbles

in the medium produced by the liberation of gases from

the sugar which it contains. Exactly similar changes are

produced by both types of the paratyphoid organisms.

The typhoid bacillus grows in this medium, but neither

decolorizes it nor produces gas. \Ve have not tried the

neutral red gelatine recommended by Czaplewski ( 27).

The writer claims that cultures kept at 37 C. give sharp

reactions in nine hours.

Our results with media containine- metallic salts were

I

~

so unsatisfactory that we do not consider them of suffi-

cient importance to discuss in' this paper.

I,

NEUTRAL RED MEDIUM.

LEFT, TYPHOID BACILLI.

RIGHT, COLON BACILLI.

45

Below is given a table showing the bio-chemic peculiarities of the colon-typhoid group of bacilli:

- .d <!) I ~
I
<!)
.D
... ~
rn"C
... ... s~
.. ...-"0
> ~

~
<11
"o"'l "5
btl
~
0
0 ~ ~

0
"0
..~...

~~

<!)

<!)

"~"' "~"'

.s.. .s.. <!)

<!)

.... ..<..!.)

<!)

<I)

<!)

00
0

00
0

"' "'~
ol
.J :.'J

PoTATo.

...o,i ..oi

<!)~
~o
.D ...
":<;i:). C!:l

~
<1)2
;C!:l

..::

- I 1-1-1-1- I + I Typhoid ..

NEUTRAL RED.

"0 <!) b() ~
ol
s-g
~~
-P
"0
::"s'
+

' ' ' ~<!) ...
O,t::~ 0
g"d~
~;;r.:.

s
.0..

.D

.:::.;:: s S"<C1o)<o1.>.~i ~
r"'':jJ-cOoo
<1)0<:)<1)
~

<:)
.a~..;
.0..
p..

I+

. p~~t.~~~~i~:\ 1-l-1-1 + I + I + I+ -

p~~typhoid.l

From the foregoing one inexperienced would certainly be led to the conclusion that the differentiation of typhoid from colon bacilli was comparatively an easy matter, but multiply our tests as we will, there is unfortunately no absolutely certain method by means of \vhich this result can always be accomplished.
It is noteworthy that of the ten examplesof paratyphoid organisms isolated, certainly nine correspond to the paratyphoid A. This is of particular interest in view of the fact that most writers have isolated the type B, the type A variety being decidedly a rarity. As to whether these germs play any part in the original causation of "slow fever" is a matter which only future investigation can show.
Paratyphoid fever, like typhoid, is unfortunately a disease only of man. as far as is known, and we are not therefore, in a position to make experiments on animals with the view of determining this matter. The fact that

46
paratyphoid bacilli have been found in the tissues of those dead of other diseases, clearly not typhoidal in character, and that they have been isolated from the intestinal canal of animals would seem to point strongly to the view that they are not the original causative agents in the production of the fevers with which they have been associated. It seems highly probable to me that it will ultimately be found that neither the typhoid or paratyphoid organisms in reality produce the affections that they are now supposed to cause. In the albuminous exudates that come from the intestinal lesions of typhoid fcyer, we have a medium highly suited to the growth of these organisms, and it is not impossible that their presence in great numbers in the ulcers that occur in this disease is clue to the facility with which they develop under the conditions there present. That the bacteria in question are absorbed and carried into the tissues and intestinal fluids of the body \Ve know to be true, and as a consec1uence their number and virulence, of course, play a role-and doubtless a very prominent one-in the symptomatology of the disease. \Ve thus see that a secondary infection of these organisms might be a matter of great importance, even though they play no part in the causation of the disease. This theory \Ynuld readily explain the difference in the clinical phenomena observed in case of typhoid and paratyphoid infection. In a similar \Yay we could account for the agglutination reactions that occur with more or less frequency in these affections.
PATHOLOGICAL ANA'l'OMY.-It is greatly to be regretted that no opportunity permitted the postmortem stuc1y of the bodies of those dying of "slow fever," and we are, therefore, not in a position to speak as regards this most important matter. Vi!e can only ca11 attention to the fact that in a considerable portion of the cases the spleen was obviously enlarged, and that in some instances the lymph-nodes were increased in size. In a few cases rose spots were present. These fact

47
certainly bear strongly in the direction of the assumption that this so-called "slow fever" is certainly, in many cases, typhoid, with its well-knmvn pathological anatomy.
SnuTOMATOLOGY.-As the primary object of this investigatioi1 was, if possible, to determine the etiology of "slow fever", no systematic attempt was made to study the syli1ptomatology of the disease. It was, however, necessary to go into the clinical side of the matter sufficiently to determine that the cases under investigation \vere true examples of the affection in question. It is not pretended that the symptoms hereinafter enumerated furnish an accurate and clear picture of the malady throughout its course, but it is belieYecl that the principle ancl most striking clinical phenomena are given. Of the forty-five cases studied records were not ohtainecl in all cases as regards the clinical details with \Yhich we are now dealing, this accounting for discrepancies which might othen;:ise be puzzling.
In thirteen cases the"onset of the disease \Yas in April, eleven in June. eighteen in July, and t\YO in September. Thirty-six \Yere white and eight \\ere n:ogrocs; t\Yentythree \Yere males and t\Yenty-one fe;nales; forty-four were Americans and one was a German; four of the patients \Yere under ro; t\;:elYe from ro-20; thirteen from 20-30; fiye from 30-40; t\yo from 40-50, ami two from 50-60; e]e\en \':ere farmers; ten \Yere schoolchildren; six were laborers; six \Yere house\Yives; three were children; two were schoolteachers; one \Yas a cook; one a drummer, and one a bookkeeper. Five of these patients had previously had "slow fever," three typhoid. ten malaria. and twenty declared that they had previously had no fever of any kind. In twelve instances the disease was ushered in lw a chill. Headache was observed in thirty-seven cases, and pain in the limbs and back in thirty-eight. Appetite \Yas good in fourteen cases, and poor in 27. Constipation was present in eighteen cases, and diarrhea in ten; in twelve the bowels were

48
regular. Distention of abdomen and tenderness in the right iliac fossa were present in seventeen cases. Nosebleed was present in six cases. The fever had varied up to the time of observation from 99.2 to 106.6 degrees F. The temperature seemed, as a rule, to be decidedly higher in the earlier stages of the disease than is the case in typhoid. It does not appear to rise in the beginning and recede in the end in the gradual manner so characteristic of the classical forms of the latter disease. The fever was in most instances continuous, but showed regular remissions at some time during the twenty-four hours. In six cases intermissions were observed-these being usually present either in the very beginning or toward the end of the attack. Rose spots were found in seven cases. In tw~nty instances nervous symptoms were more or less pronounced. The heart, and quite curiously, the lungs, also appeared to be normal in every case examined. The spleen was enlarged in twenty-four cases, and there was more or less general.swelling of the lymphnodes in twenty-three instances. The liver appeared to be somewhat enlarged in eleven cases.
Stained preparations of the blood by the Romanowsky method were made in every instance, and not in a single case was the malarial parasite found. In eighteen cases the hemoglobin was estimated; the figures ranged from 6o per cent. to IOO per cent.; the amount of hemoglobin was not entirely dependent upon the stage of the disease, it having been found to be very low in several cases during the first week of the disease.
In only one case were the leukocytes counted, the number being 7,8oo to the cubic millimeter. The average differential counts in eleven cases is as follows:
Small lymphocytes .......... I 7. 7 per cent. Large lymphocytes . . . . . . . . . . 9. 4 per cent. Polymorphonuclears .......... 7I. 6 per cent. Eosinophiles . . . . . . . . . . . . . . . . I . 3 per cent.

