Fifth annual report of the State Board of Health of the commonwealth of Georgia transmitted to the Governor January 1, 1909 [Jan. 1, 1909]

FIFTH ANNUAL REPORT
OF THE
State Board of Health
OF THE
Commonwealth of Georgia
TRANSMITTED TO THE GOVERNOR January 1, 1909
READ CHAPTER ON FREE MICROSCOPIC EXAMINATIONS. DIPHTHERIA ANTITOXIN AND PASTEUR TREATMENT.

LETTER OF TRANSMITTAt.
CoMMONWEALTH OF GEORGIA, STATE BoARD oF HEALTH,
ExEcUTIVE OFFICE, January 1, 1909.
To His Excellency, HoKE SMITH, Governor of Georgia,.
SIR: I have the honor to make the following report of the work accomplished by the State Board of Health during the year 1908, including a statement of the ex-
penditures incident to the activities of this body.
In addition to the laboratory work to which attention has been previously ealled, we lmve added a department for the preventive treatment of rabies by the Pasteur method, which was fortunately done about the time that a more or less general epidemic of hydrophobia appeared among the dogs of this state. As a consequence of this we have treated an unexpectedly large number of people, and feel that in this alone our laboratory is much more than paying for its maintenance.
We are rapidly perfecting our diphtheria antitoxin; and will be able to dispense it in any amount desired within a short time.
Respectfully submitted, I-I. F. HARRis, Secretary.
3

STATE BOARD OF HEALTH
Commonwealth of Georgia 19 08.

President_ ______________________vV. F. WESTMORELAND Vice- President_ _______________________ CHARLES HrcKs
Secretary_______________________________ H. F. HARRIS

DR.

w.

vV.

MEMBERS. OwENs__________________________ Savannah

DR. A. P. TAYLOR_________________________ rrhomasville DR. M. S. BRowN _________________________ Fort Valley

DR. J. H. McDuFFm _________________________ Columbus
DR. vV. F. vVEST MORELAND __ ----------------- __Atlanta
DR. HoWARD J. vVILLIAMS _______________________ Macon
DR. R. M. HARBIN ______________________________Rome

DR. SAMUEL C. BENEDICT _______________________ Athens DR. GILEs H,A'l'HcocK ___________________________ Bellton DR. J. B, MoRGAN ____________________________ Augusta DR. CHARLES HicKs____________________________ Dublin DR. H. F. HARRIS _____________________________ Atlanta

PLACE OF MEETING-~;tate Capitol, Atlanta, Ga. TIME OF MEETING-Tuesday following the first Monday
January and June, at 10 a. m.

ExECUTIVE CoMMITTEE.

DR. MoRGAN, Chairman,

Dn. WrLLIAMs,

DR. HrcKs,

DR. BENEDICT,

DR. OWENS,

DR. TAYLOR.

LABORATORY STAFF.
Director ________________________________ H. F'. HARRIS
Assistant Director_ _____________________ K. R. CoLLINs Bacteriologist_ _________________________ L. T. PATTILLO Pathologist_ _____________________________ ,T. E. PAULLIN
Clerl;:_ ___________________________ Miss FLORENCE FRYER

5

FIFTH ANNUAL REPORT
OF THE
SECRETARY OF THE STATE BOARD OF HEALTH
OF THE
COMMONWEALTH OF GEORGIA.

BOARD MEETINGS
During the year 1908 the Georgia State Board of Health held two meetings, at which there was a general discussion as to health conditions in Georgia. The continued prevalence of smallpox was discussed, but on account of the lack of sufficient authority the Board deemed it wise to attempt nothing further than to advise with the authorities in afflicted communities respecting the same. A similar attitude was for the same reason deemed advisable respecting typhoid fever and other endemic diseases.
At the first meeting the Secretary was instructed to begin the Pasteur treatment for rabies as quickly as the laboratories could be properly fitted up for carrying on the work, and at the second this official was instructed to begin the manufacture of diphtheria antitoxin as quickly as was possible.

REPORT OF THE SECRETARY
OF THE GEORGIA STATE BoARD oF HEALTH FRoM JANUARY
1sT TO .MARCH 31sT, 1908, INCLUSIVE.
GENTLEMEN:
I have the honor to submit the following report of work accomplished since the last regular meeting of the Board:
During the past three months there have been, so far as I am aware, no unusual epidemics of disease in Georgia. We have sent a small number of vaccine points to different parts of the State on account of local epidemics of smallpox. Happily the conditions as regards the disease just mentioned have improved since the advent of warmer weather. I am aware of no place at present where this malady prevails.
Since the last meeting of the Board their instructions concerning improvements in the laboratory have been carried out. An automatic refrigerating machine has , been installed which admirably subserves all the requirements of the laboratory, keeping the room for the Pasteur work accurately at 70 degrees F., and maintaining at a degree or so above zero a couple of cold storage chambers for the preservation of toxins, antitoxins, tuberculin, bacteria, etc.
The old office of the Board has been converted into an antitoxin laboratory and the office removed to the front portion of the building. The present arrangement is much more satisfactory than the former one, and puts us in a position to carry on our work a great deal more satisfactorily than has been the case in the past.
10

We have converted the room adjoining the antitoxin, laboratory into an animal room~'.and have fitted the sanie

with the necessary cages; this arrangement will perhaps

suffice for the present, but we urgently need a place out

of doors in which to keep our animals, as they do not do

well, and particularly do not breed, when kept in the

house.



Following your instructions, I secured permis~ion

from the Atlanta College of Physicians and Surgeons to

build on its grounds stables in which to keep our horses.

These tables have been constructed, and everything in

the way of equipment is now ready for the beginning of

the manufacture of antitoxin. I regret to report that

inability to get rabbits and guinea pigs has seriously in~ terfered with this work. The former are absolutely nee~

essary in order to carry out the Pasteur treatment,-one

of the animals being needed daily, and the latter are

essential in the testing of toxines 'and. antitoxins. We

have recently secured a supply of guinea pigs which will

enable the antitoxin work to go forward, but so far it has

been impossible to make satisfactory arrangements re-

garding the rabbits. lf'oreseeing something like a year

ago the difficulty of procurii:ig these animals, I made ar-

rangements with a party living on the outskirts of At-

lanta to raise and furnish them for the laboratory. Not-

withstanding that some thirty or forty of them were pro-

cured for breeding purposes, for some reason, the ani-

mals have failed to multiply, and consequently the source

from which I had thought to draw a sufficient supply has

so far failed me. I have several persons working on this

at present, and I trust that in a very short time we may

be able to begin the treatment of patients.

In connection with the antitoxin work, I would call

your attention to the necessity of having a scientific vet-

erinarian to select our horses and to judge from time to

time as to their physical condition. Failure to have the

11

horses used for this work properly inspected might result in serious consequehces,-it having happened on a number of occasions that persons were given tetanus by receiving injections of serum from horses who were suffering from this disease. Bearing this in mind, I have
had a conference with Dr. C. R. Jolly who is, I think,
unquestionably the ablest vetenarian in the city of Atlanta, and he has kindly consented to give us any assistance in his power. I would suggest that he be officially appointed as the veterinarian of our Board, and would beg permission to be allowed to compensate him for whatever assistance he gives us. He has very generously offered to do this work for nothing, but I am sure that the Board would desire that he be paid something, particularly where the work entails considerable loss of time.
Since the last meeting of the Board your Secretary made a trip to the antitoxin laboratories in the vicinity of New York and Philadelphia, and had an opportunity to thoroughly familiarize himself with the methods of procedure there employed. He has no hesitation in saying that our equipment is quite as good as that of any of the laboratories visited, and there is no reason why we should not do work in every way as satisfactory. As a matter of fact none of them have so perfect a method of keeping a room at constant temperature for Pasteur work, and we are in this particular, therefore, in a superior position to any of the laboratories in this country.
In connection with the matter of furnishing antitoxin free of charge, I would say that the syringes are one of the principal items of expense, and, inasmuch as they may be used over and over again, it would seem to me wise for the Board to establish some rule whereby it will be possible to recover all or a greater part of those sent out. I would respectfully suggest that an order from the Board ba enacted to the effect that doctors would not
12

receive a second consignment of antitoxin who had not

returned the syringe previously sent.

There now follows a report of the laboratory work

accomplished :



Doubtful

Tubercle bacilli, 0 0
Hook-worm, ........................... .

Widal, ................................ .

Diphtheria,............................. .

Gonoccocci, ............................ .

Malurial parasites, ..................... .

Intestinal parasites, ................... .

Diploccoecus meningitidis, .......... .. . .

2

Staphyloccoccus, ....................... .

Streptoccoccus, ........................ .

Boab-Oppler bacilli, ................... .

Spirochita pallida, ..................... .

Tape-worm, ........................... .

.Ameba coli, ........................... .

Ascaris lumbricoides, .................. .

Demodex p'hylloides (Scokor), ......... .

.Koch-Weeks bacilli, ................... .

Ra,bies, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

Water analyses, . . . . . . . . . . . . . . . 4

Tuberculin, ................... 179 doses.

Negative
168 16 4 8 3 8 6 0 0 0 1 0 3 2 0 0 1 1

Positive
60 14 1 15 3 0 0 0 2 1 0 1 0 0 1 1 0 2

33

221 101

I would call your attention to a very kind communi-
cation from Dr. M. M. Johnson, of Waycross, Ga., together with a copy of some resolutions recently passed by the Ware County Medical Society. It is especially gratifying that our efforts here meet with the approval of our professional brethren and the thanks of the Board
are certainly due Dr. Johnson for his efforts in our behalf.

At a recent meeting of the State Committee of the International Congress on Tuberculosis, that is to be held in Washington in September, a resolution was passed requesting the State Board of Health to appoint

13

I

three members to represent them at this great assemblage.
The Secretary desires to call your attention to and ask your instructions as regards a letter recently received from Dr. Young, Secretary of the State Board of Health of Maine, pointing out certain dangers of a bill recently introduced in the House of Representatives by Mr. Hepburn. The letter and the bill are at hand if you desire to consider them.