49
Agglutination tests \vere positive in only twelve cases. In one case the malady was complicated by a phlebitis in the leg, and in another deafness and nervous symptoms followed the disease. Death occurred in two cases. It is noteworthy that so far as could be judged from our investigations, irrespective of the bacteriologic findings, the cases studied were essentially alike from the: clinical standpoint. The instances in which paratyphoid bacilli were isolated appeared to be in every way as severe as those in which the typhoid organism was obtained-indeed, the percentage of death in the cases' studied was even greater, there having been one fatal result out of nine cases of paratyphoid, and one out of twenty-three of typhoid. It is of interest to note that only three of the patients received their water supply from artesian wells, all, the others obtaining it from surface sources. In every case but one the houses in which the patients liYed were uns6reened-these being uniformly swarming with flies, and in many instances mosquitoes were also present in great numbers.
PROGNOSIS--The prognosis in "slow fever" is generally. conceded to be better than in typhoid, and I believe that. there can be no reasonable doubt that this assumption is correct. This fact in a large measure furnishes the bases. for the commonly-expressed opinion among southern physicians that "slow fever" is a distinct and separate disease. The mortality in our series of cases is certainly lower than is usually observed in typhoid fever, but of course from such a small number of instances of the disease no general conclusions could be drawn.
DIAGNOSIS-The first thought that ahnys arises in the southern physician's mind when he is called to a case of fever is: Can it be malaria? He does not depend upon the microscope for an answer to this question, but prompt-ly administers large closes of quinine. If the patient re-
4bh

50
sponds to this treatment he justly regards the affection as bei.ng of malarial origin, but, if on the other hand no effect is produced, he will call it typho-malarial, slow or typhoid fever, depending upon his preconceived ideas as to the real character of the disease we are studying. Practically, then, it may be said that we may include in the category of "slow fever" all of those instances of hyperpyrexia not responding to quinine for which no anatomical basis can be discovered, and which continues from one to ten week~. Of course an examination of the blood for the malaria parasite is of much value, but it should not be forgotten that in those regions vvhere this iever is most common the usual type of malaria is the estivo-autumnal, in which it is oftentimes a matter of great difficulty to discover the parasite. Unfortunately the Widal test, even when carried out with the paratyphoid organism, is extremely untrustworthy in this type of fever, it being indeed so much so that I am not inclined to lay any particular stress upon it.
TREATMENT-I have had no great experience in the treatment of this disease, but I think everything warrants the opinion that it should be looked after just as is typhoid-a view which I believe I share in common with the majority of Southern practitioners. It should be mentioned, however, that many excellent physicians employ large closes of quinine throughout the course of the disease with the belief that its course is thereby shortened.
I. v. Drigalski u. Conradi. Ueber ein Vedahren zum K ach\Yeise der Typhus Bacillen. ( Zeitchr. f. Hyg. Bel. XXXIX. S. 283.)
2. Terburgh. Die auf clem ,.. Drigalski-Conraclischen Nahragar waschsenden Bacillen, etc. Centralbl. f. Bakt. etc. Bel. XL., H. 2 S. 258.
3 Endo. Ueber ein V erfahren zum Kachweise cler Typhus Bacillen. Centralbl. f. Bakt. Orig. Bel. XXXV. S. 109.

51
4 Lentz u. Tietz. Eine Anreicherugsmethode f. Typhus u. Paratyphus Bacillen. Muench. med. \Vochenschrift, I903, No. 49
5 Ficker u. Hoffman. Ueber neue Methoden des
Nachweises von Typhus Bacillen. Hyg. Rundschau. Bd. XIV. I904.
6. Gaehtgens. Ulber die Erhohung der Leistungs-
fahigkeit des Endoschen Fuchsinagars durch den Zusatz von Koffein. Centralbl. f. Bakt. etc. Bd. XXXIX. H. 5 S. 634. 7 Drigalski u Conradi. Loc cit. 8. Conradli. Ueber Zuechtung von Typhus Bazli!Ien aus dem Blut mittles der Gallenkultur. Muench. med. \Vochenscher. I9o6. No. 34 S. I654
9 Schottmueller. Ueber eine das Bild des Typhus bietende Erkrankung hervorgerufen durch Typhus aehnlichie Baciiien. Deutch. med. \Vochenschr. I 900. No. 32 S. 5I 1. \Veitere Mittheilungen ueber mehrere das Bild des Typhus bietende Krankheitsfaelle hervorgerufen durch Typhus aehnliche Bacillen. Zeit. f. Hyg. 1901. Bd. 36. S. 368. Zur Pathogenese des Typhus abdominalis. Muench. med. \Yochenscher. I902. No. 38. S. I 56 I.
IO. Escherich. Bietraege zur Kentniss der Darmbactenen. Muench. med. \Voch. I886. No. 1. S. 43
I 1. Chantmesse et \Vidal. Richerches sur Ie bacille typhique et l'etiologie de la fievre typhoide. Arch. de Physiologie normal et pathologique, I887. T. IX. P. 2I7-300.
I2. Buchner. Zur Kentniss der Neapoler Cholerabacillen, u. s. w. Arch. f. Hyg. Bd. 3 I885.
I3. Weisser. Ueber die Emmerich's chen sogen. Cholerabakterien. Ziet. f. Hyg. Bd. I, I886.
I4. Cahen. Ueber die Recluktionswirkung des Bakterien. Ziet. f. Hyg. Bel. 2. I886.

52.

I 5 Loeffler. Ueber Bakterien in der Milch. Berl. Kelin.

Wochenschr. I887. No. 33

I6. Behring. Zur Aetiologie des ::\Iilzbrandes. Zeit. f.

Hyg. Bd. 5 u. 7

I 7 Petruschky. Bakterio-chemische U ntersuchumgen.

Centralbl. f. Bakt. 1889. Bd. VI. S. 625, 657.

18. \Vurtz. Note sur deux caracteres differentiels entre

le bacille d'Eberth et le bacterium coli commune.

Arch. de. 11ed. Expir. ed d'anot. path. I892, T.