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

MEETING OF BOARD.
Dr.J. B. Morgan, ............................... $ " H. J. Williams, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . '' R. M. Hal'bin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . '' Giles Hathcock, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . '' M . .S. Brown, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " J. H. M0Duffie, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . '' Charles Hicks, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " W. F. Westmoreland, . . . . . . . . . . . . . . . . . . . . . . . .

18.70 14.72 12.25 12.00 15.50 12.96 20.76 10.00

SALARIES.
Secretary, ....................................... $ First assistant, ................................ . Second assistant, ............................... . Third assistant, ........................ , ...... . Stenographer, .................................. . Office boy, ..................................... . Janitor,

.$ 116.89
500.00 120.00 180.00 300.00 250.00
75.00 90.00

EXPENSES OF .SEORETARY.
January, ........................................$ February, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . March, ............. , .. , ................ , . . . . . .

$1,515.00
6.40 185.05
11.95

$ 203.40

!NCIDENTALS.

Speeial services tendered July 1, 1907, by Dr. West

moreland, (Jan.) .......................... $

So. Bell Telephone & Tel. Co., ....... : . ......... .

Stamps, ........................................ .

Chemicals, ..... ................................ .

Sundries, ...................................... .

Books for laboratory, ........................... .

Attention to cow in milk sickness, ............... .

Freight, ....................................... .

'Mailing cases, (Feb.) ........................... .

Vaccine, ....................................... . Chemicals, ....................... .... ~ ......... .

Suntlries, ...................................... .

Rabbits, ....................................... .

Strumps, (Mar.) ................................ .

Vaccine, ....................................... .

Chemicals, ..................................... .

Sunc'ries,

0 0 0 0

16.00 100.44
10.00 13,50 33.25 34.45 15.00
1.25 15.00 10.60 7.75 21.31 10.00 10.00 13.10 4.10 29.27

PERMANENT IMPROVEMENTS.

Automatic refrigerator, ....... : . ................. $ 1,650.00

Plumbing, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -575.72

Cemeut, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4.85

Express on cork, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.50

Wiring motor, ................................. . Carpenter work, ................................ . Furuitnre for office, ............................ .

27.00 821.48
76.15

$ 345.02

Expenses of meeting of Board, ................... $ 116.89 Salaries, ....................................... . 1,515.00 Expenses of Sec.retary, .............. ; .......... . 203.40 Incidentals, .................................... . 345.02

$3,165.70

$5,346.01 On 'hand Jan. 1, 1908, ................... , ... $ 5.72
Appropriated for 1908, . . . . . . . . . . . . . . . . . . . . . . M,OOO.OO

Total, .................................. $11,005.72 Erpenses to date, . . . . . . . . . . . . . . . . . . . . . . . . 5,346.01

Balance on hand. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5,659.71

15

The Secretary wishes to get instructions from the Board as to the method of meeting a possible deficit before the end of the year. It will be observed that we have already expended a trifle over $5,000 of the $9,000 available for general purposes, and, as the salaries alone for the remainder of the year amount to $3,044.97, it will be seen that we have a very small margin for general expenses. I do not consider it possible for us to come out ahead on the amount that still remains. I am, therefore, extremely anxious that the Board should instruct me 'as to how this deficiency is to be met. It is possible that the legislature might give us a sum equal to that expended for permanent improvements in the laboratory, but, as such action is problematical, some provision should be made for funds to continue the work of the Board to the end of the year. Following the precedent established during the quarantine, it might be advisable for the representatives of the Board to give a note for any sums that may be necessary.
Respectfully submitted, H. F. HARRis, Secretary.
REPORT OF THE SECRETARY
OF THE GEORGIA STATE BoARD oF HEALTH, FROM APRIL
1sT TO DEcEMBER 31sT, INcLUSIVE.
GENTLEMEN:
I have the honor to submit the following report of the work accomplished since the last meeting of the Board:
During the past nine months the state has been happily free from general epidemics. The State Board of Health has received a few requests for vaccine points from isolated portions of the state on account of the
]()

presence o smallpox, but at no time has the disease even threatened to become generally epidemic.
We have recently distributed a small amount of diphtheria antitoxin, which we had bought at reduced rates from the National Vaccine and Antitoxin Establishment; this has only been done in cases where the patients were very poor and were not really able to pay for the drug.
During the latter part of the summer and autumn, pursuant to permission granted me to study milk-siekness, I spent some time in the northern portion of the state on this work. Previous experience having taught that the mountaineers could not be relied on to look after
the proper exposure of the animals to be used for the
experiments to the conditions which were thought to be favorable to the production of the disease, I employed a
young man to go up and sp~nd September to look after
this for us. I regret exceedingly to report that, notwithstanding every effort was made, we were unable to cause any of our animals to contract the diEease, and the investigation has, therefore, remained fruitless. I should like very much next summer to keep up the work if, in the wisdom of the Board, such a course should appear advisable.
Your Secretary has also during the past year given considerable attention to the disease called "pellagra," and is now preparing a paper on the symptomatology and pathology of the affection to appear in the forthcoming report of the Board. The disease prevailing largely in lunatic asylums, I have made a number of trips to Milledgeville for the purpose above indicated, and trust that the carrying on of the work will meet with your approval. There is no doubt that this is a most important subject, there being certainly hundreds of people who die annually of this disease in Georgia; in the chronic cases the invalidism induced by it should not be overlooked,-a period of from 20 to 25 years sometimes
li'

elapsing between the time of its beginning and the final fatal termination.
Since the last meeting of the Board our laboratory has been greatly improved. The room formerly occupied by ouranimals has been completely renovated and made into an antitoxin laboratory. This laboratory i~ fitted up with every necessary appliance and is certainly not excelled by any one of my acquaintance.
The facilities for growing bacteria being very limited in the incubator that we possess, and it being impossible to procure one of sufficient size, I have had constructed a constant temperature room, which I believe will meet every requirement of our laboratory so long as it exists. This room is insulated by cork and tarred paper, and on the interior is covered from top to bottom with cement upon which is finally placed an impervious coating of paint. The shelves are of glass and the supports of iron, making it thus possible to wash every part of the room with antiseptic solutions whenever it may be necessary. There are two secondary incubators on the sides of the main chamber which will be used for growing bacteria that require a somewhat lower temperature than is ordinarily employed. This is the nicest room of its kind of which I have any knowledge. We have also fixed up a room for a library, which is as yet quite modest, but with time should grow to much larger proportions. All the journals taken by the members of our staff are placed in this library and are at the disposal of any doctor who may wish to consult them at any time. I think it is not too much for us to hope that in the course of time we may build up a library somewhat corresponding to that maintained by the state for our brethren of the legal profession.
These improvements, together with the necessary apparatus with which to fit them up, have proven quite expensive, but inasmuch as they are permanent, I trust
1H

that our action in the matter will meet with the approval of the Board.
There remains but one requirement that is indispensable for the continued good of our work, viz.: a properly constructed and heated animal house. At the presen~ time we are using a miserable ruin across the street for this purpose, for which we pay the sum of $6.00 per month. This is not so bad in the warmer periods of the year, but at the present time it is impossible for us to interpret the results of our experiments owing to the fact that the animals, particularly when slightly weakened, immediately succumb to the cold. This has proven a serious menace to our Pasteur work, and likewise it has been impossible for us to standardize the antitoxin which has been already produced. rt'his is a very embarrassing situation, as we have a considerable quantity of this product on hand, but can not send it out for the reason that we are not entirely sure as to its potency. I would most strongly urge that the Board take some action at this meeting looking toward the erection of a suitable animal house.
The totally unexpected amount of Pasteur work that we were immediately called upon to do when our laboratory for the treatment of this disease was opened, at once clearly showed that it would require the entire time of one of the assistants to attend to it, which left us in a position of having no one to look after the preparation of the diphtheria antitoxin. After discussing the matter with the President of the Board, we decided to procure, if possible, the services of Dr. Katharine R. Collins, at that time Assistant Director of the New York City Board of Health, who had previously expressed her willingness to join us if the proper inducements could be offered. On communicating with her it was found that she was receiving a salary of $2,400 from the New York City Board of Health and for other work that she was doin~,
19

but, as she was very anxious to come to Atlanta where she had formerly lived, she offered to come for $2,100 yearly, specifying that she should be made Assistant Director of the Laboratories, and that we should give her, as soon as the finances of the Board should permit, an increase in salary up to at least $2,500. Inasmuch. as your body had been good enough to place matters of this kind in the hands of the President and Secretary, after a thorough discussion of the situation, it was determined to accept this offer, and Dr. Collins accordingly joined us on the first of October.
'l'he scientific work of our laboratory for the last nine months has been most satisfactory. "\Ve have treated :216 cases of hydrophobia with but one death. Fourteen hundred and ninety-four examinations of all kinds haYe ben made, exceeding most decidedly all former records for an equal period of time. VVTe have now on hand probably between a million and a million and a half u:q.its of antitoxin. 'rhe exact amount, however, can not be stated for the reasons already enumerated. The interest manifested by the people at large in our work has multiplied many fold during the past year, and I feel it to he a subject of congratulation that we are receiving such recognition as would indicate that there is a general belief that we are doing valuable work.
Below is the tabulated results of the work accomplished during the preceding nine months:

Negative.

Tubercle bacilli,

513

Hook-worm, ...................................... 121

\Vidal, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Diphtheria, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 G~noccocci, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Mabrial parasites, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Inte:'tinal parasites, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Sta phyloccoceus, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 Streptococcu~ . . . . .. . . . .. . . . .. . . . .. . . . . . . . .. . .. .. . 0

Positive.
235 110 17 42
4 3 0 4 3,

20

Spirochita pallida, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

0

Tapeworm, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

0

Amt>ba coli, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1

Ascaris lumbricoides, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

5

Pneumococcus, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

0

BoasOppler bacilli, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

0

Twbercular meningitis, . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

1

ExaminaHons of animals, . . . . . . . . . . . . . . . . . . . . . . . . . 45

153

Number of doses .of tuberculin 7-14 Water analyses, ................. 91 Total number of examinations, ......... 1,494.