IV. P. 85 et 383.

I9. Beyer. Ann. d. Chern. u. Pharm. Suppl.-Bd. VII.

p. 56.

20. Kitasato. Zeitschr. f. Hyg. Bd. VII, p. 5I9.

21. Salkowski. Virchows Arch. Bd. CX. p. 366.

22. Proescher. Zeitschr. f. physiol. Chemie. Bd. XXXI:

ferner Ehrlich, Deutsch. Med. \Voche. I90I, No

I 5, unci. Freund und Lebach, Ber. d. dtsch. Chem.

Gesellsch. Bd. XXXVI.

23. Boehme. Die ~-\mv-endung cler Ehrlichschen Indol-

reaktion fur bakteriologische Zwecke. Cent:albl.

f. Bakt. etc. Bel. XL. Heft. I S. 129.

24. Erdmann u. \Vinternitz. Ueber das proteinchrom

eine klinsch uncl bakteriologich bisher nicht ver-

wertete Farbenreaktion. ::\Iuench. mecl. \Voch.

1903. No. 23. S. 982.

25. Rothberger. Differentialcliagnostiche LJntersuchun-

gen mit gefaerbten Naehrboden. Centralbl.. f.

Bakt. etc. Eel. XXIV. S. 5r 3 ; Bd. XXV. S.

r6, 69.



26. Scheffler. Das X eutralrot als Hilfsmittel zur Diag-

nose des Bacterium coli. Centralbl. f. Bakt. etc..

Bd. XXVIII. 1\o. 67, S. I99

53
TROPICAL APHTHA OR SPRUE IN GEORGIA.
H. F. HARRIS, l\I.D., ATLAKTA, GA.
Tropical aphtha, or sprue, is a disease which was first described by Hillary in 1776, his observation on this affection having been made in the Antilles. Since that time the malady has been found in most of the tropical countries of the world. and even in some sub-tropical regions. As to whether the disease has been recognized in this country in the past, I am at a loss to say. as I ha,e not had access to the literature.
:My work on this subject extends back a number. of years-my first case having been seen in January, 1901. 1\o report \vas made of this for the reason that the patient had previously to his illness Ji,ed for a time in the \Yest Indies, and I was not absolutely sure. therefore, that the disease had its inception in this country. This case, \vith another, was r~orted in American JIcdicinc for July. 1906. Since my report on these t\vo instances of the disease several others have been seen, and I. nmv take this opportunity of redting to you the principal clinical features that characterized them. and to direct your attention to the fact that this very serious affection is not uncommon in our State, and. as it is only curable \vhen a diagnosis is made early, its recognition becomes, therefore, a matter of great importance.
The clinical histories of these cases are as follmvs: CASE No. r. L. G. ?II., aged 32, white. male. a natin of Georgia, a dental student. \vas first seen on January 15, 1901. His family history is negati,e, except that one sister has had an exactly similar disease to the one the patient complains of: this sister has ahvays lind in Boston. Ga.

54
Past History.-During childhood, the patient hac! whooping-cough, measles and mumps. Ten years ago he had chills and fever; he also had malaria seven years ago. He never hac! syphilis, but ten years ago he had a bad case of gonorrhea. He had typhoid fever ten or twelve years ago.
Habits.-He uses tobacco; both smokes and chews. Before he was sick he drank moderately.
Present History.-Present trouble was first noticed about six years ago while the patient was in his home, Boston, Ga., but previously he had spent two years in the \Vest Indies. First symptoms noticed were that movements from the bo\vels were loose, but the number was not increased nor was blood or mucus observed in the stools ; no pain was present at this time.
More recently the trouble has slowly progressed, there being periods during which there were many loose stools passed in twenty-four hours, while at other times the number was normal; often the movements were of natural appearance. As the trouble gradually grew worse some pain was felt in the umbilical and hypogastric region at times. He has had backache a good deal. Sometimes. perhaps once or twice a month, or once in several months, there has been blood, and occasionally mucus, in the stools.
Toward the latter stages of the disease, the patient complained of great weakness, dizziness and staggering, and shortness of breath not influenced by exertion. His feet are at times tender, but never swollen. His appetite is always good, but after eating he complains of a tight feeling in the abdomen. He gradually became greatly emaciated, and at this period was very melancholy. Toward the end his m'ind was greatly affected. 'With the progress of the malady the number of stools gradually increased.
On first examination the patient \\'as found to be in a fairly g-ood condition, but was later g-reatly emaciated. The skin was never very pale, and in the later stages of

55

the disease became of a muddy brownish hue. The

pulse, temperature and respiration were normal at first;

later the pulse was rapid, but no elevations in tempera-

ture were ever noted. His tongue is small, very red,

fissured and generally \Yithout any coat at all; the filii-

form papillas seemed entirely absent. Later sores de-

veloped on and under the tongue-the borders being

principally affected; these ulcers come and go. Ulcers

also formed from time to time on the buccal mucus

membrane, on the roof of the mouth and between the

last molar teeth on both lower and upper jaws-the last

being knmn1 in India as Crombie's molar ulcers; these

ulcers usually presented a reddish appearance; more

rarely they are covered by a slight whitish pellicle. To-

ward the later states of the malady the patient's mouth

was so sore that mastication \vas difficult, and, doubtless

as a result of sores in the pharynx and esophagus, swal-

lowing was very painful.

The heart, lungs and spleen appeared to be normal.

There was in the beginning slight diminution in liver

dullness; in the later stage of the disease the dullness

extended from bet\nen the seventh and eighth ribs above

dmvn to \vithin about 4 em. of the costal margin in the

right nipple line. :\o other abnormality could be made

out in the abdomen. Rectal examination showed no

ulcerations of the mucosa of the gut.

The urine was examined a number of times, and, ex-

cepting only that the quantity was diminished, no abnor-

mality was found.

The feces \vere pale, frothy and exceedingly offensive

Reaction, acid.

No parasites or m-ums were found. Neither blood nor

pus \Yere ever detected.

A short time before death there \vere 3,2oo,ooo red

and ro,ojo white cells to the cu. mm. of blood. Hemo-
globin, 65 per cent. The patient gradually grew worse

and I learned that he died toward the end of the year

!904.