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

LAST MEETING OF THE BOARD.
Dr. S. C. Benedict, .............................. $ '' \V. "\V. Owens, ............................. . '' M. S. Brown, .............................. . '' T?-1. F. Westmoreland, ....................... . '' R. M. Harbin, ............................. . '' Giles Hathcock, ............................ . '' tl. 1H. Mc.Duffie, ............................ . '' A. P. Taylor, .............................. .

38.38 50.35 11.30 43.40 30.00 30.85 26.90 12.00

EXPEN.SES OF .SECRETARY.
April, ...................................... .$ May, .......................................... . ( .July, .......................................... . September, ..................................... . October and November, ........................ . Decemfber, ..................................... .

48.20 114.30 12.90 195.20
50.68 11.65

$ 243.18

SALARIES. .Secretary, ...................................... $ 1,500.00 1st assistant director of laboratories, . . . . . . . . . . . . 525.00 2nd assistant director of laboratories, . . . . . . . . . . . . 1,150.00 3rd assistant, . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . 540.00 Clerk, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 750.00

$ 438.93

21

Laboratory assistant, ........................... . Domestic assistant, ............................. . Janitor,

1227.53 10.00
290.00

CARPENTRY, PLASTERING, PAINTING, PLUMBIN-G,

APPARATUS, ETC.

Offiee supplies, (April) .......................... $ 14.80

Hardware, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.13

Power to run motor for Mar., . . . . . . . . . . . . . . . . . . . . 14.80

Chemicals, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vaccine, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8.28 14.00

Fre1ght, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5.77

Screens, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Guinea pigs, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20.00. 21.40

Stamps, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.00

Sundries, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.83

Guinea pigs, . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.25

Rabbits, (May) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.00

Drip pans, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8.05

Books for laboratmy, . . . . . . . . . . . . . . . . . . . . . . . . . . . Vaccine, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sundr~es, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PO<Wer for April, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16.50 3.00
24.83 H.4Z

Stamps, (June) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.00

Power for May, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.S.94

Feel for stock, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.70

Vaceine, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26.55

Guinea pigs, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.95

Expenses ''milk-sick'' invest., . . . . . . . . . . . . . . . . . . . 15.00

Stamps, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.00

Alcohol, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.65

Power for June, (July) . . . . . . . . . . . . . . . . . . . . . . . . . Rabbits, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13.99 27.38

Hardware, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Feed for stock, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11.55 24.62

Ghe:aicals, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.80

Stamps, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.00

Sundries, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.60

Book for laboratory, . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.75

Covr.ring for pipes, (August) . . . . . . . . . . . . . . . . . . . . 17.02

Ammonia, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28.56

Feed for stock, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mailing cases,

15.25 36.50

22

1

Stamps, ....................................... . Power for July, ............................... . Drawing, ...................................... . Chemica~s, ..................................... . Cha.. Hicks, (Special S(1rvices) .................. . Sundries, ...................................... . Rabbits, ....................................... . jStamps, ....................................... . Rent for rabbit house, ......................... . W. F. Westmoreland, (Special services) .......... . Extra stenographer, ............................ . Printing, ...................................... . Stamps, ....................................... . Expens~s '' milksick'' invest., (Sept.) ........... . Cow a:ud .calf, .................................. . Extra janitor se.rvice, ......................... . Laboratory apparatus, .......................... . Book for laboratory, ........................... . Plumbing, ..................................... . Rabbits, ....................................... . Feed for stock, ................................ . Alcohol, ....................................... . Covering for tables, ............................ . Guinea pigs, ................................... . Sta.mps, ....................................... . Chemicals, ..................................... . <Sundries, ...................................... . Cork to insulate incubator room, ................. . Rent for rabbit house, ......................... . Laboratory assistant for September, ............ . Extra stenographer two weeks, ................. , . Current for refrigerator, (October) .............. . PowP.r for September, .......................... . Rabbits, ....................................... . Feed for stock, ................................ . IStamps, ....................................... . Chemicals, ...................... : .............. . Book cases, : ................................... . C'rawing, ...................................... . Stamps, ....................................... . Carpentry, (November) ........................ .
Disinfectant, ................................... .
Co:rk, ......................................... .
Chemicals, .................................

10.00 17.74
3.00 7.75 6.00 69.81 8.25 10.00 6.00 180.00 12.00 96.08 10.00 2.6.50 25.00 769.03 6.15 6.15 13.30 7.50 27.46 13.65 10.80 9.75 10.00 35.45 85.84 194.70 6.00 50.00 24.00 70.86 12.61 14.25 30.51 10.00 10.85 78.00 9.00 10.00 500.00 5.00 11..22
9.20

23

Linoleum,, ..................................... . Office furniture, ................. ; .............. . Feed. for stock, ................................ . Rabbits, ....................................... . Stamps, ....................................... . Sundries, ...................................... . Extra janitor service, ........................... . Mailing cases, ................................. . Rabbits, ....................................... . T.wo horses, ................................... . !Stamps, ....................................... . Freight, ....................................... . Attention and board of cow ''milk-sick,'' ....... . Dra.wing, ...................................... . Stamps to ma1l report, .......................... . Guinea pigs, ................................... . Feed for stock, ................................ . Pow0r for November, ........................... . Rabbits, ....................................... . Ammonia, ..................................... . Chemicals, ..................................... . Stamps to mail report, .......................... . Sundries, ...................................... . Clerk to mail reports, ........................... . Plastering, ................... , ................. . !PlaGtering, .................................... . Carpentry, ..................................... . Carp('ntry, ..................................... . Painting, ...................................... . Painting, ...................................... . Work on 1motor, ................................ . ~taiiilps, ....................................... . .Sundries, ...................................... . Di;rectory, ............... ! ..................... . Carpentry, ..................................... . Fll'eight, ....................................... . Power for December, ........................... . Mailing cases, ................................. . Furniture and supplies, ......................... . ;Boxes, .. ................................ , ..... . Alcohol, ....................................... . Guinea pigs, ................................... . Feed for stock, ................................. . Chemicals,

34.85 28.75 28.75 13.25 10.00 58.64
7.00 33.00
7.50 137.00 10.00
29.80 24.00 35.00 50.00 19.20 34.75
5.00 18.00 28.56 35.40 40.00 44.08
7.50 8.55 >2.85 4.25 4.25 14.25 15.75 4.00 10.0'0 38.05 6.00 108.60 8.85 7.72 51.72 63.85 25.00 14.75 12.00 15.75 25.75

24

Sundries, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Apparatus, ....................... : . . . . . . . . . . . . . . Rent for rabbit house, . . . . . . . . . . . . . . . . . . . . . . . . . .

62.73 500.00
15.00

Expenses of Meeting of Board, . . . . . . . . . . . . . . . . . . Expenses of Secreta~, . . . . . . . . . . . . . . . . . . . . . . . . . . Salaries, .......................... . . . . . . . . . . . . . . Incidentals, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

243.18 438.93 4,992.53 4,900. 72

$4,900.72

$10,575.36 On hand April 1st, 1908, . . . . . . . . . . . . . . . . . $ 5,659.71 Extra appropriation, . . . . . . . . . . . . . . . . . . . . . 5,000.00

Total ........................... $10,659.71 Expenses to date, ...................... 10,575.36

Balance ............................. $ 84.35

In conclusion it gives me great pleasure to refer to the excellent character of work being done by everyone connected with our laboratory. Dr. Paullin has for the greater poriton of the time conducted with much care the Pasteur work, the very fine results of which have already been referred to.
Dr. Collins in an equally painstaking manner prepares our antito:xin, and Dr. Pattillo has rendered most valuable services, as heretofore, in the routine examination work of the laboratory. I feel we should also commend most highly the exemplary attention to work and general usefulness of Mrs. Stockton, and of our Junior Laboratory Assistant, F. W. Anderson.
Respectfully submitted,
H. F. HARRis, Secretary.

25

26

HOOK-WORM DISEASE
There is not within the whole range of human knowledge a more extraordinary testimonial to the power of habit, and the tendency to follow without question those who have preceded us than our failure for hundreds of years to discover the wide-spread prevalence of the hookworm disease in the southern portion of the United States. There can be no reasonable doubt that from a period shortly following the introduction of slaves into this country the people of the cotton-belt and mountain regions of the south have been the victims of this terrible affection, but as the disorder was unknown to the English physicians who first began the practice of the healing art in America, the true character of the malady was not discovered. The medical men of American birth who succeeded those of European origin followed closely in the footsteps of the latter, particularly here in the south, and there is not wanting even at the present day evidence of the powerful influence still eXf rcised by their teachings. Our native physicians have little disposition in the vast majority of instances to hunt up new causes of disease, which, coupled with the fact that the microscope was scarcely used at all up to a few years ago, in a large measure accounts for our overlooking this affection up to the beginning of the last decade. It is undoubtedly also true that the character of the examination required to determine the presence of this parasite played a not unimportant part in our failure to discover it, but the somewhat offensive nature of this procedure could not absolve our profession from their duty in this matter,-particularly where they were capable of carry-
27

ing it out; that this was, however, to a considerable degree responsible for our sins of omission there can be no question, as the writer can testify from many personal experiences in the earlier days of his investigations.
That hook-worm disease is the most common of all of the serious maladies of the south there can be now no sort of question. It is a fact as capable of demonstration as the presence here of man himself, and no one of the slightest intelligence could fail to be convinced after the perfectly patent facts were laid before him. It i'j of no local concern to us as to whether or not people in other parts of this country have hook-worm disease; as a matter of fact they do not, but it certainly behooves us to bestir ourselves and to remove the burden of this terrible malady from our people as quickly as possible.
Much of a misleading character has unfortunately appeared in various newspapers of the country respecting the frequency of hook-worm disease. In the absence of complete statistics it is out of the question to form any adequate idea as to the prevalence of this affection-we only know it occurs in the majority of people in many localities, while in others it is scarcely found at all. The affection is frequent in many of the valleys of the extreme northern portion of Georga, but whether it is common in the mountainous regions of neighboring states I am not in position to say. It is again found to even greater extent from the middle of the state just mentioned down to its lower border, becoming more and more frequent as the Florida line is approached. In the belt of country running from east to west from the Blue Ridge mountains down to middle Georgia the disease is clearly exceedingly rare, the writer. never having seen a case originating in this locality. It cannot be too strongly insisted upon that this is an affection almost always associated in its severest forms with poverty, and that it is peculiarly a malady therefore
28

to which the poor mountaineers and the equally povertystricken inhabitants of other portions of the state are particularly susceptible. The writer's observations, although practically confined to Georgia, indicate most strongly that the disease, as might be expected from its African origin, is most common where the negro has been most numerous. Through ages of infection the black man has acquired an almost perfect racial immunity from the effects of the parasite, but this in no way interferes with the fact that he frequently harbors a considerable number of the worms. The negro coming in contact particularly with the poorer class of white persons, the disease was quickly transferred to the latter, and the parasite, sapping the life and vitality of its new host, for the most part prevented normal mental and physical development, and precluded in many cases the possibility of further advance in life. As a consequence of this, particularly in extreme southern Georgia, and in the lower portions of neighboring southern states, there are up to this day communities the inhabitants of which are commonly known as ''dirt-eaters,'' and who present the very lowest type of the white race occurring in America. In such communities it is safe to say that practically the entire population is hook-worm diseased. A few miles away the large planter, whose family observes better the laws of hygiene, is probably himself entirely free from the infection; his younger children while going bare-foot may harbor a greater or less number of the parasites but are rarely or never so badly infect~d as the .class just referred to, and following their beginning to wear shoes-no re-infection thereafter taking place, and the worms already in their intestinal tracts dying off-become entirely normal in the course of a few years. So also is it true that in the village not far away the children, owing to the general use of the toilet, are little if any infected. It is thus seen that we have in the same
29

locality communities in which the percentage of hookworm subjects would run well up into the nineties, and others where the disease practically does not exist. Statistics, therefore, must unquestionably be one-sided until the entire population can be considered, and our ideas as to the prevalence of the disease must necessarily be of a superficial character until the latter can be done.
A man who comes into a community, examines anumber of persons of a given class, and drawing conclusions from his results, asserts that a certain percentage of the people of one or all of the southern states is affected with hook-worm makes deductions that cannot be other than erroneous. Equally false are the inferences of the "northern expert" who comes down-as recently happened-and after seeing the children of a few cotton mills loudly proclaims through the press that there are no more intestinal animal parasites in the south than in the north. In this connection attention should be drawn to the fact, as shown by Dr. Stiles, that very soon after these poor whites commence work in the cotton mills they begin to improve, and in a few ye~rs practically lose their hook-worm infection. It is unquestionably the case, therefore, that in the south child-labor in mills is the greatest possible existing boon to this class of subjects, and instead of being condemned it should be encouraged in every possible way.
Fortunat~ly the very intelligent and efficient State Board of Health of hte south are now taking up in earnest this great fight, and we may be assured that wonders will be accomplished along these lines within the next few years. In the meantime the medical profession, understanding the real nature of the situation, should use every means to appeal to the humanity of our people, which, if done, will unquestionably be of the utmost value and most far-reaching importance in this

I

30

I

most momentous of all questions confronting the people of the south today.
HISTORY: The history of our knowledge of the hookworm is of considerable interest. As has so often been found where parasites of this class are concerned, members of the genus were first discovered in the lower animals-the worm being by no means confined to man. A German clergyman by the name of Goeze in 1792 was the first to describe the parasite, his observations having been made on the particular species of hook-worm that inhabits the intestinal tract of the common badger. Some seven years later Froelich discovered a somewhat similar worm in the intestinal tract of a fox. He gave to the parasite its present common name, our word "hookworm" being the literal translation of the German "Haakenwurm," which he called it. He it was also who originated the name "Uncinaria," the same being the zoological name for the genus in which this worm, along with many other allied species, is still included by most writers.
This worm was first observed as a human parasite in 1838 by an Italian named Dubini, and six years later he described it under the name of Agchylostoma d'uodenale. This observer did not succeed in establishing thoroughly the relationship between the worm and the. ill-effects which we now know it produces, though he recognized the great probability that it was not without evil influence upon the organism of its host. Some ten years later it was however clearly demonstrated by both Bilharz and Griesinger that the profound aenemia so common in northern Africa, and known as ''Egyptian chlorosis," was unquestionably produced by_ this parasite. In 1879 it was shown that laborers working on the St. Gotthardt tunnel were almost all infected with the worm, and Perroncito, who discovered this fact, also demonstrated that the disease prevailed in the mountains of
31

northern Italy to a considerable extent, being commonly called "mountain cachexia" or "mine anemia."
Following the observations just referred to, investigators from other parts of the world began to report the finding of the human hook-worm with greater and greater frequency, until at the present time we have a vast literature on the subject coming fromalmost every place on the globe where the climatic conditions favor the development of the worm.
The writings of many American physicians clearly show beyond question that hook-worm disease-the victims of which are called "dirt eaters"-has prevailed in this country for something like 100 years, and there can be no reasonable doubt whatever that it has existed here ever since the importation of slaves began. Notwithstanding that this fact has long been known, the true nature and cause of their trouble was not recognized . until within recent years. The first case of hook-worm disease in this country where the diagnosis was definitely established was that reported by Blickhahn in 1893. This was followed by publications from a large number of American observers, resulting in the course of the next ten years in demonstrating beyond question that this disease was exceedingly frequent in the southern portion of the United States. It was shown in 1902 by Stiles that the parasite commonly found in America differs in some minor particulars from those found in Egypt and in southern Europe, and this writer therefore gave to what was supposed to be our new-world species of the worm the name of Unciniaria americana. In 1903 Stiles, on account of the peculiarities presented by the worm as found here, proposed to make a new genus for it, and renamed it theNecator americanus. As it has been shown by Loos, who has done so much for our knowledge of this subject, that this so-called American hook-worm is largely present in mimy of the negroes of
32

southern Africa, there can scarcely longer remain a doubt that it was brought over by slaves, and should therefore rather have been called Necator africanus than the name given.
(<
Hook-Worm, Natural Size; The Smaller is the Male
Male (left) and Female Hook-Worms Under Moderate Magnification.
NATURAL HISTORY oF THE PARASITE: The hook-worni belongs to the order of nematodes or round worms, being related to and much resembling the small "thread" or "pin-w()rm" with which almost everyone is more or less acquainted. On careful examination, however, the two parasites present marked differences which may be detected by the naked eye of one well acquainted with thejr peculiarities; microscopically they differ still more.
33


Like the pin-worm the hook-worm is comparatively small, being in the case of the female about one-half inch long, and of about the width of an ordinary hat pin; the male is slightly smaller than the female. In the perfectly fresh state the parasite is often of a pinkish gray; after death, however, it generally assumes a dull grayish tint.
Hook-Worms Und"r Higher Magnification; a, Male; b, Female.
34

Unlike the pin-wormthis parasite is not found except in extremely rare . instances in the feces, and the presence
of the parasites in the stools therefore plays no part ~n making the diagnosis of the disease.
'While it is true that from the general symptoms he hook-worm may be suspected in a given individual,-:the evidence being in many instances so strong as to amount almost to absolute certainty-the ; '' only method by which it is possible to determine its presence beyond doubt is to examine the feces for the eggs. This examination is an exceedingly simple one, requiring only a glass slide upon which to spread

Head and neck of hook worm considerably magnified.
a, mouth cavity; b, chitinous ventral lips; cl cuticular margin; ci, chitinous dorsal lips; e, dorsal conical tooth; f, head glands; g, cervical papillae, with duct of cervical gland; h, esophageal gland; i, cervical gland.
the material, and a microscope
of moderate power. As the
eggs are, as a rule, very numerous the diagnosis can usually be made in a few moments, although in other instances where the number of worms is small
a more careful study of the

End of tail of male hook worm considerably magnified.
a, dorsal lob e; b, lateral lobe ; c, ventral lobe; d, dorsal ray; e, dorsolateral ray; f, lateral rays; g, ventro-lateral ray; h, ventral rays ; i,
opening or cloaca; L spicules .

35

a

b

c

d

e

f

g

h

k

A, newly-laid egg; b, beginning segmentation; c, egg, further stage segmentation; d, e, advanced stage segmentation; f, preceding for- mation embryo; g, embryo in first stage; h, embryo just before leaving shell; i, embryo after leaving shell; j, embryo several days old; k, embryo cove!ed by chitinous envelop in stage to infect.