~

56
CASE No. 2. ]. C. G., aged 54, male, white, nati,e of South Carolina, a woodman, was first seen l\Iay 20, 1905.
Family History-Chills when a boy. Bowels had beer; loose from time to time for last twelve or fourteen years; when the trouble began he was living in Laurens county. Georgia. For two years he has lived in Pretoria, Ga. For a long time in the beginning he was troubled with slight morning diarrhea at irregular intervals, accompanied by flatulence and eructations. Sinc.e October, 1904, his bowels have never been natural at any time.
Habits-Since attaining manhood has indulged in occasional sprees, but in the intervals takes no alcohol in any form. Uses tobacco.
Present History-For seven months he has had diarrhea constantly, which has gradually grown worse. No griping or pain until a short time before death, \Yhen he had pain in bO\vels during exacerbations. Toward the end of his illness the bO\vels acted from fifteen to t\venty times in t\venty-four hours; movements came in paroxysms, possibly half a dozen in an hour, follO\ved by periods of rest. In the later state of the disease, hiccough was common, and there \vere spells of nausea and vomiting. The patient was melancholy, and tO\vard the end his mind became very feeble.
The notes that follow apply to the patient's condition during the latter months of his life.
He \vas frightfully emaciated. Skin was some\vhat pigmented, mucous membrane pale. The face was shrunken, and he had a vacant expression.
Tongue small and very red; filiform papillas absent. At this time minute superficial erosions occurred upon its surface. No sores of buccal mucous membrane \Yere complained of; no pain in the throat on swallowing. The tongue was practically never coated, and \Yhen so there was only the merest trace toward the back.
Respiration normal when first seen; later toward termination reduced to 8-ro per minute.

57

Temperature practically normal. A few times during

exacerbations has gone to IOI degrees F. A short time

before death it was 97.2 degrees at 2 p. m.

Red blood cells, 3,430,ooo; white, I r,8oo; hemo-

globin, 75 per cent. Count of \Yhite cells resulted as fol-

lows: Polymorphonuclear leukocytes, . 75; small lym-

phocytes, .r8; large lymphocytes, .06; eosinophile,

.027:].

.

Feces foamy, thin, \Yate.ry and br0\n1ish in color;

sometimes clots of blood \Yere present. Odor \Yas Yery

offensive. Food of all kinds nO\Y passed undigested.

Reaction, acid. Ko amebas or other parasites. No

ovums. Hydrobilirubin present.

Urine normal, though quantity \\"aS diminished.

No tumor in abdomen. Tenderness was always pres-

ent between the umbilicus and pubes. He complained of

burning pain in this region extending to the back. In

the right mammary line liver dullness begins at upper

margin, seventh rib, and extends to upper margin of the

ninth rib. Heart, lungs and spleen normal. ~o pain

in throat or neck. Rectal examination negative as re-

gards ulcerations, but considerable tenderness present..

The patient died March 2, 1906.

Case No. 3-11. B. aged t\Yenty-t\YO, female, 'vhite, native of Georgia; single; first seen J\Iay i2, 1906. Family history, negative. Past history: Her present trouble began at about the age of three with diarrhea, \vhich has continued since. The stools vary from one to four in t\Yenty-four hours; the average no\Y being t\YO. She suffers intensely with griping and bearing down pains during exacerbations. The stools are nry copious and are generally watery in consistency, and of a whitish color; no blood \\"aS ever found. \\~hen the stools are nry frequent whitish mucus is often passed. She had some small intestinal parasites during 1903-supposedly pin"orms. She had occasionally had fever, the tempera-

58
ture sometimes going to ror degrees F. Her temperature is usually 99 degrees, or onr. She has ahvays been much worse in summer in eyery \Yay. At present she looks fairly \vell, but up to this winter \vas terribly emaciated. Suffers from slight tenderness in bo\Yels. Great quantities of gas form in the intestines. Stomach is often distended, and she suffers from heart-burn after eating. Tongue gets sore and raw during exacerbations. Gives a history of having suffered about a year ago from some trouble in the arms, \Yhich was probably a neuritis. Her mind has not been entirely normal since this attack. She is a resident of Hart county, Ga.
In general appearance is anemic, but fairly healthy. No emacrat10n. Skin and mucous membrane rather pale. The tongue was not coated. There ren11ains some epithelium, but the surface is rather bare on the whole.
Pulse, 86; sepiration, r8; temperature, 99-4 Blood: Hemoglobin, 6o per cent.; red cells, 4,3600,ooo; white, 9,300; polymorphonuclear leukocytes, 63.2; large lymphocytes, r 79; small lymphocytes, r8.7. Feces offensive, Yery \Yhite, faintly acid. Leukohydrobilirubin present. Urine normal. Stomach contents: Only r 5 c. c. were obtained. Total acidity 6o HCI. 20, CHC!, 12, acid salts, 29. Physical signs: Linr begins in right mammary line at upper border of fifth ribs and extends to lower border of sixth. Abdomen shows nothing abnormal. Spleen, heart and lungs an'd abdomen appear to be normal. Kidneys in normal position. Under the treatment hereafter to be described the patient rapidly improved and was apparently well when last heard from, some six months after she was first seen.
Case No. 4.-C. P. C., aged sixty-three, female, white, widow, native of Georgia, was first seen January 24, 1907. Family history: Father died of "indigestion." One sister and one brother of clysentery, ancl one probably of apoplexy. Past history: About seven years ago, while liv-

59
ing in Milledgeville, Ga., the patient had an attack of bowel trouble lasting a few months. She was sent to Rockbridge, Va., and was much improved from a course of alum waters of that place; continuing this treatment after her return home she was finally apparently cured. Since this, however, she has had occasional attacks of diarrhea lasting from two to five weeks. At these times most of the trouble comes on from ro p.m. to breakfast time on the following day; during this period she \vould have from one to eight stools-sometimes copious, and occasiona.lly containing bloody mucus; no tenesmus. No history of indigestion.
Habits: Does not eat hot bread with butter. Takes one cup of coffee in the morning, but has not taken tea for five years. She eats much fruit, but not much sweets. She has false teeth, but chev;s well.
Present history: Present trouble began in November, as one of the attacks above described. A week or so later her mouth began to get sore, followed two or three weeks later by a similar condition of her throat. She was also affected with a like trouble in the vagina, accompanied by a whitish exudate.
Also suffered with salivation, some nausea and vomiting, and when first seen by Dr. Adams was having about hvelve stools in twenty-four hours. During the last week the number has decreased to between two and three. She passes very little mucus, but no blood. The stools were greenish-brown in color, moderately soft and very offensive; movements very copious. No tendency at present for bowels to mbve during the night. There is no tenesmus. She has lost much flesh. General appearance anemic and moderately emaciated; skin and mucous membranes pale; tongue red on top and all around the edges; along the frenum it is covered with a whitish membrane. Some membrane also on the mucous surface of the cheek. Both mouth and tongue very tender.
Pulse, So; respiration, r8; temperature, 99 to roo. Blood, hemoglobin 85 per cent.; white cells 20,500.