36

specimens is necessary. While it is true that the eggs of the pin-worm somewhat resemble those of the parasite in question, one acquainted with the peculiarities of both would have no difficulty in distinguishing between them. The former are decidedly smaller, their shelle have a double contour, they are usually somewhat flattened on one end and frequently contain live embryo. It is furthermore true that the eggs of the pin-worm are only seen in the rarest instances in the feces-even though the parasite may exist in great numbers in the intestine of the individual-and confounding the two is therefore almost out of the question.
There is nothing more curious than the development of the embryo of this parasite from the eggs, and their subsequent invasion of the human body. In fact, the method of infection is so extraordinary that when it was first announced by Loos scientific men of all classes received it with almost universal incredulity. However, in a short time the facts in connection with it were so clearly demonstrated that there could be no longer room for doubt, and we know absolutely the almost unbelievable facts concerning it.
There are certain conditions necessary for the development of the eggs of this parasite after they have passed from the infected individual. There must be to begin with a temperature sufficiently high. The eggs do not appear to hatch to any extent below 70 F. From experiments carried out by the writer it would seem that the most suitable temperature for the development of the embryo in the eggs is between 80 and 90 F., though growth undoubtedly occurs at a still greater heat. Quite as important as the proper temperature is the admission of oxygen to the eggs, which is brought about by the feces being washed over the surface of the ground by rains, and also, as I have shown, by the activities of the larvae of various flies. It is also essential that the.
37

eggs remain moist, but if they be covered entirely by water, oxygen is excluded, and they undergo degenerative changes and die within a few days when the temperature is high. It is thus seen that we must have a summer temperature, admission of oxygen, and a certain amount of moisture in order for this parasite to be propagated. All three of these conditions are ideally present during a greater part of the year in the south. The temperature is high enough to cause the hatching of the eggs, our summer showers spread the feces out over the earth and keep them sufficiently moist, and as the hot sun drinks up the excessive moisture rapidly or it soaks into the earth, the eggs are uncovered and left exposed to the action of the oxygen of the air. Under such conditions there may be observed 'Yithin the eggs in the course of from twelve to thirty-six hours, the development of a curious snake-like body called the embryo, which in a short time forces its way through the thin shell of the egg, and then burrows into the neighboring earth. vVhen the next rain occurs or when dew-drops collect in the neighborhood this tiny ]ittle creature quickly finds its way into the water, where it remains if the water does not dry up until the development necessary for penetrating the human body is completed. When the dew-drop dries or the pool of water evaporates the embryo burrows into the moist earth, there remaining until a fresh down~ pour of water beckons it to the surface again. In the meantime it undergoes a process analogous to the shedding of their skins observed in many reptiles, which after a few days is again repeated. The immature parasite is now ready to penetrate the human body, but under the proper conditions may live for months in dew-drops, pools of water or in the moist earth. It is capable of migrating to quite a distance as compared with its microscopic size, it having been shown that on the sides of moist tunnels the embryo may crawl up to a height of at least six feet.
38 .

For a long time it has been known that when these embryo were swallowed that infection with the hook. worm results, but it was only a few years ago that Loos suggested the astounding probability that they may actually penetrate through the skin of the human being, and ultimately find their way to the intestinal tract. Shortly after this Bentley made the observation that hook-worm disease and ground-itch were both exceedingly common among the coolies of India, and as he had found that the earth in the neighborhood of their habitations simply swarmed with the embryo of the hookworm, it occurred to him that the skin affection might in some way be induced by them. Acting upon this idea he exposed the skin of subjects who offered themselves for experimentation. to earth containing these immature parasites, ana observed that this was followed by typical ground-itch, and that at the same time all of the embryo disappeared from the earth that was being applied. He therefore concluded that it was not improbable that ground-itch was due to some action of the hook-worm embryo. Still later Loos established by actual microscopic demonstration that the young of the hook-worm are capable of penetrating the skin of man and of animals, and he was eventually able to show that when inoculated on the skin of the dog they pursue the following extraordinary course. After quickly boring through the skin and getting down into the deeper tissues they finally work their way through the lymphatics into the general blood-current, or bore directly into the smaller blood-vessels. Moving with the blood-current they pass to the heart, and are thence pumped into the smaller vessels of the lungs; here they penetrate through the delicate tissues that intervene between the minute blood-vessels and the air-sacks, and thence make their way into the smaller bronchial tubes, then the larger ones, and finally crawl out where the wind-pipe opens iuto the throat.
39

They are then swallowed, and passing along with the food quickly reach the small intestine, where they immediately grasp the mucous membrane with their mouths, which being especially adapted to sucking and hanging on to any tissues that they may find congenial, they hold on to without difficulty. The parasite grows rapidly and in the course of six or eight weeks is fully mature, after which the females begin to lay eggs, and the curious life cycle begins over again. The average life of the parasite is not definitely known, but it would appear that it is not less than six or eight years, being in some instances probably even considerably longer. It is rather a curious fact that some of these worms appear to cause much severer disturbances in the body than others, since it is found that some persons with a comparatively small infection of the parasites suffer much more than those who harbor a considerably greater number. This must be due either to some of the worms being more virulent than others, or to certain persons being more susceptible to their disease-producing power. In this connection it should be remarked that it is generally believed that the parasite not only acts by sucking blood, but that it secretes a poison, which, being constantly injected into the mucous membrane of the intestine, is responsible for much of the damage produced by it.
SYMPTOMATOLOGY: Our early medical writers were clearly acquainted with the results of hook-worm infection in the human being, but none of them had the slightest idea as to its cause. A typical h_ook-worm subject was generally called a "clay or dirt eater," although it is of course now known that the supposed causation implied by this name had nothing whatever to do with the production of the disease.
As would naturally be inferred, hook-worm disease is most common in those who come in most intimate contact with the ground. As going barefoot is an al-
40

most universal practice among children of the south, and as these little ones spend a large portion of their time playing on the ground around their homes~ it is not diffi. cult to understand that they are the ones who suffer most. The disease is now and then encountered. in adults,' and even in persons advanced in life, but this is exceptional. The vast 'majority of our typical hookworm subjects occur in individuals from three to four years of age to the time when they cease to be children, and begin to wear shoes and not to play on the ground. As the worm, however, unquestionably lives a number of years, young persons up into the twenties very commonly show more or less clearly the results of the presence of the parasites, and their stools contain eggs of these worms.
As has already been said, in the majority of instances ground-itch is th~ first clinical manifestation of .this affection. Where, however, the numbers of embryo entering the body is small no perceptible results are seen on the skin. It is not improbable that quite anumber of persons, particularly in later life, get the disease very slowly, only a few of the embryo entering the body at intervals during the summer months, and as a consequence these patients do not give the history of having had ground-itch.
The most pronounced effect of the presence of the hook-worm is a profound aenemia, indicated by a dry, harsh, pale, yellowish skin and bloodless lips. It is not uncommon to find the blood reduced one-half or two'thirds in richness, and as a consequence of this the unfortunate victim suffers a multitude of ill-effects throughout his entire body. One of the most notable consequences is that the boy or girl fails to grow,-it being quite common to see a young man from fifteen to twenty years of age who has the appear~nce of not being more than eight or ten. The individual remains a child mer
41

.tally as well as physically. The tissues are relaxed, as shown by the giving away of the abdominal walls, with the result that the belly protrudes unnaturally. As the malady progresses there is more or less dropsy in severe cas.es, accompanied by shortness of breath and great weakness. Ulcers may develop on the front portions of the legs. The patient presents a sad, hopeless countenance, it being evident that he is suffering from some serious malady. At this point it may be well to stress the fact that these individuals are not lazy. Unfortunately a chance remark by one of the early investigators of this subject led newspaper men to characterize this malady as the ''lazy disease.'' This is incorrect-the investigator just referred to having told the writer that he never intended to convey any such impression--and has led to the unfortunate result that the subject has been treated lightly and is still being looked upon by many as a sort of medical joke. Those affected with this disease lack energy it is true, as any sick man would, but they are by no means to be characterized as lazy, which is quite another matter. I have seen men of extraordinary energy who were subjects of hook-worm disease.
DIAGNOSIS: There is no disease that can be diagnosticated with more ease and certainty. Anyone of aver- age intelligence could be taught within a few hours to make the examination, provided they possessed a microscope of moderate power. More certain results are however attained where the specimens are examined by a skilled microscopist, such as may be found in the laboratories of the various State Boards of Health in the south, and whose services in all instances can be secured free of cost. In order to have this examination made it is only necessary to place a small quantity of the fecesone-half of a teaspoonful is sufficient-in a well-stoppered bottle, put in a proper receptacle to prevent break-
42

ing and mail to one of the laboratories just referred to. A report of the result is then promptly forwarded to the sender by the laboratory officials, and I ,would repeat again that" this is done WITHOUT COST.
PROPHYLAXIS: In order to successfully combat hookworm disease it is absolutely essential that those suffering from the malady should at once be treated, because, as has already been explained, they are sources from which the disease spreads to their relatives, friends and neighbors, and even back to themselves. This treatment should be carried out as far as possible in the fall, winter and spring months, since to do this in the summer -the ground around the farm houses by this time swarming with the embryo-would often result only in temporarily freeing those affected by the parasite. The eggs do not hatch in cool weather, nor is it probable that the embryo survive the cold that accompanies the winter months in the greater portion of the south. As a consequence patients treated during this period could not reinfect the ground, and the parasites not living from one summer to the next the disease would be thoroughly eradicated. Where the precaut:U.ons just referred to have not been taken, great care should be exercised in preventing those living in localities known to be infected from coming into direct contact with dew-drops, pools of water on the ground, or moist earth. All should wear shoes, and children should not be allowed to play out of doors except at some distance from the house. Of course the most important of all preventive means is to have a toilet, particularly for the children. Indiscriminate scattering of fecal material in the yard, around the barn and in the apple orchard is responsible for the prevalence of this disease, and the inost stringent rules should be adopted looking toward the correction of this great unhygienic nuisance. Not only does hook-worm disease spread as a consequence of this yery common
43

practice, but other affections, such as typhoid fever and dysentery, and there is consequently no sanitary advance that would be of so much importance to our people as providing a properly constructed water-closet at every home, every school house and every church, and insisting that they be used. It is also of importance that the flies be excluded completely from the toilet, and we should therefore do away with the present methods
employed for constructing them. Th feces should be
received into some proper receptacie completely protected from flies and all animals, and at proper intervals the contents should be carried to a suitable place and buried. Precautions of this kind unquestionably would be more or less troublesome, but the time consumed would in no way compare with the suffering, invalidism, and death that results from the present indifference in these matters. This does not take into account the pecuniary loss that is occasioned by the inability of the patient to work, and the oftentimes burdensome doctor bills that are a natural consequence of our present methods.
TREATMENT: Fortunately the treatment of hookworm disease is exceedingly simple, and if persisted in is always satisfactory. In most diseases the physician has to content himself with attempting to combat the symptoms of the malady from which his patient is suffering, there being in the vast majority of instances no specific treatment. It is unfortunately true that the same poisons that kill the living, disease-producing agencies in nearly all instances have the same effect on the human organism. In those cases, however, where the more highly organized animal parasites occur in the human intestine we have in several instances drugs that kill the infective agent without seriously disturbing the general health of the patient, and most happily the hook-
44

,.
worm is one of the organisms that is most easily destroyed and removed in this way.
The diagnosis having been established by miscroscopic examination of the feces, the patient is consulted as to the day of the week that can be most easily spared; in many instances, as in mill operatives, this will be Sunday, but where the patient belongs to the class of rural hook-worm subjects one day is quite as good as another, since they exist in a perpetual holiday as a rule.
On the day before the treatment is to be begun the patient is advised to eat little dinner and no supper at all. Late in the afternoon he is given a full dose of calomel, the amount varying from two to ten grains, depending upon the age and strength of the patient. Castor oil could perhaps be administered with safety, but its use is not generally advised inasmuch as all oily substances dissolve and make more readily absorbable the thymol which is to be given on the following day, and might in this way cause unpleasant effects. If the calomel acts freely during the night no other purgative need be administered on the following morning, but if it should not do so a full dose of epsom salts in hot water should be exhibited as soon as the patient wakes up. After the bowels have thoroughly acted finely powdered thymol in capsule is then given,-the quantity depending on the age and strength .of the patient. It is a good rule . to be guided by the apparent age of the individual who is to be treated rather than that stated by the patient,this being for the reason that many of these unfortunates appear as much as six, eight or ten years younger than they are in reality. The dose of thymol should be divided into two equal parts, the first half being given at once and the second at the expiration of an hour. Following the administration of the medicine the patient should be instructed to remain in bed, and lying on the right side may perhaps more or less assist in permitting
45

the drug to pass quickly into the intestine from the stomach. The amount of the drug that should be given is as follows:
Up to five years of age _____ lO to 15 grains. From five to ten years _____l5 to 30 grains. Ten to fifteen years ________ 3{}to 60 grains. Fifteen and over__________ 60 grains.
In advanced age the quantity should be somewhat le,ss than during middle life.
The patient should be allowed no breakfast and no dinner on the day of treatment. I have been accustomed to permit a cup of coffee one or more times during the day, but nothing in the nature of food should be allowed. If the patient experiences no ill effects from the thymol, it is well to put off the administration of a laxative until four or five o'clock in the afternoon, at which time some saline should be administered in hot water. After the bowels have acted well the patient may be allowed to have food.
When the treatment is carried out faithfully in the way just described I have rarely found it necessary to repeat it. It is, however, well after a couple of weeks to again make a thorough examination of the feces, and should the microscope reveal the presence of eggs the treatment should be repeated, and this should be done over and over again until exhaustive examination's of the feces show by absence of the eggs of the parasite that all have been expelled.
It is of especial importance to call attention to the fact that castor oil should not be used as a purgative on the day of treatment, as it might produce poisonous effects by dissolving the thymol and aiding its absorption. Still more should the patient be warned against taking alcoholic drinks in any form, as they act as does castor oil. It cannot be too strongly insisted upon that the
46

drugs that kill the hookworm might under certain circumstances kill the patient, and it is of the utmost importance that these medicaments be given intelligently by one acquainted with their use. Patients who have this disease should under no circumstances be treated by anyone other than a.n experienced} physicia.n, as otherwise disastrous resttlts might follow.
There are still other drugs that are more or less employed for the purpose of killing this parasite, betanaph thol especially being used by many physicians. I have never myself prescribed it, but it is said that it acts quite as well as thymol when administered in a light quantity. My friend, Dr. A. G. Fort, of Lumpkin, Ga., informs me that after considerable experience he prefers it to thymol, for the reason that he considers it less dangerous.
When I first began the treatment of hook-worm disease I made it a rule to give iron and tonics following the administration of the thymol, but I soon became convinced that these adjuvants were of no particular value, -the patient recovering just as quickly without as with them. This being the case, it appears inadvisable to give drugs of this class, to which the patient would be apt to incorrectly ascribe his cure.
The public should be especially warned against patent and proprietary medicines for hook-worm disease, as they all have as a basis thymol, betanaphthol or some other drug with more or less poisonous properties, and under no circumstances would they be safe in the hands of one unacquainted with their proper use.
47

THE PREVENTIVE TREATMENT OF
HYDROPHOBIA
This disease, as it occurs in man, is practically always conveyed by the bite of some animal-the dog being the usual offender. The poison is present in the saliva of the diseased animal, and is transmitted through wounds made by its bite.
As observed in the dog, there are two types of the disease; one, the furious; the other, the paralytic.
In the furious type of the affection the animal :first appears to be restless and somewhat excited. He seeks dark places and apparently prefers to be by himself. In this stage of the disease the dog's appetite is good, and may be e~cessive; he responds to orders, although his attention can be attracted only for a moment at a time. As the malady progresses the animal becomes more and more restless, and develops a desire to tear those things about him into pieces. There is described a peculiar bark at this stage of the disease; instead of ending as it ordinarily does, it is prolonged, and terminates. in a higher-pitched note simulating a cry. This is supposed to be very characteristic at this stage of the affection. The appetite gradually diminishes, food is refused, and swallowing becomes difficult. As the symptoms gradually progress the dog shows signs of delirium, and begins to wander. As a rule, he goes about with the tail hung, mouth wide open, and with a wild look in his eyes, biting, as he goes, anything that happens to be directly in his path; seldom does he turn aside to dis-
48

turb anything or anybody. In the latter stages of the disease paralysis generally develops, beginning in the hind legs and soon involving the body. If the animal be now carefully observed it will be seen that he can not swallow. There is no dread of water, as the name "hydrophobia" implies, and as is commonly thought, the animal often attempting to drink, but owing to the paralysis of the. muscles of the throat this is impossible. Inability, then, to swallow either water or solid food is one of the surest and most reliable signs of rabies. Weakness becomes very marked, and the animal finally lies down in a stupor and dies. The entire course of this type may last from six to ten days; generally it is four or five.
The pa.ralytic type of the disease occurs in fifteen or twenty per cent. of the cases. The onset is, as a rule, the same as that observed in the furious type. Instead, however, of the dog beginning to wander, as previously mentioned, the animal becomes paralyzed. The paralysis first affecting the muscles of the jaw, later the tongue. As is the case in the furious type of the disease, the animal loses the power to swallow both solids and liquids, but has no fear of water. The mouth remains wide open, the tongue protruding, and an abundant amount of thick saliva exudes. The animal remains quiet, does not attempt to bite any animal or individual. Death occurs on the second or third day of the disease.
Precautions.-\Vhen an individual is bitten by an animal, either supposed or known to be rabid, the wound should be immediately cauterized with some caustic, preferably concentrated nitric acid. This should be applied without fear, because it is safer to use too much than too little. In case this is not available, any strong eaustic may be used. Punctured wounds should be laid open with a knife and the surfaces freely cauterized. It should not be forgotten that the slightest scratch from
49
'

the tooth of a rabid animal may lead to the develo.pment of hydrophobia in man, and it, therefore, behooves all persons bitten by dogs to take every possible precaution. Even though the animal at the time may appear to be healthy, some strong antiseptic should be applied to the wound and the animal carefully wa1tched until all possibility of his having the disease has passed. Many persons have died from slight wounds inflicted by animals appearing at the time to be perfectly well. Attention should also be directed to the fact that wounds where the teeth of the animal pass through the clothing are not so dangerous as those where no such protection intervenes. Bites about the face and head are much more frequently followed by rabies than those inflicted on the extremities, and, of course, where wounds are deep the chances of infection are much greater; where injuries of the latter kind are inflicted it is practically out of the question to thoroughly cauterize them, and the patient should immediately receive the Pasteur treatment. It is probable that if thorough cauterization be not done within five minutes that it can not be relied upon to prevent the development of the disease; where there is any doubt the only safety lies in the Pasteur treatment. After having attended to this the animal inflicting the wound should be caught, isolated and allowed to die. Under no conditions should the animal be shot unless absolutely necessary. After death the head of the dog should be removed, packed in a. sufficient quantity of ice to keep {!i.e specimen cold, and expressedJ at once to the laboratory of the State Board of Health. The necessary examination can then be made and the presence or absence of rabies determined. A report will be furnished of the findings, either by mail or telegraph, as requested.
Treatment.-Since the epoch-making researches of Pasteur, laboratories have been installed in various parts of the world for the purpose of making vaccine by means
50

of which it is possible, hy gradu.al immunization, to prevent the development of hydrophobia in persons bitten hy rabid dogs. This is done by a series of injec-
\
Fig. I.
tions of a weak virus prepared according to the directions of Pasteur. This treatment is now given free of charge by the Georgia State Board of Health, and those people residing in this State may have it either at this laboratory or the vaccine will be sent to their local physician who can administer it at home. It is absolutely
51

necessa.ry that the vaccine> sent out be injected at once after its receipt, as it will not keep even a day. The injections should be given with a sterile syringe. After having thoroughly shaken the bottle the contents are aspirated into the syringe, and the same injected in the subcutaneous tissue over the abdomen, as shown in Figure 1. The skin should be thoroughly cleansed with 50 per cent. alcohol, or some germicide, before giving the injection. As the duration of the treatment varies from three to four weeks, different portions of the abdomen widely separated should be selected for each injection. Gradually toward the end of the treatment a slight local reaction occurs about the point of inoculation. This is treated, should it occur, after the same manner as one treats an ordinary cellulitis. It should! always be remembered that no harm can come from the treatment, whether the patient is bitten by a rabid dog or not, and thg,t in all cases of doubt no hesitation should be felt in
resorting to it.
The following information is required of those applying for treatment away from this office:
1.-Name and age of patient.
2.-Date, location and severity of the bite or bites with treatment.
3.-Any information bearing on the probability as to whether the animal infliding the bite was or was not rabid.
4.-A brief report of the patient's condition two weeks after the end of the treatment.
The dose will be marked on each bottle. Unless the history of the patient is promptly furnished treatment will be discontinued.
52