60
Feces whitish in color and very foul; reaction acid; some bloody mucus present. On microscopical examination a fe\v pus cells were found, but no amebas or other protozoan parasites. Hydrobilirubin present.
Physical signs all normal; liver appears not io be .atrophied. J\Iucosa of labia and vulva contains \vhitish patches similar to those on tongue. Skin on back of thumbs and first three fingers of both hands is very redevidently being inflamed; a similar condition is present between the thumbs and forefingers, at which site there is a small scab on the right hand.
The patient died February 25th. Before death her mind became very feeble, and toward the end \vas almost in constant delirium, sometimes low and muttering and then noisy. Her temperature just before death ran from IOO to 103.
Case No. 5-l\Irs. K., aged t\venty-se,en, female, vvhite. married, nativ-e of Georgia; occupation, housewife; first seen February 2, 1907.
Past history: She had an abscess of the right lung fron1 getting a \vatermelon seed in the bronchus. This occurred \\hen a child, and her recovery was complete. Typhoid seyen years ago. She moved to N aslnille, Ga., three years ago. Some time after this she suffered from "indigestion.'' accompanied with formation of gas, and looseness of the bowels, especially at night and in the early morning. Shortly afterwards she got better.
The trouble again grew \vorse in November, rgo6, at which time she had diarrhea, accompanied by slight fe,er.
Present history: Since the above elate she has sufft: from diarrhea, having two to eight stools daily. She still complains of gas formation in the stomach and bowels, and of indigestion. Her mouth has been very rerl ancl ulcerated a number of times. It is now better, but still much inflamed ancl behnen the back molars of lo,yer jaw the gums are somewhat ulcerated; it \\as impossible to tell how extensive this lesion is, as the patient could

61
not be made to open her month sufficiently. Has pain in throat. Suffers from occasional attacks of dyspnea. Vomits often. Persistent vaginitis. Her husband, who is a physician, says there is no ulceration. The skin of the hands has become inflamed a number of times, and is at present red and scaling on the back as far up as the wrist. Nervous symptoms severe. Occasionally she has slight clonic spasms. Mind dull and the memory is very much affected. She is much emaciated. Pulse \veak and rapid-ranging from 90 to 136. Respiration, 20 to 32; temperature 98 to IOO; tongue reddish at edges, and denuded of its epithelium to a great extent; is slightly coated in the middle. Lungs, heart, spleen and lymph nodes normal. Liver dullness extends from the seventh rib to the lower border of the ninth.
Feces: Reaction neutral. Dark (bismuth) and very offensive. l\o amebas or eggs of parasites. No blood or mucus. Hydrobilirubin present. Blood not obtained. Urine:. Specific gravity 1030; reaction acid; albumen and sugar negative; indican not increased; both uric ancl hippuric acids present. The patient died February 6, rgo7.
S:ymptomatology: From the foregoing it is seen that the clinical features observed in these cases correspond very closely with those that characterize this malady in other parts of the world. Here, as elsewhere, the affection comes on most insidiously, there being in the beginning more or less dyspeptic disturbances followed by a tendency to diarrhea, \vhich is, as a rule, most common in the early morning hours, with periods during which the patient improves followed by exacerbations; the oisease slowly increases in severity, ano in the course of a greater or less length of time finally becomes so grave that the unfortunate victim suffers a continued diarrhea, loss of strength, emaciation and ultimately sinks into a condition of mental and physical asthenia follO\ved by death.
As the disease progresses the patients' skin becomes very muddy and oftentimes shows pronounced pigmentation.

6:.!
It is strikingly characteristic of the disease as I have seen it-particularly in the later stages-that the skin of the dorsal surfaces of the hands becomes inflamed, and even shows ulceration. Similar changes are also occasionally seen in the skin of the face. Swelling of the extremities is sometimes observed. One of the most characteristic features of the malady are the ulcers which develop both under and on top of the tongue, on the buccal mucous membrane, and on the gums, particularly between the last molars; ulcers are also sometimes observed on the pharynx. It is a marked peculiarity that the surface of the tongue is stripped of its epithelium coating-the surface becoming smooth and presenting a raw appearance; in the last stages the organ is more or less atrophied. As the disease advances the liver becomes very much decreased in size. The stools have been, in every instance of the disease seen by me, of an acid reaction, a characteristic which was first pointed by Thin. Bill pigments were found in the stools in every case seen. In no instance ha,e I detected the eggs of parasites, nor have the embryo of the Strongyloides been present.
The temperature in this disease shows no great variation from the normal until the fatal termination is approached when fever varying from 99 to I03 is commonly found to be present.
The pulse is at first undisturbed, but as the affection progresses, considerable rapidity is the rule.
Salivation is pronounced in some cases. Mental disturbances are usual in the later stages of the malady, the patient sinking gradually into a state of more or less complete dementia. Ulceration of the labia and vagina in women seems common in sprue as seen hereparticularly in the later stages. In two cases of the disease seen since this paper \vas prepared, there was complete achylia gastrica; both were in women and comparatively recent.

68
\Vhile the foregoing represents the course of events in a typical case of sprue, attention should be directed to the fact that in many instances the disease does not begin in the characteristic way, thus we find that it may supervene directly upon dysentery, being apparently a sequel of this disease. I have seen recently a case of this kind. It is also stated by Manson that sprue may follow acute enterocolitis, though I have never personally observed
this. All writers call attention to the fact that there occurs
what may be regarded as incomplete sprue. Thus instances are seen in which the disease seems limited to some particular portion of the gastrointestinal tract.
Thin recognizes three distinct types; the form in which the lesions are principally found in the mouth and throat; the variety in which intestinal symptoms predominate and in which the mouth is affected only in the later stages; and lastly that type in which the disease pursues a very chroni-c course--being found usually in elderly persons or those who have lived for a long time in the tropics. The last form of the disease is also encountered in those who first show symptoms of the malady after considerable periods of time after having returned to Europe.
The disease in tropical countries seems to vary in duration from one to two to from ten to fifteen years. With but one exception, the disease as seen by me was of long duration, and even in this instance it lasted nearly three years; it seems likely that the acuter forms of the malady do not occur in our climate, though this is a matter which only future obsen-ations can determine.
The diseas~, as it occurs here, appears to differ in no essential feature from the affection as seen in other parts of the world. Noteworthy, however, are the facts that my patients have not suffered from such marked dyspeptic disturbances as writers on the tropical form of the malady say is common, nor are the stools so uniformly of a whitish color, or so copious. It is nry curious that in all of my cases where death occurred the final termination was

preceded by a considerable period of time during which the patients lost almost complete control of their mental faculties.
It is noteworthy that inflammation of the skin of the back of the hands and of the face \vould appear not to be unusual in the later stages of the disease, as it occurs here-a peculiarity that I have not seen mentioned by foreign writers.
Etiology-Space does not permit a complete discussion of the etiology of this disease. As a matter of fact, its causation is not understood, though it seems very likely that it is not a parasitic disease. It is certainly not contagious, nor does it occur in epidemic form.
At one time it was believed that the Anguillula stercoralis was the etiological factor in this disease, but more recent investigation has entirely disproved this theory. :'-Jo bacterium has been definitely associated with the malady, and it may be like,vise stated that the same m8.y be said concerning protozoan parasites.
There appears to be no doubt that diseases that are of an exhausting nature predisposed to sprue; among these may be mentioned dysentery, diarrhea, hemorrhoids, fistula, frequent child-bearing, prolonged lactation, exhausting discharges, syphilis, enterocolitis and bad hygienic surroundings.
::\Ianson, who is the greatest authority on tropical diseases, says: "Personally, I am inclined to regard sprue as an expression of exhaustion of the glandular structures subserving digestion, the result of over stimulation by certain meteorological conditions which are found in tropical countries, and which are unsuited to the European constitution. The remarkable effect of physiological rest, as supplied by 'the milk treatment' in curing sprue, seems to support this hypothesis." This view is also supported by my recent observation of achylia gastrica in two cases of sprue in the early stages.
Pathological Anatomy-The most marked peculiarity of sprue consists in that there is atrophy and disappear-