TUBERCULIN-ITS MANUFACTURE AND
USES
A tremendous sensation was created in 18!10 by the announcement of. the discovery by Koch of a substance since known a.s "tuberculin," but at that time generally spoken of in this country as "Koch's lymph." An im... pression was at first created that a specific had been discovered for that most dreaded of all diseases-tuberculosis--but it was soon found that the wild expectations of the laity, and even of the medical profession in a measure, were without justification. The conduct of Koch himself-one may say rather fortunately-hastened scientific criticism, and certainly in no small measure contributed to the reaction that so quickly followed against this much vaunted remedy. In the beginning, when there seemed a certain amount of justification for the opinion that tuberculin would prove a real specific in consumption, it had been the intention of Koch to patent, or keep secret, the process of its manufacture, an.d to tax the rest of the world for Germany's scientific acumen. It was a great conception-one that would have eniiched the fatherland at the expense of all other nations had it materialized, but the idea was one utterly repugnant to the scientific spirit, and richly it deserved failure. In part justification, however, it may be urged that in Germany it is permissible for a scientific man to patent his ideas and derive a revenue from them.
Clinical observation, which is the only way of determining the value of, a remedy, quickly showed that not
53

only did tuberculosis individuals not improve from the injection of tuberculin, but that in many instances positive injury resulted. Under such circumstances there could, of course, be hut one result; the leaders of the medical profession unanimously condemned the drug, and a reaction set in against it quite as pronounced as the enthusiasm that welcomed it. However, those who unconditionally condemned it occupied a position very near to those who had assumed too much for it, because both were speaking without caref.ul and painstaking investigation of its merits-in a word, nhther were scientific. After the excitement subsided careful, accurate and unbiased investigators took up the matter with a view of arriving at the real facts, and from their experiments this desirable result appears to ha:ve been accomplished.
Before speaking of the diagnostic and therapeutic applications. of tuberculin, attention should first be called to the method of manufacture of this substance-meaning the old tuberculin of Koch-and to also refer to the modifications made by its discoverer, and by others. To all intents and purposes the original tuberculin is an extract of the tubercle bacillus, and is prepared in the following manner: The tubercle bacillus is grown at 37 degrees centigrade on ordinary peptone bouillon to which 5 per cent. glycerine has been added. It is important that the bacilli be made to float on top of the liquid, as, if they sink, on account of the scarcity of oxygen in the deeper portions of the medium, practically no growth occurs. We should always, therefore, carefully place the organisms on the surface of the liquid, and avoid shaking until the growth has completely covered over its surface. ~he vessel in which
the organisms are grown should not be more than onehalf full of the culture medium, and free access of oxygen should be allowed by not stopping the mouth of the con-
o4

tainer too closely. If the temperature be kept at 37 degrees, and if air be admitted with sufficient freedom, the bacilli, after they begin once to grow, develop with considerable rapidity, so that the top of the liquid may become covered over in about two weeks under very favorable conditions; oftentimes, however, the growth occurs more slowly, and it is several weeks before this degree of development is reached. After the surface of the medium has been completely covered with the organisms the final steps in the manufacture of the tuberculin may begin. 'l'he fluid with the bacilli is first measured, and the quantity recorded, after which the mixture is boiled for from one-half to three-quarters of an hour. The liquid is then filtered through a Berkfelt filter into a sterile vessel, and evaporated down to one-tenth of the original volume. It is then tested as follows: A guinea pig weighing from 250 to 300 gms. is given an injedion of virulent tubercle bacilli one month previously, and this animal now receives 0.5 c. c. of the tuberculin in the same way. If the tuberculin is up to proper strength the animal dies within thirty hours with symptoms of inflammation around the tuberculous lesions found in its body. .
A dose of tuberculin is so small that it is necessary to dilute with some liquid in order to get a sufficient bulk. Ordinary sterile water may be used, but it is much better to employ an equal mixture of 0.5 per cent. carbolic acid solution and 0.85 per cent. of common salt in water,
More recently Koch has devised a number of other tuberculins.
One of these is a tuberculin made by extracting tubercle bacilli with a 1/10 normal soda solution~the resulting extract being called "T A"; this gives reactions in every way similar to those produceil by the older
55

tuberculins, but hns the disadvantage that it produces abscesses at the point of injection.
Koch early recognized the desirability of injecting not only the extract from the bacillus, but the entire organism itself, inasmuch as unquestionably certain substances remain in the germs after making the decoctions already referred to; these constituents it appeared highly probable should in some way be secured in the material to be injected in order to produce a perfect immunity. Of course, the living organisms could not be used, and experiments showed that even when killed they were not absorbed after being injected in the tissues, and they furthermore produced suppuration or the formation of nodules; this action of the organism is probably the result of the presence in their covering of unabsorbable fatty acids. In order to overcome these difficulties Koch thoroughly dried young cultures of virulent bacilli and then ground them up into an impalpable powder in a mortar, the process being earried on until only a few of the bacilli remain uncrushed. As the organisms are not previously killed, it certainly appears a little dangerous to employ a fluid containing in suspension any of the bacilli still not thoroughly broken up. For the purpose of avoiding this source of danger Trudeau places the dried bacilli in a cylinder with a number of pieces of porcelain, and then seals the chamber at the opening where the contents are introduced; then, by suitable mechanical appliances, the cylinder is turned over rapidly for seven day;s, at the end of which time it is stated that not a single unbroken bacillus can be detected. To the crushed bacilli distilled water is added and the whole centrifugated for from a half to threequarters of an hour at 4,000 revolutions per minute. At the end of this time there is found an opalescent fluid in the centrifuge tube which is poured off and is called '' T 0." To the sediment that remains in the tube more
51'

water is added and the process of centrifugating again carried out; this is repeated until no sediment remains. The different portions of the liquids, with the exception of the first, are then added together and are called ''T R."
The "T 0" contains practically the constituents of the bacillus that are found in the old tuberculin, and resembles the latter in its action on the human being. On the other hand, those portions of the bacilli present in the "T R" represent the constituents that more particularly act as immunizing agents when introduced into the living organism.
More recently Koch has abandoned the "T 0" and '' T R'' tuberculins, and has simply used a mixture consisting of equal parts of water and glycerine containing in suspension the entire bodies of the crushed bacilli; the mixture is set aside for several days and the clear supernatant fluid is poured off from the sediment that is now present in the bottom of the container. The proportions of this preparation is such that 1 c. c. contains 5 milligrams of pulverized tubercle bacilli. This is called "New Tuberculin Koch (bacilli-emulsion)."
It is of more or less interest just at the present time to recall the fact that many years ago Koch prepared a so-called refined tub~rculin which was made by precipitating the albuminous substances from the old tuberculin with 60 per cent. alcohol, and washing the precipitate with pure alcohol; it is then dried and dissolved in water. A tuberculin consisting of one part of the dried powder to 100 parts of water, as recently suggested by Calmette, furnishes an easy method of making the tuberculin test in children by placing a drop of the liquid in the eye of the suspected individual.
Following E. Buchner, who succeeded in pressing from some of the lower vegetable forms a sort of cell juice, H. Buchner and Hahn have secured a similar fluid
57

from the tubercle bacillus. Young cultures of tubercle bacilli were filtered from their culture media, and mixed with sand, the whole well rubbed together and later subjected to a pressure of from 400 to 500 atmospheres. The resulting fluid, known as tuberculoplasmin, is a clear amber-colored liquid, which is rendered free of all bacteria by being passed through a porcelain filter, and is finally preserved with 5 per cent. common salt and 20 per cent. of glycerine. It does not appear that this variety of tuberculin p,ossesses any advantages, and has not come into anything like general use.
Among tuberculin experimenters there is a more or less well-founded belief that those preparations requiring heat in their manufacture are not so satisfactory as those in which this is not necessary. There seems, then, some reason for the suggestion made by Denys that the most . satisfactory tuberculin should consist simply of filtered bouillon in which the organisms had been allowed to grow. The dosage of the liquid would, of course, be about ten times that of the ordinary tuberculin, and it is said that a number of the best workers on the subject of tuberculosis in America now employ this preparation in preference to the older one of Koch.
There are some other tuberculins, but as they have never proven of any particular value, a description of them seems superfluous.
At the present time the original tuberculin of Koch is perhaps employed more frequently than any of the newer preparations, and, on account of the fact that it is impossible for tuberculosis to be accidentally transferred by means of it, it should be, and is, generally regarded as the most satisfactory of all of the different forms of the substance. Koch's "bacilli-emulsion" and the simple bouillon of Denys are also frequently used for therapeutic purposes.
T~tberculin for diagnostic purposes: There can be
58