65
ance of the epithelial coating of the entire gatro-intestinal tract-the mucous membrane being graduaily eroded, and finally disappearing.
Superficial ulcers are also sometimes found on the surface of all parts of the intestines, giving rise to the mucus and blood that are occasionally found in the stools. Cystlike dilations of the crypts containing a muco-purulent material are also encountered. A marked peculiarity consists in the fact that the entire coat of the intestine is greatly thinned, this being particularly true of the muscular layers. The submucosa shows hypertrophic fibrous changes in some situations. The mesenteric glands are often enlarged and pigmented.
The liver undergoes gradual atrophy and finally becomes very small.
Unfortunately, I have been unable to secure a postmortem in any of my cases where death occurred, and I can not, therefore, say anything concerning the pathology of tbe affection from personal observation.
For the foregoing facts concerning the morbid anatomy of sprue, I am indebted to Manson, Scheube, Thin and other writers on tropical diseases.
Diagnosis-A diagnosis in well-developed sprue is very easy; the morning diarrhea, the dyspeptic disturbances, the ulceration of tongue, gums, lips and buccal mucous membrane, the white, frothy, copious stools, and gradual emaciation furnishes a clinical picture which could hardly be mistaken. As the disease advances all of the foregoing symptoms increase in severity, and we have, in addition, atrophy of the liver, loss of strength, profound anemia, eczema of the face and back of the hands, and greatly disordered mentality.
In the early stages, particularly in those where mouth symptoms predominate, the affection may be mistaken for syphilis. but the knowledge of the possibility of such an error should be quite sufficient to avoid it.
I have known in one instance of a very capable phy-
5bh

6G
sician mistaking the condition for simple catarrhal stomatitis. It should be remarked that the disease might be mistaken for a mercurial inflammation of the mouth.
At the time that this paper was corrected for press, a case was seen in which it would ha\e been very easy to ha,e mistaken it for pernicious anemia, and it \Yas only after a most careful examination of the blood and the patient's symptoms that a conclusion was finally reached ::\Iay it not be that these t\yo diseases are closely related and are both dependent upon digestiw errors?
Prognosis-The prognosis in sprue is always grave and leads certainly to death if the affection be not recognized and properly treated in the early stages. Four out of five cases seen by me have died and one recovered. The cases \Yith fatal terminations were seen in every instance after they had existed for a considerable period, and all were in the last stages of the disease.
Treatment-The treatment of sprue is essentially hygienic, writers on this subject practically all agreeing that drugs are of no avail.
Of the methods employed, the combined milk and rest t:eatment is the one which has proven most successful. Jt is carried out as follows :
The patient is given a dose of castor oil and is put to bed, receiving no food until the bowels have thoroughly acted. In the beginning sixty ounces of milk are given in twenty-four hours, and as improvement occurs the quantity is gradually increased to three quarts, and even more if it continues to agree with the patient. In some individuals more than eighty or ninety ounces of milk produce indigestion; in these cases the patient may secure an increased amount of nourishment \Yithin the bulk tolerated by having the milk evaporated to the extent desirable, or by adding condensed milk.
Patrick Manson, the great founder of tropical medicine, especially insists that milk be given in moderate quantities, frequently repeated, and above all, he lays stress

G7
upon the necessity of taking the milk with extreme slowness. It should be sucked through a small glass tube, or taken through an infant's nursing bottle, the latter being .the preferable way. It may be noted at this point that the bad repute into which the milk diet has more or less fallen is undoubtedly in a large degree due to the fact that patients are not instructed to take it slowly. The average man drinks it very much as he does water, and under such circumstances it is little wonder that it produces indi-
gestion. Under this treatment, if the case be not too far ad-
vanced the movements are, as a rule, quickly reduced to the normal frequency and consistency. The patii.:n t should remain in bed for at least a 'Week after this result has been accomplished, and' he should continue upon a strict milk diet for at least si.x weeks; it is of the greatest importance that these two pr~cautions be observed since a failure to do so entails with almost absolute certainty a relapse, and then the patient has to go over the entire treatment again. It is desirable that the patient remain practically at rest throughout the entire course of treatment. After six \veeks have elapsed, and the bowels remaining normal, we may begin slowly and cautiously to .add other articles of diet-in the beginning egg albumen, soups containing srnall quantities of starch well cooked, arrow root, and still later a gradual change to a full diet may be permitted. At any time during this period if the patient shows the slightest tendency to digestive disturbances, irregularity of the bowels, of if the mouth begins to get sore, he must at once be put back to bed, a dose of oil administered, and the treatment with milk resumed just as in the beginhing.
'Thin recommends that crumbs of well-cooked stale bread be the first addition to the milk diet, rather than the articles mentioned in the foregoing description; an ounce is giyen. and if this agrees "ith the patient it is repeated for three clays, and if it still be well borne, a similar quantity is given twice daily, and if still no dis-

68
turbance is produced an equal amount i administered thrice daily. If the patient continues to improve the quantity of bread is doubled, and after a week the amount still further increased. Butter may be eaten with the bread. This writer warns against the giving of eggs early, stating that he has seen relapses occur as a consequence in several cases. Thin considers boiled fish an excellent addition to the milk and bread diet when the proper time arrives.
In some instances patients do not do :well on the milk treatment, and under such circumstances it has been found that beef juice is sometimes well borne. Unfortunately the quantity of beef necessary is considerablefrom twelve to twenty pounds being required daily. The juice is expressed and administered to the patient in the raw state.
In some cases, curious as it may appear, sprue has been relieved by an exclusive fruit diet even where the milk treatment has failed. The patient is given fruits of all kinds in quantities sufficient to allay hunger, and this is kept up until the bowels return to a normal condition. It is only exceptionally, however, that it is necessary to resort to this plan of treatment, and it is highly probable that it would be successful only in a very small percentage of cases.
In some cases whenever the patient attempts to return to solid diet dyspeptic disturbances are encountered. Under such circumstances a change from an albumimJUS to a farinaceous diet, or vice versa, may be of benefit. Manson recommends under such conditions what is known as the "Salisbury cure." This consists in giving to the patient a diet of meat and warm water. The meat should be of a good quality and free from fat and gristle, ai1d should be well cooked. Small quantities are given in the beginning and gradually incl'eased to three pounds daily if it be well borne. \Varm water, amounting to four pints in twenty-four hours, is likewise given; it is taken before going to bed and on rising in the morning, and also about

69
two hours before meals-never at meals. This treatment is persisted in for six weeks, and then ~s gradually changed to an ordinary diet.
In instances where diarrhea is extreme opium may be resorted to, but its action is always temporary and never curative, and should, therefore, be dispensed \vith at the earliest possible moment.
All writers on the subject of sprue agree that a patient attacked with the disease should move to a cooler climate, but all are equally unanimous in the opinion that it is of the greatest importance that the patient should avoid getting chilled. For this reason it is advised that flannel be worn next the skin during the treatment, and for even a year after; it is particularly important to cover the abdomen well. Tobacco must not be used \Yhile the patient is under treatment.
In concluding this matter I wish most earnestly to insist upon the necessity of an early diagnosis in cases of this kind in order that treatment may be instituted before extensive organic changes occur in the gastro-intestinal tract. The treatment, if begun early, is highly successful -if late, it is usually without beneficial effect, and, though the patient may be temporarily somewhat improved, death is the inevitable result.
Except tuberculosis there is perhaps no other disease in which an early diagnosis is of such transcendent importance.
TUBERCULIN.
The tuberculin furnished by the State Board of Health
is a 50 per cent. glycerine extract of the tubercle bacillus,
and may be used for diagnostic purposes, and also as a therapeutic agent. Tuberculin is a most valuable aid in the diagnosis of tuberculous lesions, it being particularly efficacious where the patient is young and where the process is not of too long standing.

70
In recent years it has also been used \Yith a marked degree of success as a therapeutic agent. In order to obtain the best results the directions that follow must be strictly adhered to.
.1~1ethod of Administration for Diagnosis-Take the temperature every two hours for twenty-four hours in order to determine the average range, and then inject in a muscle with a hyperclermic needle, perpendicular to the surface of the skin, 0.5 milligram of tuberculin. If no reaction is seen in geventy-two hours, 1.5 or 2 milligrams may be injected, and if still no reaction is obtained, 4 or 5 milligrams may be used after an equal
length of time. At the end of seventy-two hours 7 milli-
grams, and if no. reaction occurs ro milligrams should be given after three clays. If no reaction is obtained from ro milligrams the close should be repeated after seventytwo hours.
The symptoms that constitute a reaction from tuberculin very closely resemble those of influenza, that is, a rise of temperature from roo to 103 degrees, headache, backache, pain in the limbs, general malaise, and sometimes nausea and vomiting; local irritation at the site of the tuberculous lesion is also a symptom frequently observed.
Directions for Use as a Therapeutic Agent-The best method, according to Trudeau, is to begin with very minute closes-r-roo of a milligram of tuberculin-and increase so gradually and at such intervals as to carry the patient to full closes with as little disturbance as possible. By taking sufficient time, most F~atients can be carried through the entire treatment with but occasional and moderate reactions. At the slightest evidence of intolerance, as manifested not only by the patient's temperature, but by his symptoms, by marked irritation at the site of injection, or depreciation of his general condition, the intervals between the injections should be lengthened and the dose diminished for a time. Care should be taken

71
never to let one injection follow another until all effects of the previous reaction, both on the patient's temperature and general condition, have entirely passed away. The treatment should be extended over as long a time as is needed to avoid reactions, no matter how long that may be, and that time is an important element in obtaining the best results. Six months of treatment is, almost always necessary and a year or more would be better in many cases.
The patient, while taking the injections, should show no depreciation of general health, and should have no fever above his usual temperature range-except it be occasionally for the forty-eight hours following an increase of dose; if this occurs the treatment should be discontinued, and only resumed when he has recovered his normal condition. If a full close, that is I c. c. of tuberculin, can be reached without violent reactions and without depreciation of the general health, but not othcr<.cisc, the injections should continue until this amount has been given; but the intervals should be lengthened gradually as the higher closes are reached, and extended to two weeks between the last two or three injections. The physician must, of course, individualize, and be guided by his judgment throughout the treatment as to the dosage; on his watchfulness and skill will greatly depend the safety of the patient and the degree of success attained.
Tuberculin immunity does not last indefinitely, and it may be well for the patient to take another course of treatment in four to six months if any symptoms shonlc1 reappear; but it is wry often necessary for a patient to take more than one course of injections.

72
FREE LABORATORY EXAMINATIONS.
CHARACTER oF ExA::>.nNATIONS: The Laboratory of the Georgia State Board of Health has been established \Yith the primary object in view of assisting physicians in diagnosticating those diseases that are c~used by bacteria or animal parasites. It would be desirable to include also examinations of urine and of tumors, but the appropriation at present given us is not sufficient to allow this to be done. It is to be hoped that in the future a more liberal policy will permit this work to be added to that already being carried out.
The following examinations are made:
Examina:tions for Ba:ctcria:: Examinations of this kind are conducted in two separate ways. \Yhere the organism that is being searched for is usually found in much greater numbers than other germs incidentally present, or where \\'e have specific stains for the bacterium in question, examinations are generally made by a direct inspection with the microscope of the material under investigation. In those cases where the germ that is being searched for dces not fulfill either of the requirements just referred to, the diagnosis must be made by planting the germs on some culture medium. In instances where this is to be clone the germ which is being looked for is finally isolated l~y the process known as "plating," or, in a few instances, this result may be accomplished by sowing the material on some special culture media that has the property of causing the germ in question to grow with so much greater rapidity than other bacteria that they are very soon present in overwhelming numbers. As examples of these different possibilities we may mention the micrococcus intmcellularis which represents the first, the tubercle bacillus the second, and the diphtheria: bacillus the

73
third; thus, if we wish to examine the cerebrospinal fluid for the germ of meningitis, it is only necessary to precipitate the cellular elements present in the liquid by means of a centrifuge, and to then place the sediment upon a slide or cover glass, dry, stain and examine; if we wish to examine for the tubercle bacillus, we have only to place the suspected material upon a slide or cover glass, and dry and stain according to one of several methods which are practically specific for this organism; lastly, if we wish to examine for the diphtheria organism it is best to plant the suspected matter on Leoffier' s blood-serum-glucosebouillon medium, and at the end of from eighteen to twenty-four hours we examine any growths that may be present in the usual way.
The specimens that are to be examined directly may be either sent to the laboratory after having been smeared upon a slide or cover glass and subsequently dried, or, which is more desirable, the material may be placed in a thoroughly cleansed wide-mouth bottle and sent by mail.
If cultures are necessary-and practically this is only the case where we wish to examine for the diphtheria bacillus-the specimen should be planted upon the appropriate culture medium, and then immediately sent to the laboratory; if the proper culture medium is not obtainable the physician may send the material to us in a sterilized container, or he may swab off the surface from which he wishes the culture made with a S\:vab of sterilized cotton. A portable, sterilized swab may be easily prepared by wrapping a small piece of cotton around the end of a wire and then inserting the end upon which the cotton is fixed into a wide-mouthed bottle; it is held in place by a cotton stopper. The bottle is then wrapped in a cloth and heated in an ordinary cooking stove until the cotton begins to turn brown; it is ready for use as soon as cool. The swab is thoroughly rubbed over the surface from which the culture is to be made, replaced in the bottle and shipped to us immediately. Of