no question that great aid is oftentimes rendered by the administration of tuberculin in making a diagnosis in the early stages of tuberculosis. The basis on which the procedure rests is that a normal man can receive by injection without the slightest effect 10 milligrams of tuberculin, while those suffering from tuberculosis in any form have fever, a feeling of malaise, and pain in the back and limbs in from ten to fifteen hours after a much smaller dose; the symptoms just referred to are spoken of as constituting a "reaction." It should, however, be mentioned that those who have advanced tuberculosis, or who have suffered from the disease for a long time, are not so susceptible to the action of the drug as those who have the malady only to a slight degree and who have been recently attacked. We, therefore, can not regard a negative result as being absolutely conclusive that the patient has not tuberculosis, as, taking them altogether, perhaps not more than 60 per cent. react. Many writers recommend as much as 5 milligrams of the old tuberculin as the first dose for purposes of diagnosis, but inasmuch as this quantity of the drug frequently produces most violent symptoms, of the kind already described, we follow Trudeau in recommending a very small dose to begin with, and gradually increasing up to the maximum dose of 10 milligrams. In the majority of instances patients that react at all will do so with the first or second dose. We give for the first dose 0.5 milligram, for the second 1 milligram, for the third 2 or 3 milligramf', for the fourth 5 milligrams, and for the fifth 10 milligrams, repeating the last dose in some instances if thought necessary; the injections should be given at intervals of at least two or three days. The best time to administer the drug is late in the afternoon or evening, as we can then on the following morning begin to watch the symptoms that result in case the
reaction is positive. The injecti9PS should be made with
59

a sterile syringe, and the needle, instead of being merely introduced under the skin, as in ordinary hypodermic injections, should be pushed directly down into the muscle beneath the subcutaneous cellular tissues. Perhaps the best site for the injections is the back or the buttocks, as in either of which situations the muscular tissues are near the surface and the slight soreness that frequently results does not very seriously interfere with the patient's movements. It is, of course, advisable to cleanse the skin with some antiseptic just before introducing the needle. If the patient's t~mperature has been running normal an elevation amounting to one-half degree is looked upon as being of positive significance.
Reference was made to the fact that Calmette has recently employed the alcohol-precipitate from tuberculii;l dissolved in water and placed in the eye of the suspected individual as a means of diagnosis. This was suggested by the observation of von Pirquet, who noticed with children a little ordinary tuberculin rubbed into some part of the skin previously sacrificed as for vaccination was rapidly followed by evidences of inflammation in the part in case the subject had tuberculosis; if the child was healthy no result was observed. Calmette modified this procedure by simply making a- per cent. watery solution of the precipitate of albumens from tuberculin and instilling into one of the eyes of the patient a single drop of this. In from three to eight hours hyperemia of the mucous membranes of the eye follows in tuberculous individuals, with a sandy feeling and more or less lachrymation; the inflammatory process in the conjunctiva reaches its height in from twelve to twenty-four hours, and remains for several days; at the end of about a week the eye usually returns to a normal condition. That this test is sensitive and very convenient there can, of course, be no two opinions, but, as might have been expected, in some cas.es it is followed by very
60

severe inflammation in the eye. So far as is known no instance has been recorded where the eye was lost as a consequence, but the reports that have been made to the present time would indicate that this is not impossible. Under. such circumstances it is doubtful if this method should be employed, as even the possibility of putting the patient's eye out should warn us against the 1n~oeedure.
Therapeutic 'Ltses of tuberculin: Recent investigations have pretty clearly shown that tuberculin, in addi- . tion to being a valuable diagnostic agent, is also of considerable importance from a therapeutic standpoint. It is believed by all those who have used it in very minute doses in chronic tuberculosis that their patients have been more or less improved in consequence, and, as no instances have been recorded where harm was done under such conditions, the matter is certainly worthy of the consideration of every physician. The point made, particularly by Trudeau, who is one of the best of all authorities on the subject, living or. dead, is that the drug should be given in very small doses, the quantity, so far as is possible, being always sufficiently small not to produce a perceptible reaction. It is perhaps safer to begin with 0.01 of a milligram, though, as a rule, we might without danger start with 0.05 of a milligram. These injections are made once e'very three or four days, and the amount of the drug cautiously and carefully increased. If the patient's temperature should go up in the least following the injections, the next dose should be smaller. If he presents the slightest evidence of not doing well, as shown by malaise, headache, mental irritability, anorexia or increased cough, the injections must be at once stopped. On the other hand, if the patient continues to improve no hesitation may be felt in continuing the use of the drug, gradually increasing it until finally a considerable dose, even as much as from ~'2 to 1 e. c., may be administered. There should,
61

however, be no rule about this, as the final amount, as well as the quantity given in the beginning, has to be the result of closely watching the peculiarities of the patient, exhibiting the drug in such quantities and at such intervals as may seem to be attended by benefit, and decreasing it or stopping it altogether if the patient appears not,to be doing well. If the "bacilli-emulsion" be used the beginning dose should be from 0.001 to 0.002 of a mi11igram. The injections should be, of course, given in the same way as for diagnostic purposes. In conclusion, it may be said that there is every reason to believe that we have in tuberculin, when properly employed, a safe means of diagnosticating tuberculosis in its early stages, and that if given properly, it is of decided therapeutic value. Here, however, as in all other things connected with medicine, the physician must use his brains and not a pocket formulary-the drug must be used according to the requirements and susceptibilities of the patient.
The State Board of Health furnishes tuberculin to all practicing physicians of this State free of cost, and it nwy be obtained in any desired dose by requesting the same by letter or telegraph. It should particularly be borne in mind that the required dJose rnust be specified, as it would only be possible for the physician in charge to know how to prescribe for the patient intelligently.
It should, of course, be understood that in no 'instance does the State Board of Health advise treatment of tuberculosis indiv,iduals by tuberculin alone. At best it can only be considered as an aid in this umy, and should be used always in connection with the fresh air treol rnent.
6:2

FREE LABORATORY EXAMINATIONS
CHARACTER OF ExAMINATIONs: The Laboratory of the Georgia State Board of Health has been established with the primary object in view of assisting physicians in diagnosticating those diseases that are caused by bac-
teria or animal parasites. It would be desirable to in-
clude 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: , Exam1inations for Bacteria: Examinations of this kind are conducted in two separate ways. \V"here the organism that is being searched for is usually found in much greater numbers than other germs incidentally present, or where we 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 does 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 done the germ which is being looked for is finally isolated by 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 over-
63

whelming numbers. As examples of these different possibilities we may mention the rnicrococcus intra.cellularis which represents the first, the tubercle bacillus the second, and the diphtheria bacillus the 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 Leoffler's blood-serum-glucose-bouillon 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 swab 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
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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 he made, replaced in the bottle and shipped to us immediately. Of course, under such circumstances, we have to make the culture after the specimen is received, and the report consequently cau not he made immediately.
We examine for any pathogenic organisms, among which may be mentioned the bacillus tuberculo.sis, the bacillus diphtheriae, the bacilhts pneurnoniae, the micrococcus intracellularis meningitidis, the g'onococcus, the spirocheta of' syphilis, the streptococcus, and the various species of sta,phylococci.
Attention should be called to the fact that the so-called bacillus typhosus 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 f'eries of bacteriologic manipulations. Where the patient is willing the most satisfactory results me obtained by isolating the germ from the blood, hut, 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 he added to prevent it from coagulating. It is next to impossible to isolate the so-called typhoid! bacill1ts from water-there not being more than half a dozen instances on record where this has been accomplished.
Examination of Blood1 for the Malarial Parasite: 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
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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. 1). 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 of the blood to it (l!,ig. 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
Fig. I.
the slide upon which the blood has been spread is vigorously waved in the air-preferably at some distance above a flame-until it is thoroughly dry. If tliese pre-
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cautions 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.
Blood for the Widal test [o1 typ:hoid 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

Fig. II
not a diagnostic symptom of typhoid fever; 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 o~ 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
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good, drops may be allowed to fall on ordinary writing paper. It is always desirable that four or five drops of blood be procured, and they should be placed at separate points on the object selected to carry them. It is very important that the blood be allowed to dry spontaneously-never held above a flame in order to hasten this 1esult.
we Examination of the feces for animal 'parasites:
examine for all intestinal parasites by searching for their
Fig. Ill.
eggs,-this being the only sure and satisfactory method of determining as to wl1ether or not they are present. The most important among these are the Uncinaria americana or book-worm, the Oxyttris vennicularis or pinworm, the Ascaris lumbricoides, th~ Trichocephalus dt:spar, the Distomata, and the various species of Teniae or tape-worms; we likewise examine for 'the embryo of the Strongyloides intestinalis.
A11 that is necessary in the preparation of specimens for examinations for intestinal parasites is to have the
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feces sent us in a properly stopped bottle; it is not essential to take any particular precaution in cleansing the bottle in which the specimens are sent.
Examinatim~ of water to deter'mine its fitness fur drinking purposes: Examinations of this kind require a great deal time and work, and we are, therefore, unfortunately in the position of not being able to examine thoroughly every specimen sent us. Where it is desired to have such examinations made the Board of Health has made a ruling requiring the person who wishes such an analysis 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 necessary the examination will then be made. It is to be hoped that our appropriation will soon be increased so as to allow 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 water 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. rl'he bottle is then corked with a stopper 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 especially 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 circumstances the specimens are very rarely delivered while still fit for analysis.
PHYSICIANS SHOULD ALWAYS REMEMBER TO PLACE THEIR
NAMES AND ADDRESSES ON THE SPECIMENS SENT TO THE LAB-
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ORATORY, AND THEY SHOULD ALSO GIVE THOSE OF THE PATiENT EITHER ON THE SPECIMEN OR BY MEANS OF A LETTER OR POSTAL CARD.
WHERE IT IS DESIRED REPORTS WILL BE MADE BY TELEGRAPH AT THE EXPENSE OF THE PHYSICIAN OR THE PATIENT FOR WHOM THE EXAMINATION IS BEING MADE. WHERE POS. SIBLE WE WOULD ALWAYS URGE THAT SPECIMENS BE SENT BY MAIL, AS THEY INVARIABLY REACH US SOONER THAN WHEN SENT BY EXPRESS. SPECIMENS SHOULD NOT BE DIRECTED TO THE LABORATORY ASSISTANTS, AS UNDER SUCH CIRCUMSTANCES THEY oFTEN GO ASTRAY. ADDRESs, LABORATORY STATE BoARD OF HEALTH, ATLANTA, GA;
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