74
course, under such circumstances, we have to make the culture after the specimen is received, and the report consequently can not be made immediately.
\Ve examine for any pathogenic organisms, among which may be mentioned the bacillus tuberculosis, the bacillus diphtheriae, the ba:cillus pneumonice, the JJI!icrococws i11tracellularis meningitidis, the gonococcus, the spirocheta of syphilis, the streptococcus, and the various species of staplzylococd.
_-\ttention should be called to the fact that the so-called bacillus t~>'phosus is a germ which is exceedingly difficult to isolate. It is only possible to obtain it from the excretions from sick individuals in something like two-thirds of all cases, and only then can it be done after a prolonged series of qacteriologic manipulations. \Vhere the patient is willing the most satisfactory results are obtained by isolating the germ from the blood, but, as the quantity required is quite considerable, it is not often that this procedure is permitted. In cases where physicians wish to test the blood for these bacteria, they should first write to the laboratory, and we will forward them a tube containing a mixture of ox-bile to which the blood should be added to pre\ent it from coagulating. It is next to impossible to isolate the so-called typhoid bacillus from water-there not being more than half a dozen instance:o, on record where this has been accomplished.
ExamiJZation of Blood for the Afalairial Pa.rasite: In order to properly examine blood for the parasite of malaria it is necessary to spread it in a thin layer on a clean slide, and to then dry it immediately. The accompanying illustrations show the technique of the procedures necessary to accomplish this. The patient's finger is cleansed with 50 per cent. alcohol, which is allowed to dry; it is then pricked with a sharp needle which has been sterilized, preferably by heat (Fig. I). When a small drop of blood exudes the operator touches it with the end of a slide in such a way as to transfer a small portion

75
of the blood to it (Fig. 2) ; immediately this end is placed on the flattened surface of a second slide somewhere near its center, and it is then pushed with a quick stroke in such a way as to smear the fluid along the surface to the second slide (Fig. 3) ; as soon as this is done the slide upon which the blood has been spread is vigor-
FIGURE 1.
ously waYecl in the air-preferably at some distance aboYe a flame-until it is thoroughly dry. If these precautions are properly carried out the examination for the parasite can be satisfactorily made; on the other hand, if this be not done it is impossible to make accurate reports.

76 Blood for the Widal test for typhoid fever: This test will at all times be cheerfully made where physicians desire it, but we feel it our duty to say that we are satisfied, for some unknown reason, that even where typhoid or paratyphoid fever exists a reaction is obtained in Georgia in a very small percentage of cases. Where the results are positive we consider this test as a good but not
FIGURE 2.
a diagnostic symptom of typhoid feve~; if absent it means nothing.
In order to carry out this test, the patient's finger should be pricked with the same precaution already detailed when speaking of the method of obtaining blood for the detection of the malarial parasite. The blood may be placed upon a slide, or, what is quite as good, drops may be allowed to fall on ordinary writ-

77 ing paper. It is always desirable that four or five drops of blood be procured, and they should be placed at sep-
arate points on the object selected to carry them. It t"s verv important that the blood be atllowed to dry spontaneo-usly-never held above a: fla:me in order to hasten this result.
E.xa1mina1tion of the feces for a:nimal pa~rasites: We examine for all intestinal parasites by searching for their
FIGURE 3.
eggs,-this being the only sure and satisfactory method of determining as to whether or not they are present. The most important among these are the Uncina'fia, omeric01w or bookworm, the Oxyuris verm~:cularris or pinworm, the Ascaris lumbricoides, the Trichocephalus dispar, the Distomata,, and the various species of Teniae or tapeworms ; we likewise examine for the embryo of the Strongyloides intestinalis.
All that is necessary in the preparation of specimens for examinations for intestinal parasites is to have the feces

78

sent us in a proper!y stopped bottle ; it is not essential

to take any particular precaution in cleansing the bottle

in \Yhich the specimens are sent.

ExQIIm:nation of watt:r to determine its fitness for drink-

ing pu.rposes: Examinations of this kind require a great

deal of time and work, and we are, therefore, unfortu-

nately in the position of not being able to examine thor-

oughly every specimen sent us. \Vhere it is desired to

have such examinations made the Board of Health has

made a ruling requiring the person \Yho wishes such an

a'1alysis made to first communicate with the member of

the State Board of Health in whose district he resides.

and if the member of the Board considers it necessan the examination will then be made. It is to be hoped

that our appropriation will soon be increased so as to al-

low us to make examinations of this kind for all who

may desire it.

.

In sending specimens of water for analysis it should

always be remembered that for a satisfactory examination

a considerable quantity is required, it being always best

to send at least a gallon. The container in which the

\nter is to be placed should be baked thoroughly in a

stove, and, after cooling, the water to be analyzed should

be poured directly into it from the primary source of

the water supply. The bottle is then corked \Yith a stop-

per that has likewise been sterilized. It is then

placed in a vessel, ice packed around it, and the specimen

sent to our laboratory as quickly as possible. It is espe-

cially to be desired where examinations of this kind are

to be made that the sample be sent by some one, and not

entrusted to the express company, as under such circum-

stances the specimens are very rarely delivered while

still fit for analysis.

PHYSICIANS SHOULD AL\YAYS REME:MBER TO PLACE THEIR NAMES AND ADDR~SSES ON THE SPECI:MEKS SE~T TO THE LABORATORY, AND THEY SHUCLD ALSO GIVE THOSE

79
OF THE PATIEKT EITHER ON THE SPECIME~ OR BY MEA:-JS oF A LETTER OR POSTAL CARD.
\VHERE IT IS DESIRED REPORTS WILL BE MADE BY TELEGRAPH AT THE EXPENSE OF THE PHYSICIA::-.< OR THE pATIEXT F'OR WHOM THE EX"nUNATIOK IS BEING :MADE. \VHERE POSSIBLE WE WOULD ALWAYS URGE THAT SPECIMENS BE SEKT BY MAIL, AS THEY IK\"ARIABLY REACH US SOONER THAK WHEK SE::-.<T BY F.XPR(SS.